Inspection on 06/02/07 for Caxton Lodge

This inspection was carried out on 6th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Caxton Lodge 01/06/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Caxton Lodge North Road Ripon North Yorkshire HG4 1JP Lead Inspector David White Key Unannounced Inspection 6th February 2007 09:00 Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caxton Lodge Address North Road Ripon North Yorkshire HG4 1JP 01765 604418 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) info@homestogether.net www.homestogether.net Homes Together Ltd Position Vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category LD may also have associated physical disability and/or a sensory impairment 1st June 2006 Date of last inspection Brief Description of the Service: Caxton Lodge is registered to provide residential, personal, and social care for ten service users with learning disabilities, some of whom may also have an associated physical disability and/or a sensory impairment. The home comprises of a large Victorian building, which has been extensively modernised. The home is situated near to the town centre of Ripon to which service users have access via the home’s minibus. Communal facilities such as lounge and dining room are located on the ground floor. Service users’ bedrooms are situated on the ground and first floor. The There is no lift to the first floor so only those service users who have good mobility have rooms on that level. Homes Together Ltd, which owns the service, provides information to service users in their Statement of Purpose and Service User Guide. Fees charged by the home are from £750 to £ 1,200 per week with additional charges made for holidays, toiletries, hairdressing and chiropody services. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit undertaken on 6 February 2007. This visit was carried out by one Regulation Inspector and took 7 hours with 5 hours preparation time. Surveys were sent out and received from six relatives, one health professional and a Care Manager. The report includes information from the Regulation Inspector’s inspection record, which details the history of the home and relevant information about what has been happening in the home since the previous inspection visit. The site visit included an inspection of the premises. The visit involved looking at three service users’ care records, including service users’ assessments, care plans and medication records. Staff rotas, accident records and health and safety documentation were inspected. A service user, two members of care staff, the maintenance manager and the manager talked about their experiences in the home and time was spent observing the interaction between service users and staff. The focus of the inspection was on a number of key standards and inspecting the case records of a number of residents to establish whether they corresponded with their experiences of life in the home. The manager was available throughout the inspection as was a director of the organisation for some of the time and the findings from the site visit were discussed with them both at the end of the visit. What the service does well: Service users are encouraged as much as possible to be independent and to make their own choices about how they live their lives. A number of service users benefit from a structured activity programme and this enables them to have involvement with the local community. Service users are supported in attending their activities and health care appointments by an activity organiser and other members of the staff team so making sure that service users health care and social needs are met. A service user said that staff are “helpful” and respect his privacy. The home is very clean, bright, comfortable and spacious and this provides a pleasant environment for service users to live in. Service users are encouraged to be involved in decision making about how the home is run in their best interests. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care planning information must be more specific and detailed so that staff are given clear guidance about the actions they need to take in order to meet a person’s needs. The home’s medication policy needs to include information about controlled drugs so that staff are aware of the procedures that need to be followed and the arrangements that need to be put in place if they are to be used in the home. The medication policy also needs to include more detail about the use of homely remedies in the home so that staff have the proper guidance and are able to follow procedures in making sure that the service users’ health needs are being met safely and their interests are safeguarded. The registered person must take action to clarify issues around the use of homely remedies for one particular service user in order to protect the service user’s interests and meet their health needs. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 7 All staff must have updated fire safety, first aid, food hygiene and moving and handling training so that service users are not at risk from poor working practices. Staffing levels need to be improved on an evening and at the weekend in order to make sure that all service users’ needs are being met. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Proper pre-admission procedures are in place so that prospective service users can feel confident that their needs will be met by the home. EVIDENCE: The home has not had any admissions since the previous inspection visit. However in the past proper pre-admission procedures have been followed. A number of the service users moved into Caxton Lodge from other homes that are owned by Homes Together Limited. Prior to this happening the service users were able to visit the home and make a choice as to whether they wished to live there. Reassessments of service users’ needs were also undertaken to make sure that the home was suitable for meeting their identified needs. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ are encouraged to be independent and make their own choices, however, improvements are needed to the care planning documentation in order to make sure that their needs are fully understood and met. EVIDENCE: Service users’ looked well cared for and a service user said staff are “helpful and supportive”. The service user also said that he is encouraged to make his own choices about his daily routines and felt that the staff helped to encourage his independence. Each service user has an individual care plan that identifies the person’s needs and how these are to be met. The quality of the care planning documentation varies. In some cases the information is informative and detailed, however some of the care records are not as detailed and do not provide specific information to staff about the actions they need to take to Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 11 meet the person’s needs. In the care records there is some good information about how the service user is trying to communicate through individual behaviours and what staff should do to respond to this. One