Caxton Lodge is registered to provide residential care for up to 10 younger adults who may be living with a learning disability or autistic spectrum disorder, a physical disability or sensory impairment. The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

This inspection took place on 4 and 8 October 2018 and was announced. We gave 72 hours’ notice of the inspection because the location was a small care home for adults who are often out during the day and we needed to be sure people would be in when we visited. At the time of our inspection there were 10 people living there.

The service was larger than the small local community-based settings recommended for providing good quality care for people with a learning disability. The majority of people who used the service were funded by other neighbouring local authorities. Good practice guidance recommends providers and commissioners should be working towards reducing the number of ‘out of area’ placements. Despite this the provider and registered manager had taken steps to develop the service 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 using the service can live as ordinary a life as any citizen.

The service had a registered manager. They had been the registered manager since December 2015. A registered manager is a person who has registered with the 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 supported by a deputy manager and a director of care in the management of the service.

At our last inspection in March 2016, we rated the service ‘good’. At this inspection, we found improvements were needed to make sure the service was consistently safe and well-led.

Statutory notifications had not been submitted when legally required. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. We are dealing with this matter further outside of the inspection process.

The risk of choking had not been consistently well-managed. This placed people at increased risk of harm. We shared concerns regarding fire safety with North Yorkshire Fire and Rescue Service who visited Caxton Lodge. We will follow-up the actions needed to improve fire safety in more detail outside of the inspection process. We made a recommendation about developing audits and quality monitoring to more robustly monitor these shortfalls in future.

Staff were safely recruited. They were attentive to people’s needs and quick to respond during our visits when people asked. Staff supported people to take their prescribed medicines.

Detailed plans were in place to guide staff on how to safely support people who might be anxious or upset and act accordingly.

Staff completed regular training on how to effectively meet people’s needs. The registered manager used supervisions and appraisals to monitor staff’s performance and support their continued professional development.

Staff sought people’s consent and supported them to make informed choices. When people lacked the mental capacity to make particular decisions, best interest decisions had been made and documented on their behalf. The registered manger had made appropriate applications to deprive people of their liberty. This ensured their rights were protected.

The service was spacious and adapted to meet the needs of the people living there. It was a short walk to the local shops and amenitie

This inspection took place on 19 March 2016 and was unannounced. There were no breaches of regulation at the last inspection on 24 August 2014.

Caxton Lodge is registered to provide residential and personal care for up to ten people with a learning disability and an associated visual impairment. The home is a large Victorian building near to Ripon town centre. There is a garden to the rear of the property and parking for visitors and staff.

The home has 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.

We found people were cared for and supported by sufficient numbers of suitably qualified and experienced staff. Robust recruitment procedures were in place to make sure suitable staff worked with people who used the service and staff completed an induction when they started work. Staff received the training and support required to meet people’s needs.

Staff had received training in the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff ensured that people were supported to make decisions about their care where possible. People were cared for in line with current legislation and they were consulted about choices.

Staff had a good understanding of safeguarding vulnerable adults and knew what to do to keep people safe. Relatives we spoke with also told us they thought people were safe at the home. There were systems and processes in place to protect people from the risk of harm. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines safely.

People’s care plans contained sufficient and relevant information to provide consistent care and support. People’s mealtime experience was good with ample assistance available for those who required one to one help with their meal. People received good support which ensured their health care needs were met. Staff respected people’s privacy and dignity.

Staff had been responsible for encouraging and supporting people with new interests which they had benefited from. The home made a particular effort to communicate with relatives and other interested parties to make sure that people were ‘given a voice’ despite their complex needs.

People were supported to take part in activities and daily occupations which they found both meaningful and fulfilling. Relatives told us that they appreciated how staff had thought of new ways to make sure people could join in daily routines and events they could enjoy.

We were told by relatives, and we also observed throughout our visit, that people were treated with patience and kindness. Staff responded quickly to people’s changing needs and knew people well enough to know when a subtle facial expression or a sound indicated they needed assistance or support. Staff knew how best to communicate with people. This included the use of gestures, touch, key phrases and noises, which the person understood. We saw people smiling and engaging with staff. Needs were regularly monitored through staff updates and staff meetings. We saw staff had a good rapport with people and worked together as a team.

The home was kept clean and tidy and staff were trained in infection control.

