Inspection on 19/07/06 for Shakti Lodge

This inspection was carried out on 19th July 2006.

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

Shakti Lodge 15/03/10

Shakti Lodge 06/05/09

Shakti Lodge 30/05/07

Shakti Lodge 06/02/06

Shakti Lodge 24/08/05

Shakti Lodge 22/11/04

Shakti Lodge 18/10/04

Shakti Lodge 09/08/04

Shakti Lodge 15/07/04

Shakti Lodge 18/03/04

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

CARE HOMES FOR OLDER PEOPLE Shakti Lodge Ltd Shakti Lodge 208, 210 And 212 Princes Road Dartford Kent DA1 3HR Lead Inspector Debbie Calveley Key Unannounced Inspection 19th July 2006 10:00 X10015.doc Version 1.40 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 Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shakti Lodge Ltd Address Shakti Lodge 208, 210 And 212 Princes Road Dartford Kent DA1 3HR 01322 288070 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) Shakti Lodge Limited Ms Chan Teeluck Care Home 26 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (26) of places Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: Shakti Lodge is registered to provide care and accommodation for twenty-six older people, up to fifteen of the twenty-six residents may have an admission diagnosis of dementia. Accommodation is provided on two floors, which can be accessed via a shaft lift. The home has fourteen single and six double rooms, one of which has an en-suite facility. All bedrooms have a staff call system, washbasin and television aerial point. The service provides prospective service users with a copy of the service users handbook and a brochure as part of the pre-admission process. Copies of inspection reports and the homes Statement of Purpose are made available on request. Fees charged as from 1 April 2006 range from £395 to £425, which includes toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. Residents have access to a pay phone or can use the homes cordless phone. The garden to the rear of the building is large and well maintained. Off road parking is available to the front of the building. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Shakti Lodge Care Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home by two inspectors and follow up contact with resident’s representatives and visiting health and social care professionals. The unannounced visit also included a meeting with the registered manager who received the inspector’s feedback at the end of the inspection. On the day of the home visit the inspectors spent most of their time meeting with residents and their visitors, speaking with staff and observing practice in the home. During the inspection visit 6 residents care documentation was reviewed in depth. A further selection of documentation was reviewed as part of the inspection process and this included the statement of purpose and service users guide, staff duty rotas, training records, 5 recruitment files, records relating to health and safety and a number of policies and procedures. four staff members were also interviewed in private. In addition service users surveys were given to 10 residents or their representatives and surveys were sent to health care professionals that have contact with the home. The information contained in the returned surveys has been incorporated into this report. What the service does well: Shakti Lodge provides a good standard of support and care within a friendly and homely environment. Thought has been given to the colours used to decorate the home resulting in a warm and cheerful environment. The ethos of the home is to provide support in a relaxed and family environment, which the home evidences very clearly. The focus of the home is the well being and contentment of the residents. Staff spoken to said that they enjoyed working in the home and all the staff worked as a team. Residents and visitors expressed a high satisfaction with the care provided and their comments included ‘the home should be commended for its care’, ‘I am very happy and content here’ ‘ I am well looked after’, ‘ my mother is very well looked after, I have no complaints.’ Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 6 The care staff demonstrate a good understanding of the residents needs and preferences and respond in a considerate manner to these. Links with resident’s family and friends are actively encouraged along with any community link that a residents wishes to maintain. Residents receive a varied diet with meals being of good quality and plentiful. Staff provision is well maintained. The staff group on the whole is stable, both residents and their relatives spoke highly of all the staff saying ‘staff are always nice and kind’ ‘staff are helpful, approachable and are available to talk to’. The staff enjoy working in the home and were complimentary regarding the support they receive from senior members of the staff. What has improved since the last inspection? What they could do better: Whilst it is acknowledged that there has been a review of the pre-admission assessment document and process, there are still some improvements to the documentation that are needed to ensure that the home are prepared and able to meet the prospective residents social, health and personal needs. More detail concerning the individual residents past and present lives, who was involved in the assessment, where it took place, date it was performed and who performed it. