CARE HOME ADULTS 18-65
Keevan Lodge 98 Clive Road Enfield Middlesex EN1 1RF Lead Inspector
Jane Ray Key Unannounced Inspection 14th August 2006 09:15 Keevan Lodge DS0000034275.V303570.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 Keevan Lodge DS0000034275.V303570.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. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Keevan Lodge Address 98 Clive Road Enfield Middlesex EN1 1RF 020 8367 0441 020 8367 0441 SANJAYENATH@AOL.COM 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) Saivan Care Services Ltd Danwantee Bundhun-Ramsaha Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One specified service user who is over 65 years of age may remain accommodated in the home. The home must advise the registering authority at such times as the specified service user vacates the home. Date of last inspection 10th January 2006 Brief Description of the Service: Keevan Lodge is a care home registered to provide residential services for three adults with a learning disability. The home is situated in a quiet residential street close to a supermarket, restaurants and a cinema. The Enfield Town Centre is approximately fifteen minutes walk away from the home. Each bedroom in the home has a shower, a wash hand basin and a toilet. The home has a separate bathroom and a toilet on the first floor. The kitchen/diner, a lounge and one bedroom are on the ground floor. The home is not accessible for people with physical disabilities. There is a large garden at the back of the home, which service users can use for sitting and relaxing when weather permits. The home was registered on 2nd August 2003 and has admitted three service users in the time it has been open. The registered manager is Ms Danwantee Bundhun-Ramsaha. The home has no vacancies. The philosophy of the home is to to promote a positive image of people with learning disabilities and create and maintain a homely environment conducive to the delivery of care and providing comfort. The home has an aim of creating a warm and supportive environment within which quality care can be delivered according to individuals holistic needs. At the time of the inspection there were three service users living in the service. The current range of fees in the home is from £1030 - £1668 a week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place on the 14 August 2006 and was unannounced. The inspection lasted for the five hours and was the key annual inspection. The inspection looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to meet, speak to and observe the support given to two of the three current service users. The inspector was also able to spend time talking to the registered manager as well as the two members of care staff who were working in the home. The inspector did a tour of the premises and also looked at a range of records including service users records, staff files and health and safety documentation. What the service does well:
The home provides a high standard of care and support to a group of service users with a range of complex needs. The home by working consistently and professionally with the service users in partnership with other care professionals is able to support the service users to make significant progress with their personal development. The manager and staff demonstrated a good knowledge of the service users and were able to recognise their individual needs and how to respond appropriately to them. The service users are supported to have their individual needs met by a comprehensive care planning system, which incorporates ongoing review meetings. The service users are supported to access a range of educational and leisure activities based on their individual interests and this enables them to have participation in the local community. The home has a well established and stable team of staff who are being supported by a registered manager. The staff have access to a comprehensive induction and an ongoing programme of training. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 6 The home is very comfortable and homely and the service users each have a single bedroom with en suite facilities. The home also has access to a people carrier vehicle that is helpful in facilitating some of the community activities. The service users are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures, comprehensive risk assessments and health and safety procedures. What has improved since the last inspection? What they could do better:
Eleven requirements and six recommendations were made at this inspection. A requirement was made under the heading choice of home for the service to provide updated assessments for each of the service users. A second requirement was also made for the contracts between the service users and the home to all include the current fees and details of the placing authority. In addition a recommendation was made for the Service User Guide to be put into a user-friendly format. Two recommendations were made under the heading individual needs and choices. These were to ensure staff understood the key-worker role and for risk assessments and care plans to be clearly separated in the service user case notes. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 7 A requirement was made in the lifestyle section to support service users to eat a healthy diet and for problems in achieving this to be addressed through individual care plans and risk assessments. A requirement was made under the heading of personal and healthcare support for all the service users to be supported to have optical checks. Two requirements and one recommendation were made in the section concerns, complaints and protection. The first was for one service user who is unable to manage her own finances to be supported to have an appointee. The second is to ensure all staff have received training on the protection of vulnerable adults and for this training to be recorded in their training records. It is also recommended that the complaints procedure is prepared in a userfriendly format. One requirement was made in the environment section to ensure all the light bulbs in the home are working. In the section on staffing three requirements and one recommendation were made. The first was to ensure that where staff were waiting for their CRB disclosure that they only work with supervision. The second was to ensure the staff contracts contain all the necessary information including the current rate of pay. It is also necessary to confirm a date for epilepsy training with the community nurse. It was also recommended that the shift leader is clearly recorded on the rota. One requirement was made in the section called conduct and management of the home. This was to ensure all the smoke detectors in the home are working properly. A recommendation was also made to arrange the service user case notes so all the documents currently in use are available in one file. 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. Keevan Lodge DS0000034275.V303570.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 Keevan Lodge DS0000034275.V303570.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. Service users are having their complex needs effectively met by the home. Service users have been assessed but this information would benefit from being updated. Contracts between the home and the service users need to be fully completed. EVIDENCE: The inspector read the Statement of Purpose and this contained all the necessary information. The inspector also read the Service User Guide, which also contained the necessary information but would benefit from being available in a format that is accessible to the service users. The inspector read the three service user case notes. The service users all had assessments at the time of their admission to the home and the manager has provided an update of their assessment for previous review meetings. The service users would benefit from having an updated individual assessment that reflects their current needs. These assessments need to look at all aspects of each service users physical, social, cultural and emotional needs. The manager explained that there have been no service users admitted to the service since the last inspection. The service user who most recently moved to the home made a few visits and then had a trial period to see if he wanted to
Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 10 move to the service and also for the staff to confirm they could meet his needs. The inspector looked at the contract for the three service users between the home and the service user and two needed to include the current fee and one needed the details of the placing authority. The inspector observed that the staff were supporting the service users in an appropriate manner that reflected their knowledge and understanding of their individual needs. The service users were also observed to be comfortable and relaxed within their home environment. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is excellent. This judgement has been made from evidence gathered during the visit to this service. Service users are each supported to have comprehensive individual care plans and risk assessments and are working towards clearly defined goals agreed in partnership with families and other care professionals. Service users are supported to make decisions about their daily lives within the home and service user meetings take place regularly. EVIDENCE: Three service user case notes were inspected. Each service user has detailed individual care plans. These reflect the decisions made at each service users review meeting. These meetings take place with the care manager and other care professionals. These review meetings were clearly recorded and demonstrated multi-disciplinary working. The care plan goals are clear and easy to understand and are monitored on a monthly basis. These goals focus on supporting the service users to gain
Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 12 greater independence and to look a how their lives can be further enhanced by improved activities or by addressing healthcare or behavioural issues. The three service users all had a named key worker. For two of the service users the manager acts as their key worker and the third service user has a key worker who is on maternity leave. A support worker is undertaking this role but from speaking to the staff member it was evident that she did not understand fully how to carry out the role and needed further guidance. The three service users whose case notes were inspected all have complex behaviours. Each service user has a document describing these behaviours and this enables the staff to identify when the service user is distressed and what action they should take in response to this situation. The service users have restrictions in place for their own safety, for example one service user keeps his cigarettes in the office and is given a cigarette on an hourly basis. The reasons for these restrictions are recorded in their care plan, risk assessment and behavioural guidelines. Each service user has a record of the individual arrangements in place to support them to manage their personal finances. The three service user case notes inspected all included individual risk assessments covering all areas of potential risk and these identified what action the home would take in response to the identified risks whilst at the same time promoting each service users independence. These covered a number of areas including epilepsy, road safety, managing finances etc. For one service user the risk assessments were mixed in with the care plans and needed to be clearly organised. Throughout the inspection the service users were observed being consulted about decisions concerning their daily lives. This included being asked what they wanted to drink and when they felt ready to go out. One service user was able to choose to go to the shops later to buy toiletries. The record of the service user meetings was inspected. These took place on a regular monthly basis and discussed activities, feelings about the other service users and things that were happening in the home. One service user has been supported to access an individual advocate. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. The service users are supported to have full and active lifestyles. They also enjoy contact with their relatives and friends. The service users choose not to eat a particularly healthy diet and this must be addressed as part of their assessment, care plan and risk assessment. EVIDENCE: The manager explained that the service users access a range of activities based on their individual needs and interests. One of the service users attends two colleges and the other service users are supported to access local leisure and community facilities. The leisure activities offered to the service users include going to the local Gateway club and enjoying a visit to the pub or eating out on a regular basis. In addition other activities outside the home include shopping, using the gym, local walks and visiting parks. Each service user has a daily activity record and
Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 14 three were inspected and these showed that the service users were enjoying an active lifestyle and being supported to access local community resources. The manager explained that one of the service users is supported to enjoy his religion and culture by going to the temple and an Asian Community Centre each fortnight. The service users have recently enjoyed a break at Great Yarmouth at a holiday village. The manager explained that two of the service users have contact with their families. They are made welcome in the home or service users are supported to go to their family homes. At the time of the inspection one of the service users had gone to stay with his relatives. It was observed that there was a comfortable atmosphere in the home with the staff communicating appropriately with the service users. The service users were observed to be relaxed with the staff. The manager and staff explained that the routine depends on each service user and that they choose to get up and go to bed at different times. The menu for the week was inspected and this offered a healthy and varied diet. The manager explained that the service users do not follow the menu but make individual requests for what they wish to eat based in individual preferences and cultural needs. The inspector looked at the record of the food consumed and saw this was not very healthy with lots of takeaways, fried breakfasts, convenience food, sausages and burgers. The staff explained that the service users are very reluctant to change their dietary choices. This needs to be addressed in the service users assessments and care plans. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. Service users are supported to receive personal care according to their individual needs and wishes. Service users are supported to access healthcare services based on their requirements although two need to see the optician. Service users have their safety maintained by appropriate medication administration procedures. EVIDENCE: It was observed during the inspection that the service users were given support with their personal care based on their individual needs. Some just need prompting whilst others need individual support. The service users were all adequately dressed and groomed. The healthcare records were inspected for three service users. They had all been supported to access the GP and dentist for their primary healthcare checks but two needed support to access the optician. They all see the consultant psychiatrist and community learning disability nurse on a regular basis. In addition service users receive input for their specialist healthcare needs and it is also positive to note that a number of other therapy services including psychology and occupational therapy have been accessed as required for specialist advice.
Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 16 All the service users are supported to check their weight on a monthly basis. One of the service users has epilepsy and his seizures are recorded in a comprehensive manner. The medication administration records were inspected and are completed correctly. The medication entering the home is recorded appropriately on the medication administration record. There is a separate record for medication returned to the pharmacist. Some of the service users have PRN medication and there are guidelines in place for them explaining when the medication should be administered. Training records were inspected for four members of staff and they had all received medication training in the previous six months. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made from evidence gathered during the visit to this service. Service users can be confident that they will protected by a robust adult protection procedure but staff do not have a record of receiving adult protection training. The complaints procedure needs to be made available in a user-friendly format. One service user does not have an appointee for her finances even though it is recorded that she is unable to manage her own finances. EVIDENCE: The manager explained that the home has not received any complaints since the previous inspection. The inspector looked at the complaints procedure and whilst this was comprehensive it was not in a format accessible for the service users. The inspector saw that the home had the Enfield protection of vulnerable adults procedures. Staff training records were inspected for four members of staff. These indicated that none of the staff had received training on adult protection. The manager explained that she had been trained to be a trainer and had provided in house training but this had not been recorded. She also said that two staff were attending training provided by Enfield Social Services in October. The staff training records also showed that the staff had not received training on how to work positively with service users who have complex challenging behaviours. The manager explained that this training was booked in September 2006.
Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 18 The inspector looked at the personal finances for two service users. One of the service users did not have an appointee and yet her records showed that she needed assistance to manage her finances. There are records of expenditure with receipts available. The third service user is supported by his family to manage his finances and keeps his cash in his own room. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. 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 from evidence gathered during the visit to this service. The service users live in a homely, comfortable and safe environment that is clean and well maintained. Light bulbs that are broken must be replaced. EVIDENCE: The inspector did a tour of the home and looked at two of the three bedrooms. The home was clean and tidy throughout. Each service users bedroom was well furnished and was homely and personalized. The communal space consists of a lounge and kitchen / dining area. These were also well furnished and comfortable. There are adequate bathing facilities with each bedroom having en-suite facilities and a bathroom on the first floor. All the equipment in the home was observed to be in good working order apart from the light in the lounge where three of the bulbs were not working. Keevan Lodge DS0000034275.V303570.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is poor. This judgement has been made from evidence gathered during the visit to this service. The service users are supported by a stable staff team. The staff receive a comprehensive induction and have an ongoing supervision and training. Two staff recruited in the last year are working without a CRB arranged by the current care provider which places the service users at risk as they are not always supervised. EVIDENCE: The inspector looked at the staff rota. The staff team consists of a manager, deputy manager, 1 senior carer and a team of five carers. The staff turnover is very low and one member of staff has left in the last year and two new members of staff have joined the team. The manager explained that the home does not use agency staff. During the day there are one or two staff working according to the activities planned for the service users. At night there is one waking member of staff. The rota did not clearly identify who is the shift leader. The manager explained that three members of staff are studying for NVQ level 2 or 3 in care. The deputy manager is studying for the Registered Managers Award. This means that more than 50 of the care staff are studying for an NVQ in care.
Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 21 The recruitment checks were inspected for four staff and these were partly in place including two references and application form. Two of the four staff who had been recruited in the last year did not have a CRB disclosure arranged by the service. These staff according to the rota, were working unsupervised at times. Each member of staff had a signed record of their contractual details. These did not include the staff hourly rate of pay. The record of staff team meetings was inspected and these meetings take place on a monthly basis and discuss a wide range of operational issues. The induction records were inspected for four staff. These consisted of a comprehensive induction checklist to work through. These induction records were complete. The staff training records were inspected for four staff. Staff are provided with training to support them to work effectively with the service users although three of the four staff had no current record of training on epilepsy including administering rectal diazepam. The manager explained that she is trying to arrange a date for this training with the appropriate community nurse. The staff supervision records were inspected for four staff. All the staff were receiving regular individual supervision on a two monthly basis. Keevan Lodge DS0000034275.V303570.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. The service users are benefiting from living in a well-managed service where the focus is on providing a high standard of care and support. Health and safety measures to protect the service users are in place. Ongoing quality assurance monitoring systems underpin continuing self-improvement. There is scope to improve the organisation of the service user records. EVIDENCE: The home has a registered manager who has completed the NVQ level 4 in management of care and is waiting to receive the certificate. The home has completed its most recent quality assurance exercise in May /June 2006. This has included asking service users, relatives, care professionals and other stakeholders who know the home to complete questionnaires asking for feedback on the service. The results of these questionnaires have been collated and an action plan prepared.
Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 23 The home has appropriately reported any serious incidents concerning the service users to the CSCI. Fire safety measures are in place. The fire safety records were inspected and weekly fire alarm checks, fire drills and emergency lighting checks are recorded. On the day of the inspection the fire doors in the home were closed. The fire alarm and extinguishers had received their service and records were available to confirm this had taken place. The home has a fire safety risk assessment and evacuation plan. One smoke detector was bleeping during the inspection and needed to be checked. The certificates were in place to confirm the gas system and electrical installations and portable electrical appliances had been serviced. The current insurance certificate was displayed and was satisfactory. The staff training records showed that staff had received appropriate health and safety training including fire safety, first aid, moving and handling, and food hygiene. Keevan Lodge DS0000034275.V303570.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 3 2 2 3 4 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 3 x 3 2 x Keevan Lodge DS0000034275.V303570.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 YA2 Regulation 14(2)(a) Requirement The Registered Person must provide for each service user a current comprehensive assessment covering their healthcare, living skills, social, emotional, behavioural, family and cultural needs. The Registered Person must ensure each service users contract with the home contains all the necessary information including their current placement fee and details of their placing authority. The Registered Person must ensure that all the service users are supported to eat a healthy diet and where this is not possible this must be addressed in the individual care plans and risk assessments. The Registered Person must ensure each of the service users is supported to have an optical check. The Registered Person must ensure all the staff have received current adult protection training and this is recorded in their training records.
DS0000034275.V303570.R01.S.doc Timescale for action 30/09/06 2. YA5 5(1)(b) 30/09/06 3. YA17 16(2)(i) 30/09/06 4. YA19 12(1) 31/10/06 5. YA23 13(6) 31/10/06 Keevan Lodge Version 5.2 Page 26 6. YA23 12(1) 7. 8. YA24 YA34 23(2)(b) 19(1)-(5) 9. YA34 17(2) 10. YA35 18(1)(c) 11. YA42 23(4) The Registered Person must ensure that the service user who is unable to manage her own finances is supported to access an appointee. The Registered Person must ensure that all broken light bulbs are replaced. The Registered Person must ensure that staff who have not received their CRB disclosure do not work unsupervised until these documents are available. The Registered Person must ensure that each staff member has a completed contract that includes their rate of pay. The Registered Person must arrange a date for the staff to receive epilepsy training including the administration of rectal diazepam. The Registered Person must ensure that all the smoke detectors are working properly. 30/11/06 31/08/06 20/08/06 31/08/06 30/09/06 31/08/06 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. 2. 3. 4. 5. Refer to Standard YA1 YA6 YA9 YA22 YA33 Good Practice Recommendations The Registered Person should provide the Service User Guide in a format accessible to the service users. The Registered Person should ensure that the staff team fully understand the key-working system. The Registered Person should ensure that the service user records clearly show which documents are the care plans and which are the risk assessments. The Registered Person should provide the complaints procedure in a format accessible to the service users. The registered person should indicate on the staff rota their role, who is the designated person on duty and the number of hours staff are contracted to work.
DS0000034275.V303570.R01.S.doc Version 5.2 Page 27 Keevan Lodge 6. YA41 The registered person should ensure all the current service user information including their assessments, care plans, care plan monthly reviews, healthcare log, risk assessment, service user contract, records of review meetings, current professional reports are available in one file in clearly arranged and indexed sections so they are available for the staff to access as required. Keevan Lodge DS0000034275.V303570.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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