Care Home: Caxton Lodge

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What the care home does well Staff encourage people to be independent and to make their own decisions. This enables people to have control over their lives. Staff are respectful to people and sensitive in meeting their needs. This helps in making sure people receive care in the way they prefer. The home now has a settled staff team so that people receive consistent care from staff who know them well and have a good understanding of their needs. The environment is homely, clean, comfortable and suitable for the needs of the people living there. The atmosphere is relaxed and friendly and there is a lot of good humour and banter between people living in the home and staff. This makes the home a happy and pleasant place to live. These are some of the comments made by people who live at the home, relatives of people living at the home and health and social care professionals: "Staff are helpful and supportive you can have fun with them and they are also patient". "The new manager has to be congratulated for the work she has done in addressing the concerns we had about the care of our son. There has been masses of improvement to the service and is completely different now. I am really impressed". "The problems that the home initially have been resolved. The new manager has worked hard to formalize relationships with families, there is now a much needed consistency for people living at the home". "My son is much brighter and has become much more independent". "The home has been turned around it is 100% better than it was, the quality of life for my client has improved. He now goes out to activities and went on holiday recently". What has improved since the last inspection? The home has reviewed the way in which information is now gathered and kept about people living at the home. This now means staff can provide support in a way that people need and prefer. It also means staff have in depth knowledge and understanding about each individual person and so encourages them to develop skills and experiences safely. The home`s manager has introduced better working systems for staff that are consistent for the people that live at the home. There has been much work in"building good positive relationships with families and much needed consistency for the people living at the home". Improvements are being made to the environment. The downstairs bathroom is being converted to a wet room. This will mean that people in wheelchairs can access a shower more easily. The Quality assurance system that is in place has improved and is much more effective. It is based on seeking the views of people living at the home and all interested parties. What the care home could do better: There was nothing that the inspector identified that the home could do better. There were no requirements or recommendations made following this visit. CARE HOME ADULTS 18-65 Caxton Lodge 10 North Road Ripon North Yorkshire HG4 1JP Lead Inspector Irene Ward Key Unannounced Inspection 18th March 2008 09:00 Caxton Lodge DS0000064853.V352992.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.V352992.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.V352992.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caxton Lodge Address 10 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 Vacant Post Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Learning disability - Code LD The maximum number of service users who can be accommodated is: 9 Service users in the category LD may also have associated physical disability and/or a sensory impairment 29th November 2007 2. 3. 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 £1,100 to £ 1,300 per week with additional charges made for holidays, some activities, toiletries, and hairdressing and chiropody services. The home has a statement of purpose that explains the aims, objectives and philosophies of the home. The most recent inspection report is made available to anyone who wishes to see it. Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use the service experience good quality outcomes. The Commission for Social Care Inspection inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk We went to the home without telling them that we were going to visit. This report follows the visit that took place on the 18th March 2008. The visit lasted for 5 hours. The purpose of the visit was to make sure that the home was operating and being managed in the best interests of people living there. Information has been used from different sources for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager in the Annual Quality Assurance Assessment questionnaire. Telephone discussions with three relatives, one health care professional and two care managers. During the visit time was spent talking to two people who were in at the time. One person who lived at the home and someone who was staying at the home on a temporary basis, one member of the care staff, the manager and one of the directors of the organisation. Documentation and records were also looked at as part of the site visit and time was spent observing the interaction between people at the home and staff. This all helped to gain an insight into what life is like for people living in the home. The manager was available throughout the site visit and the findings were discussed with her at the end of the inspection. Verbal feedback was given by telephone to the manager on the following day from the site visit. Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has reviewed the way in which information is now gathered and kept about people living at the home. This now means staff can provide support in a way that people need and prefer. It also means staff have in depth knowledge and understanding about each individual person and so encourages them to develop skills and experiences safely. The home’s manager has introduced better working systems for staff that are consistent for the people that live at the home. There has been much work in Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 7 “building good positive relationships with families and much needed consistency for the people living at the home”. Improvements are being made to the environment. The downstairs bathroom is being converted to a wet room. This will mean that people in wheelchairs can access a shower more easily. The Quality assurance system that is in place has improved and is much more effective. It is based on seeking the views of people living at the home and all interested parties. What they could do better: 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.V352992.