People’s needs in relation to their diet were met. We saw plenty of food and drinks being made available throughout our visit. People seemed to enjoy their meals and their individual preferences had been incorporated into menus. The dining arrangements were organised to make sure people were settled and calm during their meal. This included three sittings, so that smaller groups were seated at any one time so that people could be given the indivi

Is the service effective?

We spoke with three people who used the service. They told us they were happy living in the home and were given choices as to how they spent their days. One person said “I like living here. I went out for a meal yesterday and it was nice. I play the piano twice a week” Another person described what they did on individual days and said they were very happy living in the home. Some people were unable to communicate verbally with us but we observed them doing various activities and interacting with staff.

Is the service caring?

Three people we spoke with said they were happy with the care they received. We spoke with three members of staff who gave examples of how they treated people with dignity and respect and involved people in their care. We observed staff speaking with people in a kind and caring manner and found that people were comfortable in the presence of staff.

Is the service responsive?

During our visit we looked at three peoples care plan records. Each contained assessments of people’s individual needs. We saw that any risks to people’s safety were determined and care was planned to mitigate any risks that were identified. We saw that risk assessments had been reviewed but some were not up to date. We saw that healthcare professionals were involved in people’s care and treatment when required.

Is the service well led?

The home carried out a quality assurance survey which was sent to families and other professionals involved in peoples care. We saw that families and other professionals were happy with the care. We saw that audits were carried out across areas such as medication, infection control and care records. The audits we saw demonstrated that good standards of care were in place and that any actions required were cascaded to staff for improvement.

We found that people who use the service, their representatives and staff were asked for their views on the care and treatment and they were acted on. We saw that the provider held regular meetings with people and their families.

We saw that people looked cared for. They were clean and comfortable and told us that they felt “Very well looked after". They said staff were very kind and helpful. One person said “I like the staff they make me laugh if I need cheering up".

People who lived at Caxton Lodge had access to a variety of activities that included horse riding, gym, piano lessons and shopping trips.

We saw that people had a choice of well-cooked and nutritious food. Staff monitored people's weight and recorded the food and fluid intake of people who they had identified as being at risk of dehydration or malnutrition and took appropriate action promptly.

We also found that staff received regular training and were given the support they needed to carry out their jobs properly.

We saw that the area manager undertook quality audits and worked to an action plan to resolve any outstanding matters that had been identified. They confirmed that they visited the home at least weekly. However, Caxton Lodge had until recently been without a manager and therefore they had been based there to offer managerial support and stability to the home. During the inspection we spoke with the recently appointed new manager who was undergoing an induction program. When we spoke with them they said that they had settled very well at Caxton Lodge and were looking forward to working at the service.

We spoke to three people who use the service who were able to tell us about their experiences. They told us “I’m loving it, the staff become like friends and I can’t think of anything I’m not happy with” and “It’s really nice here and they look after me.” We observed the care of people who could not talk with us. People using the service were calm and relaxed, and staff interacted with them in a nice friendly manner.

We spoke with a visiting professional from the community Mental Health team, who told us they had no concerns and thought the home provided a good service.

Staff told us they felt settled and happy in their jobs, and were well supported by their manager and area manager. Comments included “It’s a good service and the people get out and about all the time, they’re well known in the local area” and “The manager is brilliant and I really like it here.” The recently appointed manager and area manager were present for the inspection to help answer questions and advise us.

We talked with three people when we visited about the care they received and what it was like living at the home. People told us that they were well looked after and that they were happy with the care they received. One person commented “Really good here, the staff are very nice. The food sometimes is nice sometimes it isn’t” another person said “It is all right living here. The food is good. We are well looked after and the staff are all right” and another person told us “I am happy living here at Caxton Lodge. In the summer we have trips to the seaside and theme parks. Staff here are very nice”

We spoke with the two visiting accordion teachers. They told me that they had known the person they taught for sometime. They said “The staff here are lovely, there is a good continuity of staff and they are always welcoming when you visit”

We also had opportunity to speak with a visiting care manager who told us that the home had been provided her “with the best information before a review” she had ever seen. She told me that her client was more confident and was doing more things with support from staff and was overall “very impressed”

We spoke with the Local Authority Contracts Officer who informed us that they did not have any concerns about this service.