service user communicates using Makaton and there is Makaton signing information in the service user’s records to instruct staff how to communicate with this individual and observation showed that staff are able to do this effectively in meeting the service user’s needs. A range of risk assessments are in place to promote service users’ independence and safety and on the whole provide adequate information although in one care record the information is basic in providing staff with guidance on how to manage one service user’s challenging behaviour. Although the care records and risk assessments are reviewed this needs to be done on a more regular basis so that any changes to the service users’ needs can be identified and acted on. It is the intention of the management to introduce new care planning documentation into the home in the form of “Individual Service Plans” which will focus more on how each individual service user wishes to be cared for and takes into account the views of others involved in their care such as relatives and care managers. The new documentation will provide more detailed information about each service user in order to maximise their potential to develop their skills and to meet their needs, however this has yet to be implemented. The home has daily records to reflect activities and these are kept up to date and include input from other healthcare professionals. Observation of the care practices in the home showed that service users are encouraged as much as possible to make their own decisions and choices. One service user has an advocate. There has been a recent incident at the home in which a service user was threatening towards other service users. This had led to the service user moving into a more appropriate environment in one of the other organisation’s homes until a re-assessment of the service user’s needs has taken place. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy their lifestyles and have opportunities to have involvement with the local community. EVIDENCE: Service users are encouraged to enjoy a varied lifestyle with the support of the staff team and each service user has an individual activity programme. In some cases service users prefer to spend time alone in the home and the staff team respects this. Due to their complex needs some of the service users prefer a lot of structure to their day and tend to like to do the same things from day to day. One service user who likes having his own personal space was observed to be sitting quietly listening to music for long periods but accessed staff when he wanted some support. Other service users are involved in various community settings such as attending local day centres and social Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 13 clubs and being involved in such things as computers, music and arts and crafts where appropriate. One service user enjoys horse riding and there are visits to the local pub, gym and swimming baths. At the time of the site visit one service user was having a piano lesson from a member of the local cathedral. The activities are co-ordinated by an activities organiser who is employed to work at the home. She supports service users in getting to day centres and other daytime activities. The home has a minibus to help facilitate this and to enable staff to take service users on day outings. Most of the activities are planned for during the week when there is more staff on duty whilst the weekends are quieter with fewer activities on offer. The home has flexible visiting times and residents are encouraged to maintain their friendships and relationships with family and friends. One service user goes home to see his family for a month in the summer. Relative surveys indicate that they still feel that the home could do more to communicate important matters about their relatives with them. At the time of the site visit the manager was in the process of sending letters out to all relatives to keep them updated about a number of aspects in the home and correspondence in the care records shows that some information has been sent to relatives to inform them of care issues regarding their relatives. Observation of the care practices in the home indicates that the service users’ rights are respected. They have keys for their own bedrooms and lockable facilities within the bedroom to store valuables and other personal items. A service user said that he was able to have privacy whenever he wanted and this could be observed at the time of the site visit. Service users feel that the quality of the food is “good” and they are able to choose an alternative meal if they do not like what is on the menu. Some service users cook for themselves using the microwave oven with the support of staff. Fresh meat and vegetables are supplied to the home from a local farm and a weekly shop is done at the local supermarket for other foods. One service user is a diabetic and has a specialist diet. A diabetic nurse who sees the service user every month has provided the home with good guidance on what types of food should be given to meet specialist dietary needs. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ receive the support they prefer and have access to heath care services, however improvements are needed to staff’s understanding of medicines, medication policies and practices to make sure that the service users’ health needs are met safely and their interests are safeguarded. EVIDENCE: Each service user is registered with a General Practitioner through whom specialist services are accessed. Service users receive support from staff in attending dental and other health care service appointments. A number of service users have been assessed by the local Physical Disabilities Team to look at ways of supporting service users with their communication, mobility and independence. One service user who was experiencing increasing anxiety problems has had some involvement from a psychiatrist. Since the previous inspection visit the commission has received a concern from a relative that the home had not acted to address a health problem with a relative living at the Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 15 home. The care records show that service users are referred to a doctor if they have a health problem and are supported in attending appointments by the staff team. Records of input from health care services are clearly evident in individual service user’s care records. The Medication Administration Records show that all service users are receiving their medication as prescribed. At the previous inspection visit one service use was getting up late in a morning and so was not getting his prescribed medication and this matter has since been addressed satisfactorily. Since the previous inspection visit all staff who administer medication in the home have been provided with medication training by Boots. There are concerns about some aspects of the medication procedures. Staff incorrectly thought one type of medication was a controlled drug and although this medication was being stored in a separate container, it was located alongside