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.V352992.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People can be confident that the home can meet their needs. This is because people are properly assessed before being admitted into the home. EVIDENCE: The records showed that the home carries out detailed pre-admission assessments when referrals are made to the home. They visit people and get information from relatives and other professionals to help them decide if they will be able to meet people’s needs before a place is offered. The manager said that three people from one of the organisations other homes, were moving into Caxton Lodge and assessments have already started. People are also invited to visit the home to look around. People who stay at the home on a temporary basis are also assessed before they come to stay. This also is to make sure that the person coming to stay will be able to mix with other people in the household and benefit from their stay. Caxton Lodge DS0000064853.V352992.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are encouraged to be independent and make their own choices and are supported by a committed staff team. EVIDENCE: People looked well cared for and one person said staff are “helpful and supportive you can have fun with them and they are also patient”. They also said that they are encouraged to make their own choices about daily routines and felt that the staff helped to encourage their independence. Each person has an individual plan of care detailing their individual needs and the actions that staff need to follow to meet these. People spoken to said that they are encouraged to be independent and to make their own decisions about how Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 11 they live their lives. The quality of the care planning documentation has improved since the last inspection. Care plans are now informative and detailed and provide specific information to staff about the care that people require. Care plans showed that people are encouraged as much as possible to make their own decisions and choices. At the last inspection care plans identified people’s behaviours but did not say how staff were to manage a person’s behaviour. Care plans have also been improved in this area and include how people’s behaviours are to be managed consistently by the staff team. Care plans are reviewed regularly. Also present were a range of risk assessments with the purpose of supporting people to live as independently as possible with safeguards in place, these were reviewed regularly. Policies and procedures have commenced to be put in Braille. The home records in care plans what activities people participate in and these are kept up to date and include input from other healthcare professionals. Observation of the care practices in the home showed that people continue to be encouraged as much as possible to make their own decisions and choices. Whilst staff were supporting people during the day it was clear they understood individuals needs. They supported people sensitively and encouraged them to make choices. Everyone looked well cared for and made positive comments about the care they received when spoken to. One relative spoken to said, “ The new manager has to be congratulated for the work she has done in addressing the concerns we had about the care of our son. There has been masses of improvement to the service and is completely different now. I am really impressed”. Another said, “ A huge improvement has been made”. One care manager said, “The problems that the home initially have been resolved. The new manager has worked hard to formalize relationships with families, there is now a much needed consistency for people living at the home”. Caxton Lodge DS0000064853.V352992.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are able to make choices about their lifestyle and are supported by staff to carry these out. EVIDENCE: People living at the home are encouraged to enjoy a varied lifestyle with the support of the staff team and each person has an individual activity programme. In some cases people prefer to spend time alone in their own rooms and the staff team respects this. Due to their complex needs some people prefer a lot of structure to their day and tend to like to do the same things from day to day. Two people who were in at the time of the site visit were sitting together listening to music and talking to one another. Other people are involved in various community settings such as attending local day Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 13 centres and social clubs and being involved in such things as computers, music, baking and arts and crafts where appropriate. One person enjoys horse riding whilst another attends accordion practice and there are visits to the local pub, bowling, gym and swimming baths. In-house activities such as bubble painting have been introduced. Once a week people enjoy a take-away meal. The home has a minibus to help facilitate this and to enable staff to take people 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 allowing people to either “chill out” or some go home to their families for the weekend. Two people like to e-mail home their weekly programme keeping families informed of what they are doing. Three people had recently been on a holiday to Blackpool. People when asked what it was like living at the home said, “it’s good you get to go out more to the pub and to socialise”. One relative said, “My son is much brighter and has become much more