Inspection on 20/11/08 for Diwali Nivas

This inspection was carried out on 20th November 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Diwali Nivas Diwali Nivas 38 Westcotes Drive Leicester Leicestershire LE3 0QR     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Fiona Stephenson     Date: 2 0 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Diwali Nivas 38 Westcotes Drive Diwali Nivas Leicester Leicestershire LE3 0QR 01162334440 01662334440 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Diwali Ltd care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 16 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 categories: Old age, not falling within any othercategory - Code OP Dementia - Code DE Mental Disability Code MD Date of last inspection Brief description of the care home Diwali Nivas is situated in Leicester City, close to the Narborough Road. It has easy access to local shops, a post office and the Jalaram Mandir temple is in walking distance. The house has been converted from a private dwelling to become a registered care home. The care home has been established to meet the needs of elderly people from the Asian community. The service is registered to provide care to a Care Homes for Older People Page 4 of 27 16 16 0 Over 65 0 0 16 Brief description of the care home maximum of 16 people. The service can provide care to elderly people, people with dementia, and people with mental health conditions. There are Gujerati speaking staff available 24 hours a day, and the home caters for vegetarian diets only. The facilities include 12 bedrooms, consisting of eight single rooms and four double rooms. Eight bedrooms have en-suite toilet facilities. There are two walk-in shower rooms and a bathroom. Bedrooms are located on the ground and first floor. Access to the first floor is by means of a passenger lift or the stair case. There are two communal lounge/dining rooms, and a landscaped garden with patio area. The fees are £303 £393 per week. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection included a visit to the service. Although the home has been open for many years, this is the first inspection of the home since it changed ownership in June 2008. We (the CSCI) visited Diwali Nivas on the 13th November 2008. The Registered Provider, Kishen Sachdev, the deputy manager and staff in the home helped us during the visit. One inspector carried out the inspection arriving at the home at 8.15am and finishing at 3.15pm. She was joined by an interpreter who worked with her during the morning to help translate information provided by people who live at Diwali Nivas and the staff who work there. The main method of inspection we used was case tracking. This means looking at the care given to people in different ways. We did this by, Care Homes for Older People Page 6 of 27 - talking to the people who live in the home, - talking to staff and management, - watching how people are given support, - looking at records. We looked at the Annual Quality Assurance Assessment (AQAA). This is a document the provider (the person who owns the service) sends to us at the CSCI, and it tells us what the provider thinks about the service they deliver to people who live at Diwali Nivas. We also looked at the surveys called Have your Say About.. which are sent out to people who live and work at Diwali Nivas, to health care professionals who support the health care of people who live in the home, and to relatives of those living at Diwali Nivas. We received two surveys back from staff, and two from health care professionals. We spoke with four people who live at Diwali Nivas during our visit, and one relative who was visiting the home during the inspection. Everyone we spoke with was very positive about the care being given at the home. We spoke with four members of staff during our visit to the home who told us about working in the home and gave us their views. All staff spoken with were happy working at Diwali Nivas, and felt well supported by management. We checked all the standards that the Commission for Social Care Inspection has decided are key standards during this inspection. The information below is based only on what we checked in this inspection. We have kept details about individual people out of the report to make sure we respect their confidences. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Older People Page 8 of 27 The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 27 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Diwali Nivas is providing the type of home it sets out in its Statement of Purpose. Evidence: We looked at the Statement of Purpose. This is a legal document which tells us what the providers (owner) aims and objectives are for the service, and how they intend to meet the needs of people who live at the home. We observed the way the service was being provided and found that it was being provided in the way the Statement of Purpose said it should. We saw that the statement of purpose was only written in English, and not Gujerati. Most of the Asian elders living at Diwali Nivas speak Gujerati. We checked the records of a person who had recently been admitted to Diwali Nivas. We saw that the person had a well documented needs assessment, and the staff at Diwali Nivas had used this to set up a plan of care (care plan) for their stay. We spoke Care Homes for Older People Page 11 of 27 Evidence: to the resident themselves, and they said that staff knew what their needs were. The care plan also noted that the person had a risk of falls, and they informed us that staff were always on hand to support them when walking to reduce the chances of falls. Care Homes for Older People Page 12 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and