This inspection took place on 6 December 2018 and was unannounced. At our last inspection in April 2017 we found the service met all the regulations we inspected. During this inspection we found two breaches of the regulations and other areas of practice which required improvement. The service is rated "Requires improvement" overall. This is the first time the service has been rated "Requires improvement."

21 Lucerne Road is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to accommodate up to four people with learning disabilities. At the time of our inspection there were three people living at 21 Lucerne Road.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 2008 and associated Regulations about how the service is run. The registered manager was also the provider and had managed the service since first registration with the CQC.

The care provided was not sufficiently developed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism living in the home were not fully living as ordinary a life as any citizen. People had limited opportunities to participate in activities go out in the community. Furthermore, the registered manager and staff had not refreshed their knowledge of the Mental Capacity Act (MCA) 2005 and therefore did not have a clear understanding of how the MCA applied to people as their circumstances changed. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the lack of procedures and systems in the service supported this practice.

Staff received training and supervision but the scope of both could be further developed to better meet the needs of people and staff. People told us they felt safe living at 21 Lucerne Road and with the way they were supported by staff. There were arrangements in place to help protect people from the risk of abuse. Staff knew how to identify potential abuse and how to report any concerns. People knew how to make a complaint.

Risks to people’s health, safety and well-being were assessed and management plans devised to guide staff on how to protect them from harm. However, we found that people's care records including their risk assessments were not always fully completed or accurate. Additionally, more needed to be done to ensure information regarding people's care was in a format which was accessible to people.

People told us staff were caring and kind to them; they were satisfied with the quality of care provided. Staff respected people’s privacy and dignity and treated them with respect. Relatives and other visitors were made to feel welcome and told us they were free to visit people at any time. Staff knew people well and understood their communication needs. There were sufficient staff recruited in a safe way to provide care and support to people.

People received their medicines as prescribed. People had access to external health care professionals to maintain their health. People had sufficient food and drink to meet their nutritional needs. People told us they enjoyed the meals provided.

There was not a system in place to ensure that people's views were obtained and used to make improvements if needed. There were limited systems in place to assess and monitor the quality of service provided and the systems which were in pla

We inspected 21 Lucerne Road on 15 April 2017. We previously carried out an unannounced comprehensive inspection of this service on 31 March 2016. After that inspection we received concerning information in relation to there being a lack of suitable staff working at the service. The inspection on 15 April 2017 was an unannounced focused inspection to look just at this issue. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 21 Lucerne Road on our website at www.cqc.org.uk.

21 Lucerne Road is a care home which is registered to provide accommodation and personal care for a maximum of three adults with learning disabilities. The home is located in a terraced house on a residential road in Thornton Heath. At the time of our inspection there were three people living in the home.

The home had 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 2008 and associated Regulations about how the service is run.

There was a sufficient number of suitably qualified staff to care for people safely and meet their needs. There was a system in place to determine the number of staff required to care for people safely. On the day of our inspection, the registered manager and deputy manager were on duty. The staffing arrangements were sufficiently flexible so that in the event of an emergency, there were enough staff to cover the emergency and routine work of the service.

This was an unannounced inspection that took place on 31 March 2016.

21 Lucerne Road is a family run home which provides care for up to four people with learning disabilities. On the day of our inspection there were three adult males living in the home.

The home had 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.

At our last inspection in February 2015, we found there were inadequate systems in place to ensure people received their medicines safely, appropriate checks were not conducted on staff before they began to work with people and staff were not receiving regular supervision or appraisal. We also found that people were not involved in the care planning process and people’s care plans were not up to date. There were not effective systems in place to monitor the quality of care people received. We asked the provider to take action to make improvements. The provider sent us an action plan and this action has been completed.

During this inspection people told us they were satisfied with the care they received and that they enjoyed living in the home. Relatives were also satisfied with the care provided. Staff had formed good relationships with people. The staff team were caring, attentive and provided the care and support people needed in a kind and friendly way.

Staff were knowledgeable about the people they supported. They had appropriate skills, training and were focused on providing individualised care. Staff were further supported through induction, supervision and the opportunity for career advancement.

There were appropriate arrangements in place to help ensure people received their medicines safely. Appropriate checks were conducted before staff began to work with people. People's care was planned to minimise the risk of foreseeable harm.

People were encouraged to discuss their health needs with staff and were supported to access community based healthcare professionals. People were protected from nutrition and hydration associated risks with balanced diets which also met their preferences.

The home was clean and provided a safe environment for people to live and staff to work in.

We spoke to two of the three people using the service. They told us they had care plans and they had a key worker. They had regular meetings with their key workers to talk about what was in their care plans. They told us staff treated them with dignity and respect and they felt safe living at the home. One person told us they knew how to make a complaint if they needed to and the home would do something about their complaint.

We observed positive interactions between staff and people using the service during the course of our visit.

We spoke one person who uses the service. They told us that they liked living at the home, staff were very nice, they knew how to make a complaint if they needed to and they were able to make choices and their choices were respected.

We observed positive interactions between staff and people using the service during the course of our visit.

People who use the service had limited or no verbal communication skills however each person had a communication profile indicating their method of communicating that they and members of staff understood.

We spoke one person who uses the service. They told us that they were happy living at the home and staff treated them with dignity and respect.

We observed positive interactions between staff and people using the service during the course of our visit.

This inspection took place on 4 and 17 February 2015 and was unannounced.

21 Lucerne Road is a small family run care home that provides accommodation and personal care for up to four adults with learning disabilities. Three people were using the service at the time of this inspection.

We last inspected 21 Lucerne Road in May 2014. At that inspection we found the service was meeting all the regulations that we assessed.

There was a registered manager in post at the time of our inspection. 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 2008 and associated Regulations about how the service is run.

People we spoke with said they felt safe living at 21 Lucerne Road and were treated with dignity and respect by the registered manager and her staff team.

Safe practice was not being followed when giving medicines to people and keeping up to date accurate administration records.

Recruitment procedures did not fully make sure that people using the service were protected from risks associated with receiving support from unsuitable staff.

Staff received mandatory training to help them carry out their role effectively however supervision and appraisal sessions were not taking place consistently. Staff were not familiar with and had not received training on the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).

People were supported to see health care professionals as required to help ensure their health needs were met. They could choose what they wished to eat and drink.

Care records were kept however these were not always up to date and did not fully document the care and support being provided to each individual.

The systems in use to monitor the quality of the service or to drive improvement were not effective.

There were limited opportunities for people, their relatives or friends to be involved in or consulted about the way the service ran.

The registered manager had failed to notify CQC of an allegation of abuse as required by law.

You can see what action we told the provider to take at the back of the full version of this report