independent”. Another relative said, “ My son now has routines and goes to various activities”. A community nurse said, “The home has been turned around it is 100 better than it was, the quality of life for my client has improved. He now goes out to activities and went on holiday recently”. The home has flexible visiting times and people are encouraged to maintain their friendships and relationships with family and friends. People living at the home have their rights respected. They have keys for their own bedrooms and lockable facilities within the bedroom to store valuables and other personal items. Two people said that they were able to have privacy whenever they wanted and this was observed at the time of the site visit. People when asked felt 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. One person does their own menu in Braille. Some people cook for themselves using the microwave oven with the support of staff. One relative gave one example of how things have improved at the home. She said her son now makes his own supper although it may take him sometime, previously staff would have done it for him. The relative said this has given her son much more independence. People requiring special diets such as diabetics are provided for. Dietary needs assessments have been completed for everyone living at the home. Caxton Lodge DS0000064853.V352992.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s personal and healthcare is provided appropriately and sensitively according to individual needs. EVIDENCE: Each person living at the home is registered with a General Practitioner through whom specialist services are accessed. People receive support from staff in attending dental and other health care service appointments. A number of people have been assessed by the local Physical Disabilities Team to look at ways of supporting them with their communication, mobility and independence. Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 15 There had been a number of problems at the home regarding health care issues raised by one relative. This was looked at during the last inspection. It was identified that the home was not clear about how to manage the welfare of this person, as the information they held was not comprehensive enough. The home’s management team have taken steps to address the issues by introducing systems that staff all follow consistently to make sure that people’s health and welfare are constantly monitored and records that are more detailed. This makes sure that people ‘s health is not put at risk. One relative commented that they have had concerns over the last two years that their son had not received appropriate psychiatric support. However the home has now employed a consultant psychiatrist on a temporary basis to address this. The organisation has employed someone to look at people’ s nutrition. This will also include training for staff, specifically looking at health and nutrition for the people they provide care and support. The home operates a monitored dosage system. There is a policy in place for the storage and administration of medication this has been recently updated. The Medication Administration Records show that everyone receives their medication as prescribed. The Medication Administration Records were up to date and well maintained. Medication seen in the home was securely stored in a locked cabinet. The home does not hold any controlled drugs at the moment. All staff that administers medication in the home have been provided with medication training by Boots. Caxton Lodge DS0000064853.V352992.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Clear complaints and adult protection policies and procedures are in place and are understood by staff which safeguards the interests of people living at the home. EVIDENCE: The home has a complaints procedure that details how complaints are dealt with. The complaints procedure is available in alternative formats including Braille to meet the needs of the people living there. Because of the complexity of some of people’s 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 someone was unhappy or dissatisfied about something and would take actions to address this. When people were asked whom they would speak to if they were worried or had a complaint they said “staff”. Since the last key inspection relatives and the local authority’s Behaviour Support Team raised a number of concerns. These were health care needs of people living at the home, appropriate staffing levels, staff training, poor communication between staff and people living at the home and poor Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 17 management. These have all been addressed and improvements have been made by the introduction of good working practices by the new manager of the home. Since then, relatives spoken to have said that they are now much happier with the care at the home, however they still have concerns that the home could slip back to how it was if there are any changes made to the management of the home or if staff leave. One relative said, “ The new manager has worked her socks off to improve things. In the past there have been constant changes, what it needs now is some continuity”. One care manager said, “It is still early days, although it has improved. My client is more than happy and likes it there. The manager has been brilliant”. Another care manager said, “One year ago my clients family had concerns about the home. They felt that there relative’s health care needs i.e. psychiatric involvement was not being met. Since the new manager came into post things have massively improved and now my client has had the support they needed, and has become less agitated”. The home has a policy and procedure in place for the protection of vulnerable adults and staff have received abuse awareness training. This makes sure that people living at the home are protected from abuse. Caxton Lodge DS0000064853.V352992.