other service users’ medication. There were no special recording arrangements in place for the administration of any controlled drug and no systems in place for the monitoring of controlled drug supplies. This indicates that staff would not know the procedures to be followed if a service user was prescribed a controlled drug and this could lead to service users being at risk from not receiving the proper medication. The home does have their own medication policy but this is brief and does not include information about the administration and storage of controlled drugs. In another case one service user is receiving homely remedies that are being brought into the home by a relative. The medication records show that the service user is receiving a number of these homely remedies on a regular basis. The manager made comments that the service user’s GP had been consulted about the use of the homely remedies but this is not recorded anywhere. There is no guidance for staff as to how often a homely remedy has to be used before the matter is referred to a doctor as the frequent use of a homely remedy could indicate that the service user has a health problem. The service user has some verbal communication difficulties and there is no information in the records about the service user’s agreement in the use of the homely remedies. All these issues need to be addressed to make sure that the service users’ health needs are being properly met and to safeguard their interests. The home’s medication policy briefly mentions homely remedies but needs to be more detailed to provide staff with all the necessary guidance. It is also recommended that the home should seek advice from their supplying pharmacist about their medication systems and procedures. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear complaints and adult protection policies and procedures are in place and understood by the staff to safeguard the interests of residents. EVIDENCE: The home has a complaints procedure that details how complaints are dealt with. The complaints procedure is available in alternative formats to meet the needs of the service user group. Because of the complexity of some of the service users’ needs it is unlikely that they would all be able to use the procedure, however staff feel confident that they would be able to recognise if a service user was unhappy or dissatisfied about something and would take actions to address this. Since the previous inspection visit the commission has received one complaint from a service user which the registered provider was asked to investigate. The registered provider was able to provide information to the commission to show that they had followed their complaints procedures in carrying out their investigation and appropriate actions were taken to resolve the issues from the complaint. Three surveys received from relatives indicate that they are not aware of the home’s complaints procedure. As mentioned earlier in the report under the heading of lifestyle, the manager is sending relatives updated information about different aspects of the home and this includes a copy of the home’s complaints procedure. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 17 The home has a policy and procedure in place for the protection of vulnerable adults and staff have received abuse awareness training. A member of staff made comments that discussion about adult protection issues had taken place the previous day in a staff meeting so that staff are kept updated on how to recognise and respond to abuse. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, comfortable and safe environment. EVIDENCE: Accommodation is over two floors and can be only reached by stairs so people with mobility problems would need to be located on the ground floor. There is ramped access to and from the home to accommodate people who have mobility difficulties. Furniture and fittings throughout the home are modern and suitable for the service user group. Aids, adaptations and call bells are in place to support the service users’ needs and to help maintain their independence. The bedrooms are personalised, generally spacious and mostly have en-suite facilities. A service user said that he likes his accommodation and has a key for his bedroom so this offers him the chance for some privacy. The gardens areas are large and spacious and the main garden area has a greenhouse. A lot of the service users enjoy gardening as part of their Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 19 activities and it is intended that the greenhouse will enable service users to pursue their interests in this. However access to the greenhouse and garden lawn is currently limited for people with mobility problems and this is supported by the views of two relatives’ in surveys received from them. The management of the home are well aware of these problems and have arranged for a local firm with specialist experience to begin work on the garden next month to improve access to the garden areas for all service users. This firm will also be responsible for the upkeep of the gardening work once the initial work is completed. The home is very clean and tidy and a cleaner is employed to maintain standards of cleanliness in the home. There are separate laundry facilities where service users’ personal clothing and bed linen are looked after. The kitchen is well maintained and regular checks are carried out to promote safe food hygiene practices. The home has a fire risk assessment in place and it is recommended that the manager seek guidance as to whether this meets fire safety requirements. Since the previous inspection visit door release mechanisms have been fitted to the fire doors so that none of the fire doors are now wedged open by unauthorised means. The home has systems in place for the monitoring of hot water temperatures and any problems are referred to the maintenance manager for the organisation. A random check of the hot water temperatures in two bathroom areas found that these both slightly exceeded safe limits. The manager contacted the maintenance manager immediately and the necessary work was completed. A further check of the water temperatures was then carried out and found to be satisfactory. The home has an ongoing programme of re-decoration and refurbishment. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been improvements in the home’s recruitment procedures and staff now receive training that is more specific to the service users’ needs. However staffing levels need to be improved and some staff need updated health and safety training to make sure that service users needs are being met safely. EVIDENCE: The duty rotas show that there is a sufficient number of staff on duty at all times during the day. In the afternoon and at weekends there tends to be not as many staff on duty. The last month of the duty rotas show that there are usually three staff on at weekends, however on occasions there has only been two staff on duty to care for eight service users. Two service users are in need two staff to support them in going out so this is difficult if staffing levels are depleted. Comments from relative surveys also indicate that there is a need for more staff and staff said that it could be difficult meeting all the service users’ needs when there is only two staff on duty. The management of the home are aware of the need for more staffing and it is their intention to increase the Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 21 staffing numbers on an evening and at weekends. Advertisements for vacant posts have been met with a “positive response” and it is intended that an “enabler” will also be employed to specifically support service users with activities. Three staff records show that proper recruitment checks are now being followed and since the previous inspection visit the home has always obtained two written references and all the other required records before offering employment to prospective employees. Through discussion with staff and by looking at the training records it is clearly evident that there has been a lot of improvement in the specialist training being offered to the staff team This includes training in autism awareness, visual impairment awareness, managing challenging behaviour and non-violent crisis intervention and staff said this had given them a better understanding of the needs of the service user group. New staff receive induction through the organisation’s Mulberry House programme which covers a number of aspects of care practice and the home is in the process of introducing the Common Standards Framework which is used nationally for new employees in care settings and which aims to provide staff with a good basic knowledge of care practices and principles. The home has an ongoing commitment to NVQ training and most of the staff have either competed or are in the process of completing the training. The training files show that a number of staff are in need of updated first aid, food hygiene, moving and handling and in particular fire safety training to make sure they are aware of and up to date with good working practices on order to safeguard the service users’ interests and maintain their safety. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home are developing the service to improve the lives of the service users and this could be helped further by improvements to the home’s quality assurance systems. EVIDENCE: The manager of the home has been in post for five months. He has a lot of management experience in the care sector and is doing the Registered Manager’s Award to enhance and develop his management skills further. Staff describe the manager as “approachable” and feel that the home is “going in the right direction” and that staff training has improved since the manager’s Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 23 appointment. The manager has started the process of applying to register as the manager of the home to the commission. The home is looking at ways of seeking the views of others about the care and services on offer at the home as part of their quality assurance systems. A questionnaire has been developed for relatives and an accompanying letter is to be sent out informing relatives about different aspects of the home and reminding them of how to raise any concerns. However, as yet these actions have not been taken and this needs to happen so that relatives and others views are taken into account in order to improve the care and services on offer at the home. Staff and service user meetings are held and recorded on a regular basis and people’s opinions and views are encouraged. Records from the meetings show that staff and service users are informed about any changes that affect the home. Whilst there are a number of policies and procedures available in the home these are in need of updating to reflect good practice and current legislation. A director of the organisation who was present for some of the site visit commented that there are plans to undertake reviews of all the home’s policies and procedures in the near future. The home has a number of health and safety policies and procedures to promote a safe environment for residents, relatives and visitors to the home. A random selection of the required health and safety certificates are up to date and satisfactory. Proper health and safety checks are in place to promote fire safety and there is a range of general risk assessments to support the safety of the premises. All staff receive a range of health and safety training although some are in need of updated training to promote safe and good working practices. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 2 X X 3 X Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The registered person must put in place measures to make sure that all care plans are specific in detailing how identified needs are going to be met so that staff are clear about the actions they need to take to meet these needs. • The registered person must make arrangements so that staff are fully aware of which prescribed medicines are controlled drugs. The registered person must have guidelines within the home’s medication policy about the arrangements for the recording, handling, safekeeping, safe administration and disposal of controlled drugs. The registered person must provide clear guidance for staff about the use of homely Version 5.2 Page 26 Timescale for action 06/03/07 2. YA20 13, 17 06/03/07 • • Caxton Lodge DS0000064853.V325654.R01.S.doc remedies in the home in order to make sure service users’ health needs are safely met and their interests are safeguarded. 3. YA20 13 The registered person must take action to address the issues around the use homely remedies for a service user who was identified at the time of the site visit, in order to make sure their health needs are being met and their interests are safeguarded. The registered person must take action to make sure that staffing levels are sufficient at all times in order to meet all the service users’ need. 06/03/07 4. YA33 18 06/04/07 5. YA42 18 The registered person must 06/03/07 make arrangements for all staff to have up to date training in fire safety, moving and handling, food hygiene and first aid so that service users are not at risk from poor working practices. Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The registered person should make sure that care plans and risk assessments are reviewed on a regular basis so that changing needs can be addressed. The registered person should seek guidance from the supplying pharmacist about the home’s medication systems and procedures. The registered person should seek guidance from the fire authority about the home’s fire risk assessment to make sure that proper measures are being taken to promote fire safety in the home. Further improvements are needed to the home’s quality assurance system so that the methods for seeking the views and opinions of relatives and professionals visiting the home are implemented. 2. YA20 3. YA24 4. YA39 Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Caxton Lodge DS0000064853.V325654.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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