Inspection on 26/04/07 for Keevan Lodge

This inspection was carried out on 26th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Keevan Lodge 14/08/06

Keevan Lodge 10/01/06

Keevan Lodge 09/09/05

Keevan Lodge 25/02/05

Keevan Lodge 19/07/04

Keevan Lodge 25/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Keevan Lodge 98 Clive Road Enfield Middlesex EN1 1RF Lead Inspector Jane Ray Unannounced Inspection 26th April 2007 09:30 Keevan Lodge DS0000034275.V333013.R05.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.V333013.R05.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.V333013.R05.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.V333013.R05.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 14th August 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.V333013.R05.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 26 April 2007 and was unannounced. The inspection took three and a half hours to complete. The inspector was able to spend time with all of the service users. The inspector was also able to speak to the registered provider who was on duty. The manager assisted the inspector. The inspector did a full tour of the premises and also looked at all the relevant records including service user records, staff files and health and safety information. The inspection is the annual key inspection and the aim is to look at how well the service is meeting the key National Minimum Standards for Younger Adults. The inspector also assessed the progress made by the service in meeting the requirements from the previous inspection. The inspector would like to thank the service users and staff for their assistance with the inspection process. What the service does well: The home provides a good standard of care and support to a group of service users with a range of complex needs. The people who live in the home are supported by the staff to access members of the multidisciplinary team to ensure their personal care, social and emotional health needs are met. The staff demonstrate a good knowledge of the residents and are able to recognise their individual needs. The people who live in the home are supported to have their individual needs met by a key working and care planning system. The residents are offered access a range of structured and leisure activities that they said they really enjoyed. The people who live in the home said they enjoyed the food. The home is comfortable and homely and the residents each have a single bedroom that is personalised to their taste. Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 6 The people who live in the home are supported to maintain positive contact with their relatives. The people who live in the home are supported to practice their religion in line with their personal wishes. The residents are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures, comprehensive environmental risk assessments and health and safety procedures. What has improved since the last inspection? What they could do better: Six requirements and five recommendations have been made at this inspection. One requirement and one recommendation was made under the section choice of home and this was to update the statement of purpose and to ensure all the staff have received training on how to positively work with people who have complex challenging behaviours. One requirement and one recommendation was made under the heading individual needs and choices. This was to ensure each person living in the home has a record of how they are supported to manage their personal finances. It was also recommended that the residents are supported to have regular meetings so they can contribute their ideas to the running of the service. Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 7 One recommendation were made under the heading of lifestyle to continue to support the people in the home to eat a healthy diet by reducing the use if convenience meals and using fresh produce. A requirement was made under the heading of personal and healthcare to ensure that where a person is prescribed PRN medication that guidelines are in place on when this should be administered and also to ensure the temperature of the medication cupboard is monitored to ensure it remains within an appropriate temperature for the medication. A requirement was made in the section concerns, complaints and protection to ensure that all staff have received training on the protection of vulnerable adults. In the section on staffing one requirement and one recommendation was made to ensure all staff have a record of their induction available and to also have a completed and signed contract of employment. One requirement and one recommendation was made in the section called conduct and management of the home to support the manager to review her practice and ensure the manner in which she speaks to the people who live in the home is calm and uses an appropriate tone of voice. She may also wish to access training as required. It was also required that the record of fire drills includes the time of the drill and who was present. 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. Keevan Lodge DS0000034275.V333013.R05.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.V333013.R05.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): Standards 1,2,3,4 and 5 have been inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the service can be assured that their needs will be thoroughly assessed as part of the individual care planning process. The statement of purpose would benefit from being updated so that people who want to know more about the home can have access to the most up to date information. EVIDENCE: I looked at the statement of purpose prepared for the home and this was very comprehensive. I did however note that some of the information was out of date including the training details for the manager and staff team. It is recommended that this document is updated. I looked at the case notes for three people who live in the home. They all had comprehensive assessments prepared by the home manager that reflected their current individual needs and provided a good basis for the care plans. I discussed the current needs