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People live in a clean, comfortable and safe environment EVIDENCE: The home provides spacious accommodation for people. Accommodation is over two floors and can be only reached by stairs so people with mobility problems are 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 people who live there. Aids, adaptations and call bells are in place to support people’s needs and to help maintain their independence. The bedrooms are personalised, generally spacious and mostly have en-suite facilities. There are seven bedrooms that have en-suite toilet and wash hand basin. Three bedrooms have Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 19 en-suite showers. The gardens areas are large and spacious and the main garden area has a greenhouse. The home continues to be very clean and tidy and a cleaner is employed to maintain standards of cleanliness in the home. There are separate laundry facilities where 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. A range of maintenance checks is completed on a regular basis to make sure that the house is safe and secure. People spoken to on the day that live at the home all said that they liked their rooms. On the day of the site visit there were workman working in the downstairs bathroom. The manager said that the existing shower was being removed and it being turned into a wet room with a bath. This would meet people’s needs that currently live in the house. Also repairs were being made to the flooring between the kitchen and dinning room that had been damaged. Caxton Lodge DS0000064853.V352992.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): 32,34 and 35. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Sufficient staffing levels, proper recruitment procedures and good staff training meant that people’s needs are met and their interests were safeguarded. EVIDENCE: Staffing levels were sufficient for meeting the needs of the people living at Caxton Lodge. The manager said that staffing levels had been increased .The duty roster showed that there were four members of staff on duty throughout the day when people are at home. This did not include the manager’s hours. At night there is one staff that sleeps on the premises and one waking night staff on duty each night. The organisation operates an on-call service in case there is an emergency. All the homes managers are on a rota and take it in turn. The on-call service operates from 8.00 pm to 8.00am on the following day. Both the directors of the organisation are also contactable in cases of emergency. Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 21 The staff records of three staff including a recently appointed member of staff were looked at. These showed that all the necessary pre-employment checks had been carried out prior to the new workers starting in post. All records showed completed application forms, two written references, CRB (Criminal Record Bureau) checks had been obtained. A POVA (Protection of Vulnerable Adults) first check had also been carried out. The home provides all the mandatory training that is required. A range of other training has been completed by staff such as working with challenging behaviour and autism. This provides staff with the knowledge and skills to perform their duties in a competent manner. Staff confirmed in discussions held with them that they received regular supervision and regular staff meetings are held. Records of supervision were seen at the site visit to the home. Comments made by relatives and health and social care professionals have been positive. A health care professional said, “the home has been turned around and is 100 better to what it was”. One relative said, “The staff are very positive now, there used to be a lot of agency staff where as now there are more permanent staff”. Staff confirmed in discussions held with them that they received regular supervision and regular staff meetings are held. Records of supervision and of staff meetings were seen at the site visit to the home. Caxton Lodge DS0000064853.V352992.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 and 42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The management of the home has improved making sure that people’s best interests are promoted at all times. EVIDENCE: The manager of the home has been in post for eight months. She has a lot of management experience in the care sector and has NVQ (National Vocational Qualification) Level 4 and the Registered Manager’s Award. Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 23 Caxton Lodge now has a good and effective management team that has developed and promoted good practice in the best interests of the people that live there. The ethos and philosophy is now open and positive. People who live at the home, relatives and care managers commented highly about how the home has improved. And how much work the manager and the staff team have put in. All accidents are recorded as required and an accident book is maintained in line with the requirements of Data Protection. People’s finances were not checked at this site visit. Historical evidence from previous reports gives evidence that their financial interests are safeguarded. Regular house meetings for people living at the home are in place. This gives people autonomy on how they like the home to be run. Effective quality assurance and quality monitoring systems are now in place. Questionnaires/surveys had been sent to relatives. One relative said on their survey that their relative was now “content and well cared for”. Information provided from the (AQAA) Annual Quality Assurance Assessment and the examination of selected health and safety documents show that regular checks to electricity and gas and fire safety equipment are regularly undertaken. Caxton Lodge DS0000064853.V352992.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 X 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 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 X 3 X 3 X X 3 X Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Caxton Lodge DS0000064853.V352992.R01.S.doc Version 5.2 Page 26 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.V352992.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!