This inspection took place on 21 November and 1 December 2016. Lucerne House is registered to provide accommodation for 75 people who require nursing and personal care. The service consists of three units known as; Shillingford unit, which provides care for older people living with dementia; Ide unit, which provides care for older people; and Alphinbrook unit, which provides care for younger people with physical disabilities. At the time we visited, 66 people lived at the home. We found Lucerne House to be providing an excellent service.

There was a registered manager and deputy manager employed at the home who were clearly passionate about providing a high quality, individualised service. The registered manager was on an additional temporary assignment within the company, so the deputy manager who commenced employment at the home in July 2015 temporarily manages the home when the registered manager is absent. The registered manager was present at Lucerne for the majority of the time.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the last inspection in October 2014 we found the domain of ‘responsive’ required improvement. At the time, people’s feedback was mixed about how they were supported to interact, avoid social isolation and pursue their individual interests and hobbies, and further improvement was needed in this area at that time. All of the management team had changed during 2014 and the two heads of unit were then relatively new in post. During this inspection in November 2016 we found there had been extensive improvement and we rated responsive as ‘outstanding’. People had access to and were involved in developing personalised activities that complemented their individual hobbies and interests. Links with the local community had been established and people were supported to participate in community events and other events that were important and meaningful to them. Some people were able to improve their independence so they were able to return home to the community. This provided people with a sense of purpose and wellbeing.

People were supported by very kind, caring and compassionate staff who often went the extra mile to provide people with good, high quality care. This high standard of care enhanced people's quality of life and wellbeing. The staff as a whole, supported by the activities team, were extremely passionate about providing people with support that was based on their individual needs, goals and aspirations. They were pro-active in ensuring care was based on people's preferences and interests, seeking out activities in the wider community and helping people live a fulfilled life, individually and in groups.

The staff were happy working in the home and felt very supported in their role. They were clear about their individual roles and responsibilities and felt valued by the registered manager, deputy manager and the wider provider, senior management team. Good leadership was demonstrated at all levels with a pro-active effort to encourage ideas from staff to further benefit the people in their care and maintain a strong, stable staff team with a shared goal. Each individual staff member was engaged in sourcing new opportunities for people and putting ideas into practice.

People were safe living at Lucerne House. There were enough staff to meet people's care needs safely and also to provide individualised support in and out of the service. There was a strong culture within the home of treating people with respect. The staff and managers were always visible and listened to people and their relatives/friends, offered them choice and made them feel that they mattered. Staff spent time with people to get to know

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Lucerne House is comprised of three units known as Shillingford unit, which provides care for people with dementia; Ide unit, which provides care for older people, and Alphinbrook unit, which provides care for younger people with physical disabilities.

At our previous inspection on 24, 26 February and 03 March 2014 we identified significant concerns about the care and welfare of people, staffing levels and quality monitoring at Lucerne House. CQC took enforcement action by serving three warning notices on the provider, which required them to make urgent improvements in these areas within four weeks. We also identified concerns about five other standards, which were less serious.

This was a follow up inspection to check the most urgent improvements required had been made. We visited the home on 21 May 2014 and found the provider had complied with the warning notices served and had and made significant improvements in people’s care and welfare, staffing and in quality monitoring. We have since received an action plan from the provider about the remaining improvements underway at Lucerne House in relation to the other five areas of non-compliance. We will carry out a further inspection later this year to check further improvements have been made and to ensure existing improvements have been sustained.

At the time of our inspection there were 59 people living at Lucerne House nursing home. Following the previous inspection, the provider agreed not to admit people to the home until improvements in care had been made. We spoke with 23 people who lived there and with seven relatives to seek feedback about the care. We spoke with 24 staff who worked at the home which included the manager and other senior staff, nurses and care workers, agency and other support staff. We also spoke with five health care professionals who regularly visited the home to seek their feedback.

Is the service safe?