of the people who live in the home with the manager and inspected the staff training records. This indicated that the Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 10 residents have a number of very specific needs including one person who has epilepsy and everyone needs support with their complex behaviours. The staff training records show that most of the staff have received training on these issues although some of the new staff need training on working with people who have challenging behaviours. I looked at the admission process in the statement of purpose and this confirmed that people are able to visit the home as part of the process of deciding whether they want to move in and that their relatives are also welcome to visit. There have been no new people moving to the home in the past few years. I also looked at the contracts between the people who live in the home and the owners. These contracts are in place and explain what services the residents can expect to receive. These contracts are appropriately signed. Keevan Lodge DS0000034275.V333013.R05.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,8 and 9 have been inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people living in the home can be confident that they will be supported to have an individual care plan and risk assessments. They would however benefit from clarity in documenting the arrangements for each person to be supported to manage their finances to ensure these systems are robust. They would also benefit from being given an opportunity to participate in regular house meetings so they can express their views on what is happening in the home. EVIDENCE: I inspected care plans for the three people currently living in the home. I also spoke to the manager about the care plans. All of the people whose records were inspected had comprehensive care plans in place. These were clearly laid out and covered all aspects of each persons needs in a user-friendly language. Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 12 The care plans had all been reviewed in the last six months. The people living in the home had all been supported to have a review meeting with their care manager and relatives in the last year as well as internal review meetings on a three monthly basis. The minutes of these reviews were available and the action from these meetings had been addressed. Each resident had a named key worker and co-worker. I read the risk assessments for the same three people who live in the home. It was possible to see that an effort had been made to identify areas of personal risk and look at how this can be managed without placing unnecessary restrictions on people. Where restrictions are needed, for example the staff hold one persons cigarettes on his behalf, the reasons for this are clearly recorded. The risk assessments addressed how staff should support each person with any complex behaviours. The arrangements to support the people living in the home to manage their personal finances were read in each persons care plan and did not clearly state what these arrangements were including who acts as their appointee, who holds the building society books, who deals with queries from the DSS etc. The manager told me that one of the residents has an advocate and they visit on an ongoing basis. I looked at the records of the residents meetings and noted that these had not taken place since Christmas, although prior to this they had taken place mostly on a monthly basis. Keevan Lodge DS0000034275.V333013.R05.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11,12,13,14,15,16 and 17 have been inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home will be able to follow a routine based on their individual choices and be supported to enjoy a range of activities and lead active lives. They will also be supported to eat the food they enjoy but additional work is needed to ensure this represents a healthy choice. EVIDENCE: I spoke to the people living in the home and the staff about the activities. The manager explained that one of the people currently living in the home goes to college three times a week and an Asian Centre once a week. The other residents enjoy a range of leisure activities and their daily records show that this includes visits to museums and parks, shopping, meals out and a weekly Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 14 visit to a local social club. On the day of the inspection one resident told me he was going to the gym and the other two were looking forward to lunch at the café. In terms of holidays the manager explained that all of the residents went to Great Yarmouth last year and are discussing where they want to go this year. The manager explained that one of the current people living in the home has chosen to practice his religion and is supported to go to the temple on a regular basis and follow dietary practices. The manager explained that two of the people living in the home have regular contact with their relatives and either go to see them or the relatives visit the home. One of the people I spoke to said how much he enjoyed seeing his relatives. I was able to observe during the inspection that the people living in the home were able to follow a routine of their choice. One person who lives in the home said she likes to get up early and then go to bed early. The staff were observed sitting with the residents and chatting to them throughout the day. I saw the record of the food eaten by the people who live in the home. One person told me he sometimes likes to eat Indian food and other days likes to eat English food. Another resident told me what she liked to eat for breakfast. One of the residents likes to have Chinese takeaways and an agreement has been made to restrict these to three times a week for health and financial reasons. The people who live in the home are able to say what they want to eat and have clear individual preferences. The record showed that individual choice is facilitated but I was concerned about the regular use of convenience pre-prepared meals and recommended that where possible home cooked food is prepared using fresh produce. Keevan Lodge DS0000034275.V333013.R05.