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 7 The care plans still need to be improved to ensure all the care needs of residents are recorded along with clear guidance to staff on how to meet these needs. At present the staff rely on memory and knowledge of the residents. An area that needs to be developed is the social preferences and needs of the residents to ensure that all residents are involved in the decision of what activities take place in the home and out of the home and are given the opportunity to be involved on a daily basis. Risk assessments for specific problems such as swallowing difficulties and behaviour traits need a clear plan of action documented for staff to follow if the need arises. The daily records of the residents would be of more value if written by the key person responsible for the individual resident each day. The training records evidenced that more than half the staff still have not received any training in the ‘Protection of Vulnerable Adults’. It was also not seen to be included in the induction programme. To ensure the safety and well being of the residents, all staff need to attend a training session. To ensure that the environment remains safe and homely, there needs to be a maintenance programme, and a book for staff to log minor issues. During the inspection there were a number of maintenance shortfalls to be addressed, e.g. lights not working, no plugs for baths, curtain rails not fixed and trip hazards identified. The call bell facility in residents’ bedrooms need to be accessible to the residents for their safety and well-being. The provision of mandatory training needs to be updated on a regular basis. 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. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is evidence that the pre-admission procedure is followed therefore ensuring that Shakti Lodge Care Home can meet the prospective residents’ needs. EVIDENCE: The Service Users Guide and the Statement of Purpose were last updated in the latter part of 2005. They are written in a user-friendly format and include information about life in the home, accommodation, staff and facilities available at Shakti Lodge. However, whilst they are available to all residents, families and to prospective residents on request, they are not routinely supplied. Two visiting relatives said they were not aware of these documents and had not read the last inspection report, three residents when asked, could not remember if they had seen a Service Users Guide. Whilst it is understood that not all the residents admitted to Shakti Lodge will have use of these documents, it would benefit the relatives and visitors if up to date copies are more readily available, displayed by the visitors book or residents bedrooms for easy access to pertinent information. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 10 All residents receive a comprehensive written contract/statement of terms and conditions on admission to the home. The pre-admission assessment of seven recent admissions to the home were viewed, it was found that the pre-admission assessments whilst of an improved standard, were still brief and impersonal on three residents. The staff performing the assessment must ensure that they are signed and dated on completion as it forms an important part of the assessment process and as a benchmark for the progression of an illness. It would also be beneficial to ensure the document includes the venue where the assessment took place and the people involved: family or other health professionals. Shakti Lodge provides a friendly and sympathetic environment for people with dementia. The manager and staff are aware of the registration category of the home. Staff are sensitive and receive appropriate training to care for the residents living in the home. Prospective residents and their family are actively encouraged to visit the home and accommodation is initially offered on a trial basis. Shakti Lodge does not provide intermediate care. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The resident’s individual plans in place do not adequately provide staff with the information they need to ensure that residents individual care needs are met. Residents are enabled to make decisions in all areas of their daily living during their stay and are treated with respect and dignity at all times. EVIDENCE: The manager and staff of Shakti Lodge are knowledgeable regarding the personalities and needs of the people they care for. This knowledge could be more beneficially used in creating care plans that give a full life history of each resident, medically and socially, thus creating a whole profile of each resident. The identified needs of the residents need to have a clear action plan that staff follow to meet the care need identified in a consistent safe manner to ensure positive outcomes. Staff spoken with were aware that the care plan system needs to be reviewed with care plans that detail the care required to meet individual residents needs and that undertaking the NVQ qualification in care had highlighted the shortfalls in the documents they are presently using. Their insight and acquired knowledge will be essential in the formation of a new comprehensive system. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 12 Seven residents individual plans (profiles) were viewed in depth and there was evidence of regular review and daily entries for all the residents. However there is still no evidence of resident or family consultation either on formation of the care plans or on the review or of the care staff taking responsibility for writing the daily entry of the residents they had taken care of for the day. The individual plans are kept together in folders; it would be beneficial for all documentation relating to each resident to be kept in the one folder to enable visiting health professionals to access all residents information. The risk assessments in place need to reflect any changes noted by staff as they happen and detail strategies to follow to minimise any further deterioration: e.g. weight loss, pressure damage, swallowing difficulties and communication problems. The accuracy of the weighing scales in use in the home needs to be monitored as the weights were for many residents remained exactly the same over a period of time, but staff mentioned appetite loss for several. Staff