As a result of the concerns identified at the previous inspection, a multiagency safeguarding process was convened to oversee the improvements. A multi-disciplinary plan was drawn up by the provider and health and social care professionals to protect people's safety and well-being. This resulted in health professionals visiting the home as part of a safeguarding investigation and in a protection role. Feedback we received from health and social care professionals confirmed our findings that care had improved across all areas of the home and risks had significantly reduced.

One person said, “I like it here and I feel 100% safe”. We found that people were well supported to have adequate nutrition and hydration and we found the health of people previously at risk of malnutrition and dehydration had improved and they had gained weight. Security in the home had also been improved to prevent visitors having unauthorised access to the home. Health and safety systems had been improved, all damaged crash mats and bed bumpers had been replaced and were being closely monitored. People on Shillingford unit who needed hoisting had individual hoist slings, which had increased their safety and reduced cross infection risks.

Is the service effective?

Since we last visited, staff on Ide unit had undertaken training on nutrition, hydration and on end of life care. Staff we spoke with demonstrated much more knowledge and confidence in caring for people’s needs. Nutritional care plans had been reviewed and updated to give staff much more information about how to support people’s nutrition and hydration needs. Health professionals also reported they received fewer phone calls for advice between their visits due to increased staff confidence in providing care. People and relatives also reported improvements. One said, “Absolutely fantastic, they are more organised” and another said, “I can see huge improvements”.

Is the service caring?

Throughout our visit, we saw that people were treated in a caring and compassionate manner and with dignity and respect. We saw that staff were engaged with in meaningful conversations with people and treated people as individuals. Comments included, “Mum is very well cared for” and “Overall my family and I are very happy with the care our mother receives”.

Is the service responsive?

Staffing levels at Lucerne House had significantly increased. A number of staff we spoke with told us how the increased staffing levels had improved people’s care. One said, “Staff are not so stressed, we can sit with people at lunch and engage with them”. One relative said, “X seems much calmer, staff can now spend more time with him, he is getting more to eat and drink regularly and I am pleased with that”.

We found that people were being regularly supported with personal care and that people who needed support to eat and drink regularly received that support. We also saw how care records had improved and provided better information for staff about how to respond to people’s individual needs. Staff were responsive when people called out and quickly went and reassured them and they also responded quickly to call bells. We observed that staff sat down next to people who needed support with their drinks and discreetly assisted them, where necessary. We saw that staff were patient and allowed people time to eat in a calm unrushed environment.

Is the service well led?

People and relatives we spoke with reported improvements in the leadership and management at the home. The manager has been in post for three months and is currently undergoing registration with the Care Quality Commission to become the registered manager at Lucerne House. One relative said, “The home feels more stable, the manager seems to be here more often, his door is always open which makes me feel happy to approach him if I felt I needed to”. Another relative said, I feel things are much better, we feel more confident in the home”.

We found the quality monitoring systems at the home had been improved and that prompt actions had been taken to reduce the risks we highlighted previously and to improve people’s health, welfare and safety.

We carried out this inspection at the request of the coroner under Rule 43 of the Coroner's Rules. The coroner asked us to look at how the risks to people who are assessed as being at risk of choking were being managed. Concerns were also raised with us that safeguarding procedures were not being followed.

We carried out the inspection on Shillingford Unit where people with dementia are cared for. We identified three people who had been assessed as being at risk of choking due to swallowing problems. We read their care records, spoke with them, and/or observed their care over a mealtime period, and talked to staff about their needs.

During our visit the majority of people living here could not speak with us directly. However, we observed staff interacting with people in a kindly, discreet, calm and respectful way. We were told by one person that they enjoy the meals here and we saw people enjoyed their food. We also saw that people had choices about what to eat, including both hot and cold food choices. We saw that the mealtime in the dining room was managed in a skillful way ensuring that all people were attended to and that the experience for people was calm and relaxed. People are receiving a nutritious diet.