personal care is delivered well, but supporting documentation needs to be improved. Evidence: We checked the care plans of the four people we case tracked. They had enough information to support the care being provided, but it was not always easy to find the information, and it wasnt detailed. Although the care needs of one of the people case tracked had changed, and staff were aware of this and meeting the new needs, the written care plan had not been updated. We received information from two health care professionals who regularly visit Diwali Nivas to support residents with their health care needs. They were generally happy with the care and support given to people living at Diwali Nivas, although they were concerned that sometimes information they give staff is lost because of the language barriers. They were very positive about how staff treat people living at Diwali Nivas with dignity, and respecting their privacy. Care Homes for Older People Page 13 of 27 Evidence: We checked the way medication is given to people living in the home, and how it is ordered, stored and disposed of. We observed staff administering medication, and were satisfied that they followed good practice guidance in the handling of medication, and the recording of medication being administered. We checked the storage of medication. This was satisfactory apart from the storage of medication which requires being kept in a fridge. This medication was kept in the fridge with the food in the kitchen. It should be kept in a separate fridge. We also saw that there had been good systems to check stock in and out of the home, however more recently this system had changed, which meant there was not a written record of medication being sent back to the pharmacy. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Daily life and social activities support the well being of people living at Diwali Nivas. Evidence: We arrived at Diwali Nivas at 8.15am. Most people living at the home were up and dressed when we arrived and were having breakfast of weetabix and toast with a hot drink. During the day we saw people being given drinks and fruit, and we saw a hot meal of spinach curry, rice, chapati and dahl. The people we spoke to said they enjoyed the meals they get. We saw a three-week menu which showed a range of food being provided, all of it vegetarian. Although there is no choice on the menu, staff are happy to make an alternative meal if a person who lives at Diwali Nivas doesnt like what is on offer. We saw good relationships between people living at Diwali Nivas, and between staff and people living at the home. We observed a real family environment. We were told by people living at the home that they were happy there, and that staff treated them well, one said they are like daughters to me and that the owner is like a grandson. During the inspection we spoke with a visitor to Diwali Nivas. He told us that his Care Homes for Older People Page 15 of 27 Evidence: relative was happy with the home, the food and that their health had been fine. People living at Diwali Nivas told us that they had visitors who could visit at any time. We saw people listening to an Asian radio channel, and watching an Asian network TV programme. We were also told by one person that they go to the day centre once a week, and another said that staff help her to go to the temple. People told us they can get up when they want, and go to bed when they want. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this 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 living at Diwali Nivas are being well protected. Evidence: People who live at Diwali Nivas told us that they would feel able to make a complaint if they were not happy with the care they were receiving. They felt able to talk to staff and to the new owner, who they thought was very approachable - one person said I would tell people directly if I had a concern, I have a confidence in the manager and new owner..they are sensitive to the needs of people living here. Since the new ownership, there have been no complaints raised. There is a complaints procedure that is clearly set out in the Statement of Purpose. We spoke with staff to check they understood how to protect people living at the home from abuse. The two staff we spoke to about this were very clear about what they should do if they felt someone was being abusive to a person living at the home. T hey were also clear about what the manager should do as part of their responsibilities. One of the staff did not understand what whistle-blowing meant. This is when a member of staff can contact the authorities to inform them of their concerns, and their identity will be kept in confidence. Care Homes for Older People Page 17 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this 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 living at Diwali Nivas live in a safe, homely environment. Evidence: We spent time in the communal lounge areas and in the bedrooms of the four people living at Diwali Nivas that we case tracked. We found the communal areas to be bright and airy, and had been decorated to celebrate Diwali. There was plenty of space for people living at the home to move around. We thought the armchairs looked worn, and the new owner agreed with this saying that he hopes to change these in the near future. We observed the whole home to be clean and tidy. We found the majority of the home to be well maintained, only seeing two items requiring repair. One was a leaking tap in an en-suite toilet, and the other was an adaptation for the toilet in the communal bathroom. This had become rusty in places and could cause skin tears. The owner agreed to remove this on the day we