Lucerne House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

It had been identified that improvements were needed to the oversight and governance of the service. Changes had been made to the management team and a range of checks and audits. Action plans had been developed to address the identified shortfalls and these were regularly reviewed. These improvements had started to be implemented but further time was needed to fully implement and embed into daily practice. Staff were committed to the changes and spoke about the improvements they had seen. There was a positive, inclusive culture where staff felt valued and well supported by the management team.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A new team took over the management of the service this year. When they started in post they identified a number of concerns and drew up an action plan to move forward. Staff told us about the changes that were taking place and were committed to the changes. Whilst most of the staff team told us they had not recognised the need for change they could see the improvements and potential benefits from the changes. Other staff told us they had been aware changes were needed and could also see the benefits. One staff member said, “The majority of changes are positive. I can see what has been wrong and what is now being done now we’re seeking right advice.” Another staff member said, “We are improving ourselves and learning with support from the managers.” Staff told us they felt supported by the management team. They told us they were supported both with work and personally.

There had been changes to the structure of the management and staffing team. Staff worked consistently at the same location which helped ensure they knew the people they were supporting. Work was ongoing to ensure staff received the training and support needed to develop the service.

Staff told us the management of the home was good. Staff comments included, “I can always talk to [name].” The management team was aware of the importance of developing a supportive and consistent management team and to share findings and areas for development with the wider staff team.

There was a clear management structure which included an on-call system. Staff were regularly given opportunities to feedback any issues through supervision, staff meetings and an open door approach within the management team.

Staff told us how and when they would raise concerns. They told us they were comfortable to raise any issues with senior staff and the management team. One staff member told us, “We’re not afraid to speak to management at any time.”

The management team had an open door policy where staff could talk to them at any time. There were regular staff meetings and supervision where staff were able to discuss any concerns. There was a whistleblowing policy which was available to staff.

The management team told us as far as possible they supported reasonable adjustments to support staff at work. This included taking into account individual staff abilities and working with them to improve lives for people. There was a zero tolerance to bullying, discrimination and racism. One staff member whose first language was not English told us how they were supported by their colleagues and people at the services to improve their language skills.

Staff completed equality and diversity training as part of their induction. Staff were regularly asked for their feedback which enabled them to raise any concerns. The management team was working with the local authority to support staff, where English was their second language, to attend further training. The management team recognised that the use of ‘slang’ and local words and phrases could be confusing for staff and the local authority sessions would help with this.

The management team told us about the changes and improvements that had been made and were being implemented since they were in post. They told us about a new governance system which was being implemented to ensure appropriate oversight of the services. They told us they were aware more work was needed and this improvement process would be on-going.

The service had been through a period of instability with changes to the management and staffing. As a result of safeguarding investigations, concerns were identified, and the local authority provided ongoing support to the service to make improvements. These concerns had not been identified by the provider. Following on from the safeguarding, a new governance system had been developed and was being implemented. This had helped the management team gain more information about the improvements that were required. The governance system included support to change the culture of the service. This involved having regular governance meetings, staff meetings, staff supervision and feedback from people. Regular audits had commenced at Lucerne House and were being completed. These were yet to be fully implemented in the Supported Living services. Action plans had been developed to address the identified shortfalls. These were regularly reviewed and updated to identify where improvements were still needed. As discussed throughout this report, improvements had been identified and were being implemented. This included improvements to care plans, risk assessments, daily notes, and ensuring people had been supported to set goals which were measurable so achievements could be identified. All of these changes needed further time to be fully implemented and embedded into everyday practice. Although there were managers at both Lucerne House and over the Supported Living services neither were registered with CQC. We were told applications for the managers registration had commenced. An area manager supported managers in their roles.

People and their relatives told us appropriate health and social care professionals were contacted appropriately when required. People were supported to maintain contacts with friends, families and clubs and groups to support their own interests.

The management team and staff told us how they would contact the relevant external professionals to help ensure people’s needs were met.

Health and social care professionals were generally positive about working with the service. However, one external professional told us that on occasions staff had not completed the requested monitoring forms to help them assess the persons needs and there had been a lack of interest in specific training they had arranged. Others told us the management team and staff were generally responsive to people’s needs and to suggestions / advice they gave. They had worked hard to make improvements. One external professional told us they worked well with the service. They said, “There’s never anything here that worries me, in relation to people’s care or safeguarding.” Another told us, “I was really impressed by the service leads and staff, they knew their service users well and also understood the balance between advocacy and allowing people to have a voice and choice.”

Staff worked with various external agencies including, social workers, Local Authorities, safeguarding teams, and healthcare professionals. Relevant information was shared appropriately.

Staff told us how they had learnt from the changes that had been implemented. One staff member said, “I now love to come to work. There was no communication but now communication is good. There was a vast gap when we were not told anything. Now it’s a whole different rules and regulations.” The management team gave us examples of when changes had been made as a result of lesson’s learned, for example, the way in which people were supported to manage their finances.

The governance and audit system now supported the management team to review and analyse safeguarding concerns, complaints, accidents, incidents and near misses. This enabled them to identify emerging themes. When these were identified action was taken to reduce the risk of reoccurrence. Whilst this was in place further time was needed to ensure it was fully implemented and embedded into practice.