Inspection on 16/06/05 for Satya Nivas Residential Home

This inspection was carried out on 16th June 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Satya Nivas Residential Home 11/10/06

Satya Nivas Residential Home 01/11/05

Satya Nivas Residential Home 03/02/05

Satya Nivas Residential Home 13/07/04

Satya Nivas Residential Home 11/03/04

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Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Satya Nivas 71-73 Checketts Road Leicester Leicestershire LE4 5ES Lead Inspector Bhavna Keane-Rao Unannounced 16 June 2005 12:00pm 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 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 Stationary 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. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Satya Nivas Address 71-73 Checketts Road Leicester LE4 5ES Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0116 224 1802 0116 224 1802 None Mrs Tara Pankhania Ms Devi Sundavadra Care Home 10 Category(ies) of LD Learning Disability (10) registration, with number MD Mental Disorder (10) of places Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 03/02/05 Brief Description of the Service: Satya Nivas offers long-term accommodation for 10 adults with learning disabilities. It is situated on Checketts Road off the Belgrave Road, within easy reach of the City of Leicester, in a large detached property. It is within the immediate vicinity of all amenities, and bus routes. The Homes primary purpose is to meet the cultural, religious and language needs of Asian people. The furniture and decoration in the home is authentically ethnic to suit Asian needs. Rooms are decorated to a good standard. There is a large lounge, which has television, video, and satellite facilities. There is also a rear garden, a front patio garden and parking facilities available. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during noon and early afternoon. It took four hours to complete. Discussion was held with a number of residents, but not in great detail due to their care needs. However they were observed in their daily routine. One resident was spoken with in detail. The primary method for this inspection used was ‘case tracking’ which involved three residents and tracking the care they received through looking at their records, discussion with them, and their relatives via comment cards, care staff and observation of care practices. A tour of the premises was undertaken and opportunity was taken to view residents daily records, menus of meals, fire records and staff rota. The pre-inspection questionnaire was also viewed. The registered owners were on duty during the whole of the inspection, the registered manager joined them later on. The owners and the manager spent time discussing many issues that arise in the running of a residential home and facilitated this inspection. What the service does well: The registered manager, the owners and the staff at the home are very willing to learn and improve the service provided for the residents. The activities provided for the residents is very positive, taking into account their hobbies and interest. As one resident stated “ we go on lots of trips and outings”. Residents who were spoken with stated that they feel they are consulted about the care that this provided at this home. The interactions observed between staff and residents was very positive. Comment Cards, sent out to the home for distribution to all residents and their relatives/visitors, indicated a high level of satisfaction for the provision of care provided by the owners and the manager at this home. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 8 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 standard(s) 1,2,3 and 4 The admission process is flexible and well managed, which ensures care needs are met at the home. EVIDENCE: There is now a good admission procedure which includes the assessments of individuals are carried out by the health and/or social care professionals, as part of the referral process. Three residents files were viewed; these detailed basic care needs of residents, identifying the needs that would be met by heath and/or social care professionals. The contractual agreements for residents were also viewed. This is an internal local authority document that is known as “the individual placement agreement”. One of the resident, who was spoken with in detail, was aware of the contract to stay at the home. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6,7,8 and 9 Care plans do not reflect changing needs, which may lead to individual needs not being met. Resident’s information is secure and treated with confidence EVIDENCE: Three residents were spoken with about the care they received at this home. Although detailed conversation was only held with one person, due to the care needs of residents living at the home. Two individual care plans of residents were viewed. These have not been reviewed as and when the care needs of residents change. Discussion was held with the registered manager with regards to the need to ensure that care plans are always up to date to enable staff to provide appropriate care specifically designed for the individual. One resident has recently had change in their personal circumstances and is trying to live independently. This needs to be included in their plan of care so that the transition is successfully managed. One resident spoken with stated that they (residents) very involved in what happens in this home and the care they receive. Residents are able to choose the food they ate, what clothes they wear and what actives they participated in. This was stated to be the case upon discussion with residents. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 11,12,13,14,15,16 and 17 Residents have a stimulating and varied lifestyle at the home that is individually tailored and flexible. EVIDENCE: One resident spoken with stated that he loved to go out and do something different everyday and that this was what he really enjoyed. Social organised excursions are provided through consultation with the residents. Residents are supported to access the local community and social events. Residents who enjoy helping around the home are accommodated. Some residents attend day centres as structured activities provided by the home. The residents who were spoken with also told the inspector about the last bank holiday (28th, 29th and 30th May 2005) when they all went down to the city of London for the day, then back to Ilford in London again and finally to Birmingham city centre. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 11 Residents have a very active social life, which is encouraged and supported by the staff and their own relatives. The Registered Manager and staff were seen to seek the permission of residents before entering bedrooms; all of residents hold a key to their own bedroom. Residents wandered around the home freely, accessing communal areas, including leaving and returning to the home. This was observed to be the case on the day of the inspection. Residents stated that they enjoyed the meals. Meals are cooked and prepared by staff. All the food is freshly cooked and is suitable for a home providing care for Asian lifestyles. It was noted that everyday there is a set Asian meal with all the accompaniments and there are Asian snacks and savouries available throughout the day. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18,19 and 20 Residents and staff working together meet the physical, emotional and health care needs of residents. The disposal of medication is not satisfactory. EVIDENCE: The records of three residents were viewed, records detailed visits made by and to health care professionals, which includes Community Nurses, Social Workers, Dentists and Opticians. At present residents are not able to manage their own medication, however risk assessments have been carried out to ensure that resident’s rights are not compromised. The medication administration, recording and safe handling of medication is satisfactory. However the disposal of medication is not satisfactory. Returned medication after a social visit is not recorded. Records showing what was returned, when it was returned to the home and whether or it is to be returned to the chemist must be accurately kept. Residents who were spoken with stated that they are given as much support by the staff as they wish. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 22 and 23 Residents are safe and protected from abuse. EVIDENCE: The home’s complaints procedure is displayed. Residents spoken with were aware of whom to contact and speak with should they have any concerns. The Commission for Social Care Inspection has not received any complaints since the last Inspection. There is a procedure in place to ensure that residents are protected from any form of abuse. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 24,25,27 and 30 The residents are provided with a comfortable, generally clean and generally safe standard of accommodation, which individually and collectively meets the resident’s needs. EVIDENCE: The areas, identified at the last inspection have now been acted upon. Since the last inspection some of the areas have been decorated. Areas in need of work, identified at this inspection are as follows: • • • One bedroom had strong offensive odour. The bath panel in bathroom in number 73 has come away. Both the handles on the bathroom door in number 73 are broken. A resident spoken with stated that her bedroom was “very nice”. The other residents who were spoken with were very proud of their bedrooms and were observed using the communal areas freely. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32 and 35 Training and supervision is in place to ensure staff are able to carry out their work safely and competently. EVIDENCE: Since the last inspection there have been no new recruitments or resignation. At present there are nine residents for whom care is provided. There are always at least two staff on duty, but usually three to provide care when all the residents are in the home. Staff are supported and access specialist training to focus on meeting the needs of the residents e.g. diabetic training. The responsibilities of the staff in the home, in addition to care, include cleaning, preparation and cooking of meals, the laundry and any other tasks as identified by the manager. Two staff files were viewed, these contained all required checks and paperwork. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 and 42 Residents and staff benefit from clear leadership. EVIDENCE: There are regular staff meetings, which identified the expectations of the Registered Manager of his staff. The staff and the residents who were spoken with felt that they could go to either the manager or the owners at any time with any concern. The staff who were spoken with have had formal supervisions. There is a maintenance programme for the home and the equipment. A random sample of records checked was up to date including fire drills. During the tour of the home, fire exits were clearly marked and were not obstructed. Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 2 x x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Satya Nivas Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 15 Requirement Timescale for action Immediate 2. 20 13 3. 27 23 4. 30 12,16 It is required that care plans are reviewed and up dated as and when the care needs of residents changed. It is required that when Immediate resident’s relatives return any medication after a social visit, this must be accurately recorded in the drugs Returns Book. It is required that the bath panel Immediate and door handles, in bathroom in house number 73, is repaired/replaced. It is required that problem of Immediate offensive odour in one of the bedroom. 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. Refer to Standard None Good Practice Recommendations Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicester LE19 1SX National Enquiry Line: 0845 015 0120 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 Satya Nivas D C51 C01 S6443 Satya Nivas V233772 160605 Stage 4.doc Version 1.30 Page 20 - 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. 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