We found that staff knew people's needs well. However some records relating to people'sffluid and food intake were not completely accurate and therefore could not always demonstrate that people were receiving the appropriate care. We also found that some plans in place to manage people's risk of choking were not being completely followed, which meant that this risk was not being fully managed. We saw that some people were eating some foods or food and drink combinations which were associated with an increased risk of choking.

We found that people are not fully safeguarded because actions that were to be taken against a member of staff had not been actioned, and locally agreed safeguarding procedures had not been followed.

We (the Care Quality Commission) carried out an unannounced visit on 21 May 2012 and completed the visit on 22 May 2012.

When we arrived people were going about their day as they wished. Some people were relaxing in the communal areas or in their rooms. We talked with 12 people who lived at the home. Six of those people were living with dementia and were cared for in the Shillingford unit. This meant that they could not specifically tell us what it was like to live at Lucerne. We observed people were comfortable in the presence of staff and appeared relaxed and able to move about the home keeping occupied with the wide array of interests around the home.

We spent time observing care delivery in the communal areas and looked at all areas of the home. We spoke to the manager, deputy general manager, the GP who holds surgeries at the home and with 17 staff who worked at the home. People told us that it was ‘a wonderful home’, one person said 'I wouldn’t move to another place, staff are so nice here'. Staff were all positive such as ‘it’s a fantastic place and very rewarding to work here’ and ‘everything is for the residents’. We saw two relatives enjoying a tray of tea and biscuits in one lounge with people living at the home and they were heard to say that it was ‘lovely, like a café’.

We saw that the home focussed on people’s choice about how they wanted to live their lives. We saw and were told about clear examples of how knowledge of people’s previous lifestyles and preferences had been used to enhance their life at the home in a person centred way. Staff were aware of people’s likes and preferences and there was good communication between the staff and people living there. This included regular resident’s meetings, relatives meetings, a wide choice of relevant activities and topical events and a relative’s bereavement support group. In addition to group activities, the home also supported people to engage in individual activities they enjoyed, this included reading, knitting and listening to their favourite music.

People told us they felt safe in the home and were able to raise any concerns and were confident they would be dealt with. Staff we spoke to confirmed they felt well supported, were able to raise concerns within their unit or with the management. Two members of staff we spoke to told us there was a ‘really good atmosphere’ at the home, several members of staff mentioned ‘good teamwork’ and one staff member said 'I love working at Lucerne, everything is for the residents, people have choices’.

The staff were involved in putting forward ideas and had undertaken projects to enhance the general feel of a local community within the home. At the time of our visit, a beach side themed garden was being developed.

Staff received training and were knowledgeable about people’s needs and how to meet them and said they felt valued. The home had recently been nominated for a care award relating to their dementia services and individual staff had won recent awards within the provider group relating to care and activities.

The home had a variety of quality monitoring systems in place and regular audits and checks were carried out in all areas of the home with appropriate action taken to address any issues. There was a high standard of décor and cleanliness throughout the home and we saw that people looked well cared for.

We found the home was meeting the six outcome standards we looked at during our visit.

We carried out this unannounced inspection visit to check on the service’s compliance with two warning notices that we had issued in August 2011. The notices were issued following a visit we made, on 25 July 2011, at the request of the coroner under Rule 43 of the Coroner's Rules. The coroner had asked us to look at how the risks to people who were assessed to be at risk of choking were being managed. When we did this, we found that they were not being managed sufficiently to ensure people's safety, and so we issued notices requiring the service to take prompt action to address these risks.

On this visit, we looked at the support given to five people who staff had assessed as being at high risk of choking because of swallowing difficulties they had. These difficulties were due to a range of causes. The people lived on ‘Shillingford’ or ‘Ide’, the two units for older adults. We met them and, in some cases, their visiting relatives. We observed the support they received over a mealtime, looked at their care records, and spoke with staff who supported them.