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 have been inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people living in the home are supported to access ongoing healthcare support from a range of professionals. There are however areas that need to be improved to ensure medication is administered safely at all times. EVIDENCE: I observed during the inspection that the staff were supporting the people living in the home to receive personal care in a manner that preserved their privacy and dignity. It was observed that the three residents were appropriately dressed and one of the people was able to tell me how she goes to the local hairdressers for regular haircuts. I looked at the healthcare records for the three people living in the home. They had all been supported to access a range of healthcare professionals including the GP, dentist, optician and other outpatient appointments according to their Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 16 individual needs. The residents were all having regular support from the community learning disability nurse and the psychiatrist. I observed they all had a record of having their weight monitored on a monthly basis. I also spoke to the psychiatrist who visits the home on a regular basis and he described the service as “robust and caring”. I looked at the medication, administration records and staff training records. The home uses a dossette box medication administration system. The medication is stored in a locked cupboard in the office. The temperature of the storage cupboard is not being monitored. The manager said that none of the residents are self- administering their medication. One resident has PRN rectal diazepam and there are clear guidelines in place for when and how this should be administered. Two of the residents also had other PRN medication available and there were no guidelines available on when this should be used. The home records the medication received in the home and returned to the pharmacy so an audit trail is available. The training records show that staff who have come into post in the last six months need medication training and the manager was able to show that this had been booked to take place in May. Keevan Lodge DS0000034275.V333013.R05.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 have been inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living in the home are protected by the appropriate use of adult protection procedures, complaints procedures and systems for supporting residents to manage their finances. Most of the staff team need to receive training on the protection of vulnerable adults although a training date is booked. EVIDENCE: I looked at the record of complaints and whilst there have been no complaints since the last inspection an appropriate format is available to record complaints. I observed that the home has a copy of the appropriate local authority adult protection procedure. There have been no adult protection issues since the last inspection. I looked at the staff training records and only one of the three long standing staff and none of the four new staff had undertaken training on the protection of vulnerable adults. The manager was able to show that this training was booked to take place in May. I checked the personal finances for one resident including their cash record, cash and receipts. These were all accurate and provided evidence that Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 18 appropriate systems were in place to protect the residents from financial abuse. Keevan Lodge DS0000034275.V333013.R05.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,25,27,28 and 30 have been inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home can know that they are living in an environment that is clean, comfortable and homely. EVIDENCE: I did a tour of the premises. The house is very small and each of the people living in the home has their own bedroom with en-suite shower room. One of the bedrooms is on the ground floor and two bedrooms are on the first floor. There is also the main bathroom and office on the first floor. On the ground floor there is a kitchen and dining area and a separate small lounge, which feels rather enclosed as there are no external windows. Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 20 The home was clean and tidy and has been well maintained. One of the residents had some broken furniture in his bedroom but he regularly breaks his furniture as part of his challenging behaviours and this is reflected in his case notes. The house has an enclosed garden and there is a large shed, which is being adapted to use as a second larger office. Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 21 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): Standards 32,33,34,35 and 36 have been inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be supported by adequate numbers of staff but over half of these have only joined the team recently and still need to develop their experience of working in the home. Staff need to all have a record of a completed induction to ensure they have received the necessary information to work effectively. EVIDENCE: The pre-inspection questionnaire showed that there are 10 staff working at Keevan Lodge of which there is the owner, one manager and 8 care staff. The staff turnover has been quite high over the past year with six new staff coming into post in the last six months. The staffing levels consist of two or three care staff on the day shifts and one waking night staff. The manager explained that staff meetings take place every one or two months and I looked at the records and these show that a range of operational issues are discussed. Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 22 The manager explained that six staff have completed an NVQ in care at level 2 or 3 or are currently studying for the qualification. I looked at the recruitment records for four staff recruited in the last 4 months and three staff who have worked in the home for a longer period. It was found that all the staff had two references, ID and a CRB disclosure. All the staff had a contract of employment but two had not been signed and did not include details of their rate of pay. I inspected the training records. I looked at the induction records for the four staff employed in the four months and one member of staff had no induction record available. The manager explained that an ongoing programme of training is booked that includes all the mandatory training. I looked at the supervision records for the seven staff. They had all received individual supervision in the previous four weeks. The format used for supervision is appropriate and includes a record of any action agreed. Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 23 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): Standards 37,38,39 and 42 have been inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users can be assured they are living in a well-organised service that enables them to contribute to a quality assurance monitoring system. The manager is very experienced but could benefit from some training to ensure that her approach is calm and appropriate at all times. Fire drills need to be practiced at night as well as during the day. EVIDENCE: The manager has many years of experience as a qualified nurse in working with people who have a learning disability. The manager has also completed the NVQ level 4 in the management of care. The manager clearly knows the Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 24 people who live in the home very well and has supported them to make significant progress in their lives. As I was leaving the home at the end of the inspection I observed a conversation between the manager and one of the people living in the home, who was becoming anxious and unsettled. I felt this could have taken place in a manner that was calmer and where the tone of voice could be reviewed. I felt this indicated that the manager may need some training in order to update her practice. I also spoke to the residents advocate after the inspection and she confirmed that she had also seen the manager speak to the person in a similar manner and agreed that her practice could be reviewed through training. I was able to look at the outcomes of the quality assurance exercise that was undertaken in April 2007. This seeks the views of the people who live in the home, relatives and care professionals. The results of the returned questionnaires had been collated. I looked in detail at health and safety in the home. Fire safety was mainly satisfactory and included the fire alarm and extinguishers being serviced, a fire safety risk assessment and emergency plan being in place and weekly fire drills taking place. The fire drills would benefit from recording what time they took place and which staff and residents were present to ensure they take place at different times. I looked at the staff training records and these showed that only two of the three long-term staff had current fire safety training and the manager was able to show that this training had been booked in April. I checked that the other equipment in the home had been serviced. The gas landlord safety check was in place. The annual service had been booked for the portable electrical appliances and electrical installations. I inspected the staff health and safety training records. The staff had received training in moving and handling, first aid, food hygiene and infection control although much of this training had just been completed and the manager explained that they were still waiting for the certificates to arrive. Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 25 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 3 3 2 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 2 3 x x 2 x Keevan Lodge DS0000034275.V333013.R05.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NONE 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 YA3 Regulation 18(1)(c) Requirement The registered person must ensure that all the staff have completed training on how to work positively with people who have complex challenging behaviours. The registered person must ensure that each persons assessment includes details of how the resident is supported to manage their personal finances to ensure they are protected from financial abuse. The registered person must ensure the temperature of the medication cupboard is monitored and that individual guidelines are in place for all PRN medications so the staff team are clear about when they should be administered. The registered person must ensure that all the staff receive training on the protection of vulnerable adults. The registered person must ensure all staff have a completed record of their induction available to ensure they have completed the necessary DS0000034275.V333013.R05.S.doc Timescale for action 31/07/07 2. YA7 13(6) 31/07/07 3. YA20 13(2) 31/07/07 4. YA23 13(6) 31/07/07 5. YA35 18(1)(c) 30/06/07 Keevan Lodge Version 5.2 Page 27 training. 6. YA42 23(4) The registered person must ensure that the record of fire drills includes the time of the drill and who was present. 30/06/07 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 YA8 YA17 YA34 YA38 Good Practice Recommendations The registered person should update the statement of purpose to ensure all the details are correct and send a copy to the CSCI. The registered person should support the people who live in the home to have regular meetings so they can contribute their ideas to the running of the service. The registered person should try to reduce the use if convenience meals and provide meals prepared from fresh produce. The registered person should ensure that all staff have a completed and signed contract of employment. The registered person should support the manager to review her practice and ensure the manner in which she speaks to the people who live in the home is calm and uses an appropriate tone of voice. She may also wish to access training as required. Keevan Lodge DS0000034275.V333013.R05.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: 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 Keevan Lodge DS0000034275.V333013.R05.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. 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. 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