visited. The bedrooms were nicely decorated, and people living at Diwali Nivas had their own personal possessions around them. We asked people about their bedrooms and they were satisfied with them. All the bedrooms we checked had en-suite toilets, and we checked the temperature of the water coming from the taps to make sure the water wasnt scalding hot. We found that the water was hot but safe for people to use. Care Homes for Older People Page 18 of 27 Evidence: It was a cold day when we visited. On entering the home, it was nice and warm. One person living in the home commented that she had to have her radiator turned down because it was too hot at night. She said that staff had adjusted her bedroom temperature to her needs and it was now just right for her to be able to sleep. The AQAA gave us information about the policies and procedures regarding hygiene and infection control, and we observed good practice during the inspection. Care Homes for Older People Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this 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 number of staff on duty in the home, and the skill mix of staff, support the provision of good care to people who live at Diwali Nivas. Evidence: We watched staff support the needs of people living at Diwali Nivas and were satisfied that there were enough staff on duty to meet their needs. We looked at the staff rota and talked to staff, and this confirmed that there were sufficient staff on duty during the day and night to support the needs of the people who are currently living at the home. We looked at staff training records, talked to staff and management and observed care practice. We saw that staff were putting into practice the knowledge gained from training. We observed good practice in moving a person living at Diwali Nivas who required a hoist; we observed the correct use of protective equipment to support health and hygiene when staff were cooking, or undertaking personal care tasks. We checked the recruitment records of people who had been employed to work at Diwali Nivas since the new owner had taken control. The service followed the guidance in terms of recruitment practice, however the owner was unaware that it is only in exceptional circumstances that a worker be employed at a home before the Criminal Care Homes for Older People Page 20 of 27 Evidence: Record Bureau clearance is received. The service had employed the member of staff and had ensured they were supervised until the CRB clearance was received, thinking this was acceptable practice. The owner said he would now not start the employment of anyone until after the CRB disclosure had been received. Care Homes for Older People Page 21 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this 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 Diwali Nivas have a clear sense of direction, and people living at Diwali Nivas benefit from their open and positive approach. Evidence: The registered manager has recently left the service. This was expected as part of the change of ownership. The new owner is now managing the home. We spoke with staff and people who live at Diwali Nivas. Both groups of people said they feel supported by the new owner, and believe him to be dedicated to improving the care given to people at the home. We looked at the AQAA sent by the owner. This clearly showed us the improvements made to the home over the last six months, and the improvements the owner hopes to make over the next year. There are no formal quality assurance and monitoring systems in place as yet, but feedback about the service is actively sought from people living in the home and their relatives. Care Homes for Older People Page 22 of 27 Evidence: The AQAA also told us that the service has policies and procedures in place to ensure that the working practice of staff promotes the health, safety and welfare of both staff and people living at the home. During the inspection we observed safe working practice. Care Homes for Older People Page 23 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 13 The provider must ensure that there is a whistleblowing policy in the home, and that staff are aware of the policy. To ensure that people living at the home are protected from abuse 31/12/2008 2 13 The service must ensure all disposals of medicines are clearly documented. This must show the date of disposal/return to the pharmacy, name and strength of medicine, quantity removed, person for whom medication was prescribed, and signature of member of staff who arranges disposal of the medicines. To ensure proper stock control and auditing of medication. 16/12/2008 3 13 The service must ensure there is a separate, secure 16/12/2008 Care Homes for Older People Page 25 of 27 fridge that is only used for medications requiring cold storage. The temperature of the medicine fridge should be monitored daily when in use, and the temperatures recorded. To ensure medication is kept in a safe and hygienic environment and it at the correct temperature for the viability of the medicines. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The service should consider translating the Statement of Purpose and Service User Guide into Gujerati, to enable those who live the opportunity to read and understand for themselves. Care plans should be reviewed regularly to ensure they provide up to date information about the persons current health care and personal needs. Care records could be arranged to make it easier for staff and people living at the home to find information about health Care needs. 2 7 3 8 Care Homes for Older People Page 26 of 27 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 27 of 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!