Some people living at the home had various communication needs and were thus not able to give us their views directly. We observed staff interacting with people in a kindly, patient, calm and respectful way. When we asked one person what they thought of the food provided, they said they liked it and the quantity was right for them. We saw people were served good sized portions. Most people appeared to enjoy their food, and were offered ‘seconds’ as well as more to drink.

We saw that the mealtime was managed in a skilful way, ensuring that all people were attended to and that people were not rushed by staff supporting them to eat or drink.

Two visitors we met said they knew about the risk to their relative of choking. One told us they had no concerns and considered the care to be “very good indeed”.

We found that staff knew who was at high risk of choking. They could describe the individualised support required by the people we followed up, to reduce their risk of choking when eating or drinking. We saw they provided the required support, to promote people's safety. Daily records reflected that people were given appropriate foods as indicated by advice from a Speech and Language Therapist, to avoid causing choking.

The inspection took place on 28 and 31 of October 2014 and was unannounced.

Lucerne House is registered to provide accommodation for 75 people who require nursing and personal care. The service consists of three units known as Shillingford unit, which provides care for older people with dementia; Ide unit, which provides care for older people, and Alphinbrook unit, which provides care for younger people with physical disabilities. At the time we visited, 62 people lived at the home.

The service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

During a previous inspection on 24, 26 February and 03 March 2014, we had significant concerns about staffing levels, quality monitoring and about whether people’s care needs were being met, particularly on Ide unit. We took enforcement action against Lucerne House by serving warning notices in those areas to protect the health, safety and welfare of people using this service. On 21 May 2014, we undertook a follow up inspection to check the most urgent improvements required had been made. We found the provider had complied with the warning notices served and had made significant improvements in people's care and welfare, staffing and in monitoring the quality of the service.

At the February/March 2014 inspection, we also found other breaches of legal requirements related to the safety of the premises and equipment, safeguarding, record keeping and in how the service managed complaints. The provider sent us an action plan which explained how they planned to address the breaches of regulations we had found. At this inspection we found these actions had been completed and the provider has now met the legal requirements.

People gave us mixed feedback at the home about how well they were supported to maintain their interests and hobbies. People on Alphinbrook were very satisfied as were some people on Ide unit were satisfied. Other people on Ide unit, including those who chose to stay or were confined to their rooms reported feeling bored and lonely. On Shillingford unit, staff did not spend much time interacting with people living with dementia in a meaningful way. Further improvements were needed to prevent people becoming socially isolated through more meaningful interactions with staff.

People, relatives and staff were positive about the changes in leadership at Lucerne. One person said, “It’s very good here I am pleased with it” and a relative said, “The atmosphere is much better”. Speaking about the improvements made, one relative said, “I feel much more confident (the person) is in the best place, I would recommend it, they can look after him and they are doing it, the job now is to maintain it”.

In addition to the registered manager, there was a deputy manager and a head of each unit. All of the staff in these posts changed during 2014, and two heads of unit were recently appointed. Senior staff led by example, there was good teamwork and communication to make sure each person’s needs were met. The provider used a range of systems to monitor the quality of the service provided to people. Senior staff also undertook regular ‘spot checks’ of people’s care records and equipment, cleanliness and health and safety and by talking to people and staff. All checks were documented and showed corrective actions taken on any problem areas.

Staff knew people, understood their needs and wishes and how they liked to be supported and were kind and respectful. People were offered choices in their day to day care. Where people lacked capacity, relatives, staff and health and social care professionals were consulted and involved in decision making in their ‘best interest’.

Improvements had been made in providing end of life care; staff had done training and were more confident in managing pain relief and in supporting people’s physical and emotional needs.

People were involved in developing their care plans, which were detailed about each person’s individual needs and the support they needed from staff. Significant improvements were made in how people were supported to eat and drink. People were offered food and drink regularly and where a person declined their meal, snacks and food supplements were offered. Detailed records of people’s eating and drinking were maintained and monitored and action taken to ensure each person ate and drank enough to keep them healthy.