CQC report explained · a residential care home
What the CQC found at 21 Lucerne Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2023
Rated Requires Improvement; inspectors found kind, person-centred care, but risks, care records, medicines checks and management oversight needed improvement.
The inspection took place on 16 December 2022 and was a follow-up to the previous inspection. Inspectors spoke with one person, managers and a relative, observed care, and reviewed care, medicines, staffing and management records.
The home supported three people with a learning disability and/or autism. Staff knew people well, treated them with kindness and supported their choices, independence, health care, communication and activities. The home was clean, there were enough staff, and infection control arrangements were suitable.
There were important shortfalls. Some risks, including radiator burns and falls from height, had not been fully assessed. Medicines stock checks were not always completed. Care plans were not detailed or up to date enough, and management checks had not found and fixed these issues.
The overall rating was Requires Improvement. Safe, responsive and well-led were rated Requires Improvement, while effective and caring were rated Good. The home remained in breach of two regulations, and CQC requested an action plan and said it would continue to monitor progress.
Kind and respectful care
Inspectors observed respectful interactions and found that staff provided compassionate care. People’s privacy, dignity, choices and cultural needs were respected.
“People received kind and compassionate care from staff.” from the report
Support for independence
People were encouraged to take part in household tasks, food preparation and other activities. They had choice and control over how they spent their time.
“People were encouraged to do as much as they wanted to themselves, such as household chores and preparing food and drink” from the report
Clean home and infection control
The home was clean and hygienic. Staff used protective equipment safely and the home had enough cleaning products and protective equipment.
“The premises were clean and hygienic.” from the report
Risk assessments were incomplete
seriousRisks relating to falls from height, radiator burns and people’s care were not always fully assessed or reviewed. Inspectors said this created a risk of unsafe care and treatment, although they found no evidence of harm.
“We found no evidence that people had been harmed. However, people were at risk of unsafe care and treatment because risks were not always identified or assessed.” from the report
Care plans were out of date
needs fixingSome care plans were not detailed enough or had not been reviewed for more than a year. This meant they might not reliably guide staff, especially staff who did not already know the people well.
“Sufficiently detailed care plans were not in place for people.” from the report
Medicines stock checks
needs fixingStock checks were not always completed, so the provider could not be sure how much medicine should be available or confirm stock levels robustly. Staff did record administration correctly and stored medicines safely.
“Stock checks of medicines were not always in place” from the report
Management oversight
seriousThe provider’s checks had not consistently found and fixed problems with safety, medicines, care records and risk assessments. This was part of the continued breach of good governance.
“The oversight of the registered manager to meet their regulatory responsibilities continue to be lacking and could be further improved.” from the report
Power of attorney records
minorThe provider said people had powers of attorney for health and welfare, but records confirming this were not available. The provider said it would ensure the records were kept.
“However, there were no records to confirm people had power of attorney in place.” from the report
- 01Have all risks relating to falls from height, radiator burns and each person’s care now been fully assessed and reviewed?
- 02How are you checking medicines stock so you know the correct quantities are available?
- 03Have all care plans been updated with enough detail to guide staff who may not already know the person?
- 04What checks now make sure problems with safety, medicines and care records are identified and fixed promptly?
- 05Can you show us the records confirming the relevant powers of attorney for health and welfare?
This was a follow-up inspection that assessed all five key questions and included infection prevention and control checks; the previous inspection had rated the service Requires Improvement overall. This explanation was written from the published report of 10 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2020
21 Lucerne Road rated Requires Improvement; inspectors found kind care but important gaps in risk management, consent and oversight.
The inspection was unannounced and took place on 12 February 2020. One inspector observed care, spoke with staff and managers, reviewed care and staff records, and checked records about the home's running. Relatives and a health professional were also contacted afterwards.
People appeared relaxed with staff, and relatives said they were safe and treated kindly. Staff knew people well, met their nutritional needs and supported access to health care. The home was clean, had enough staff and medicines were administered safely.
However, risks were not always assessed or managed. Examples included missing falls assessments, no suitable epilepsy guidance, no personal emergency evacuation plans and no legionella risk assessment before the inspection. Staff competency to give medicines had not been checked, and some training was missing.
The overall rating was Requires Improvement, as were Safe, Effective, Responsive and Well-led. Caring was rated Good. The home remained Requires Improvement after the previous inspection and had received this rating at two consecutive inspections.
Kind and respectful staff
Staff knew people well, understood their preferences and treated them with dignity. Relatives described the care as kind and compassionate.
“People were supported by staff who were warm and caring and their diverse needs were respected.” from the report
Enough staff
Inspectors saw that people did not wait for long periods for support. Relatives also said there were enough staff when they visited.
“There were enough staff to meet people's needs.” from the report
Clean home and safe medicine storage
The home was clean and tidy, staff followed good hand-washing practice, and medicines were stored securely. Records showed medicines had been given when they should.
“Medicines administration records detailed people's allergies and showed that people had received their medicines when they should.” from the report
Support with food and health
People were offered meal choices, snacks and drinks. Their weights and diets were monitored, and staff helped them access health professionals.
“People were supported to maintain a balanced diet.” from the report
Risks were not fully assessed
seriousThe home had not completed or maintained some important risk assessments. These included falls, epilepsy, emergency evacuation and legionella risks.
“We found no records of any falls but it was not evident that possible risks had been assessed and there was no risk management plan to guide staff” from the report
Mental Capacity Act records
seriousStaff did not always record separate capacity assessments or best-interests decisions. Inspectors said staff did not always act in line with the Mental Capacity Act.
“Staff did not always act in accordance with the MCA Act 2005, which was a continued breach of regulation 11” from the report
Staff training and medicine checks
needs fixingStaff had not received all training relevant to the people living at the home, including epilepsy, autism and learning disability training. Their competence to administer medicines had not been assessed.
“Staff had not received training in other areas relevant to people's needs including on learning disabilities, autism or epilepsy.” from the report
Weak quality monitoring
seriousThe provider's checks did not identify important safety, training and record-keeping problems. Some concerns from the previous inspection had also not been fully addressed.
“Systems to assess monitor and improve the quality of the service were not fully established or operated effectively” from the report
Activities and accessible information
needs fixingSome activities were available, but records did not show consistently that people followed their own interests. The complaints policy and meeting minutes were not always in a format people could understand.
“People did not have personalised activity organisers or other records to demonstrate that they consistently took part in a range of regular activities in the community” from the report
- 01What has been done to complete and regularly review falls assessments, epilepsy guidance and personal emergency evacuation plans?
- 02How are you now checking that staff are competent to administer medicines, including as-required medicines?
- 03How do you record Mental Capacity Act assessments and best-interests decisions?
- 04Which staff have completed training in learning disabilities, autism and epilepsy, and how is refresher training monitored?
- 05What quality checks are now in place to identify risks and make sure actions from this inspection and the previous inspection are completed?
This was a planned, unannounced inspection that looked at all five CQC questions and followed up actions from the previous inspection. This explanation was written from the published report of 17 April 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 21 Lucerne Road
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2019Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2017Goodstayed GoodSafe: Good
- June 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 16 February 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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