spoken to confirmed that they received a full report on each resident daily and read the care documentation that is kept in the main office area. They felt that their views were taken into account when planning resident’s care. Discussion with a visiting specialist nurse tutor and social workers confirmed that the home communicates well with other professionals as necessary with regard to the care of residents. They were complimentary regarding the quality of care in the home and the staff employed at the home. Relatives spoken to were very satisfied with the care provided at the home one saying that the home ‘should be commended for its care’. Residents spoken to were also very satisfied comments included’ I am very happy and content here’ ‘ I am so well looked after’ The clinical room was clean and tidy. The medication administration charts were viewed and were filled in correctly with no gaps identified. However the oral diabetic tablet for one resident had been signed for, but was still in the blister pack and so had not been dispensed. Practice of staff needs to be monitored to ensure that staff do not sign for medication before being dispensed. At the time of the inspection there were no residents on controlled medications, however there are now policies and procedures in place as well as a controlled drug book. Staff sample signatures of those trained to dispense medication were not available and when asked the inspector was told they were being updated. Interaction between staff and residents was seen to be warm and caring. The atmosphere was relaxed and inclusive. Staff laughed and joked with the residents whilst maintaining the residents’ dignity and respect. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Meals remain good in respect of both quality and variety that meets residents tastes and choice. The lifestyle experienced by residents does not always match their expectations, choice or preferences. EVIDENCE: Residents were observed being able to spend time where and how they wanted moving around the home and garden freely. Set routines are avoided as far as possible and residents are able to determine when they would like to go to bed and what time they would like to get up in the morning. Residents’ spoken with said that they could choose how they spend their time and what they wear on a daily basis. However the documentation available does not reflect that residents are consulted with at present. Residents are able to choose whether they wanted to join in the daily activities provided and include word games, quizzes, singing and movement to music. Residents and two visiting representatives felt the activities and entertainment provided was appropriate and fulfilling. Residents able to complete meaningful activities are encouraged to do so and residents were observed collecting in the washing. The morning activity was observed and was seen to be enjoyed by a good amount of the residents, however the care plans need to Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 14 demonstrate the residents social needs and how the home meet them, including reference to past hobbies and interests. From talking to staff it appears that not many trips out occur and this is an area that could be reviewed. On speaking to residents and visitors it was clear that visiting is very positively encouraged with no restrictions being imposed. One visitor expressed a satisfaction that staff always made an effort to speak with her and bring her up to date with the condition of her relative. The day’s menu with the options available are clearly displayed daily on the whiteboard in the dining room. On the day of the inspection the choice was sausage rolls or chicken casserole, residents are asked every morning what they would like, but can change their mind right up until they have lunch. The cook was aware of the residents preferences and when they are not eating well, a written food diary would be beneficial to track and monitor appetites. The evening meal provided is either cooked or sandwiches. Resident’s views on the meals provided were all positive. It is the practice at Shakti Lodge for all staff to eat lunch with the residents in the form of a family meal making it a pleasant social occasion. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There is a satisfactory complaints system with evidence that residents and their families felt confident their views would be listened to. Some staff have been trained in the protection of adults, further training for all staff needs to be planned to ensure they are familiar with procedures so that residents are not at risk of harm or abuse. EVIDENCE: The home has a clear complaints procedure and a copy of this is readily available in the home. A system of recording complaints was demonstrated to the inspectors during their visit to the home. There have however been no complaints received since the last inspection. Relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home have instigated relevant guidelines and a policy on the protection of vulnerable adults and some staff have received appropriate training, however all staff need to receive training and the induction programme needs to include an introduction to the protection of vulnerable adults. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents live in an attractive comfortable home that is generally safe, well maintained and clean in most areas. EVIDENCE: The home is located on a busy road in a residential area. The home is brightly decorated with a good use of colour schemes that provide a comfortable environment for residents to live in. The bedroom door numbers are placed quite high and some residents were not entirely sure of the location or number of their room. The standard of décor is good with minor redecoration works needed to some communal areas to ensure consistent standards throughout. A programme of routine maintenance and renewal is not maintained and the need for this was discussed with the manager. There are a number of minor maintenance shortfalls that need to be attended to, rucked carpet outside the lift shaft, Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 17 curtains hanging off rails, missing plugs, broken shower head and no hot water in certain areas. The home was found to be warm and comfortable, with good levels of light and ventilation. However a large amount of overhead lights in the resident’s bedrooms were not working and were not assessable to the residents. The home is a conversion, and was not designed to provide a service to people with physical disabilities as the stairs and other access arrangements would make it unsuitable for residents with a permanent restricted mobility. Access to the first floor is via stairs or a passenger lift with some additional small flights of stairs both on the ground and first floors. There are a variety of aids and adaptations around the building to promote residents independence. These include walking aids, raised toilet seats and grab bars. All bedrooms have a call bell system, but as discussed with the manager some are poorly positioned in that they are not accessible to the residents, this needs to be reviewed so that residents can call for help if and when they require it. It is acknowledged that not all residents will be able to use a call bell, so there is an identified need for individual risk assessments concerning call bells and a document to ensure that all residents in their rooms are checked regularly. The main lounge is used by the majority of residents for most of the day. Chairs have been arranged to make the best use of the space, however it continues to be very crowded with rows of chairs side by side lining the walls and down the middle of the room. It is not ideal for activities as some residents were seen sitting facing in the opposite direction to where the word game was being played on a white board and so could not fully be involved. The space does not allow for small occasional tables to be used so that residents can have access independently to jugs of juice or cups of hot drinks There is a smaller lounge with furniture, which can only be accessed via a flight of steps and so this is underused. There is a hairdressing room situated off this small lounge. There are still plans of extending the home and this will be of a great benefit to the residents and staff when this happens. The home was found clean and in the main free from offensive odours on the day of the inspection, two bedrooms were identified to the manager as having an odour. The laundry was very small but fairly well organised with appropriate hand washing facilities for staff. However the bin was broken and there was no soap available. The labelling of residents clothing was not particularly clear, some clothing was not marked at all, thus reliant on staff recognition and the possibility of residents not wearing their own clothes. Liquid soap dispensers, paper towels and bins were provided in the toilets inspected. Clinical waste is collected by an authorised company. The staff spoken with during the inspection demonstrated a good understanding of infection control measures and gloves and aprons are available. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Staff training has improved, but service users would be better protected by the provision of further training and a review of staffing levels based on residents dependency levels. EVIDENCE: The staff rota was studied and improvements seen at the last inspection have been on the whole maintained. The rotas evidence that in previous weeks the designation of staff have been clearly shown, but not the current week. The staffing levels evidenced that 6 care staff are on duty at 07: 00 am, for one hour it then decreases to four care staff, cook, cleaner and handy person. The manager is supernummery to the staffing levels. The staff spoken with said that they felt that the staffing levels were sufficient to meet the needs of the residents at this time. It was noted on the day of the inspection that the fourth carer went in to the kitchen at 5 pm until 6: 30 pm reducing the number of care staff for residents to three. It is asked that this be reviewed to ensure that there are sufficient carers available to supervise and care for the 26 residents in the home. The staffing levels at night are two carers, and this needs to be kept under regular review as the home is fairly large and bedrooms are situated on both floors. There are a number of stairs in the home, which are a risk if the residents wander or become confused. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 19 The recruitment practices in the home have improved and four staff folders were viewed in depth. It was mentioned again about the need to look closer at some references to ensure they are appropriate to the role they are undertaking. Further advice/ clarification is to be sought regarding student visa and work permits is required to ensure that the hours are consistent. All staff now receive a formal induction programme, which staff confirmed that they had completed, that had completed an induction booklet. A training programme for all staff has been commenced. The staff training records evidence that whilst training is on-going, there are gaps in basic training such as infection control, fire training, adult abuse and health and safety. Seven staff have received training in adult protection, but eleven care staff had not. There was evidence of training in dementia, tissue viability and food and hygiene. It was discussed of ways to evidence training completed by staff, and of devising a training matrix which will prompt refreshers and training required. The staff are encouraged and supported in enrolling on an NVQ training programme. The manager is proactive with ensuring that all staff receive the opportunity for training pertinent to their jobs, and feedback from staff say they enjoy the training sessions. However there is no record kept formally of staff development discussed during their supervision sessions and this needs to be developed. All staff have received the codes of practice for social care workers and employers in their first language. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ benefit from the ethos, leadership and positive management approach of the home, however there is a need to ensure health and safety and quality monitoring systems are fully used. EVIDENCE: The manager completed her NVQ level 4 in the management of care in the latter part of 2005. She has a nursing background and has been the manager of Shakti Lodge for twelve years. She demonstrates a strong commitment and enthusiasm for her role and continues to inspire her staff with her warmth and care of her residents. The manager now has support with the administration side of management of the home and this will be evidenced more fully when the administrator has completed her training in computer systems. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 21 The manager enjoys the interaction with residents and hands on care. Residents are offered genuine affection whilst retaining their respect and dignity. The ethos of the home is to provide support in a relaxed and family environment, which the home evidences very clearly. The focus of the home is the residents. Staff spoken to said that they enjoyed working in the home and all the staff worked as a team. The home still has to fully introduce the quality assurance and quality monitoring system and the annual development plan for the home. The manager confirmed the approach she is going to implement and the next inspection will evidence its success. The manager confirmed that no money is held in safe custody for residents and that residents or their family manage their own money. When residents use the services of the hairdresser or chiropodist the family are billed. Receipts are provided and the transactions are recorded in a book. Each bedroom has a digital cash safe which is for the use of the resident. Care staff have received formal supervision and records were provided, however they had not known that it was to be at least six times a year and this will be introduced. Staff confirmed that they had received supervision from either the manager or the deputy manager. Regulation 26 documents have been received from the provider to the CSCI area office. The office equipment such as facsimile and computer are not in working order at present. The practices and procedures in place for ensuring the safety of the residents were observed during the inspection. The Control of Substances Hazardous to Health (COSHH) register were viewed and appropriate information was recorded, however the COSHH cupboard was found unlocked at this inspection and as it is close to the residents lounge, staff need to be pro-active to ensure it is always kept locked. Risk assessments for safe working practices were found in place, all wheelchairs seen had appropriate foot rests attached. The log for testing fire safety equipment was inspected and found to be of an improved standard. Not all staff records evidenced adequate fire drill attendance and not all staff had received Fire Training. As mentioned previously in the report not all staff had received all the mandatory health and safety training. One bedroom was identified as needing to be reassessed for hazards as the television flex was stretched near to the residents’ bed increasing the risk of a fall, a chair in the laundry room with the covering ripped needs to be either recovered or disposed of, as it poses a cross infection risk. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 22 The position of call bells and overhead lights in the residents’ bedrooms need to be reviewed to ensure that they are within reach of the residents to ensure their health and safety. The Safety certificates for electricity, gas and the lift were checked and satisfactory. Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 3 2 3 3 3 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 3 2 Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14(1) Requirement The Registered Person must not provide accommodation unless the needs of the resident has been fully assessed by a suitably qualified or trained person This refers specifically to a more in depth preadmission assessment (Previous timescale of 10.01.05 & 08/03/06 not fully met) The Registered Person must prepare a written plan (service users plan) with consultation with the resident as to how their needs will be met. The care plans need to have a clear plan of action documented for staff to follow to provide consistent care and support and promote independence. 3. OP8 12(1)((b) 13(1) The risk assessments relating to identified health needs need to be developed with a clear plan of action for all staff to follow. 20/09/06 Timescale for action 20/09/06 2. OP7 OP12 15 20/09/06 Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 25 4. OP12 16(2)12(3 ) 5. OP18 OP28 13(6) 6. OP20 23(h) 7. OP33 24 That all residents have a full social history and profile in place to ensure that their lifestyle meets their wishes and expectations. That a care plan detailing their social needs is developed. That all staff have training in the Protection of Vulnerable Adults and that it is covered in the induction programme of the home. The Registered Person must provide communal space suitable for the needs of the residents. This refers specifically to not over crowding the main lounge. (Previous timescale of 08/03/06 not fully met) The Registered Person must maintain a quality assurance system for reviewing and improving the quality of care provided The Registered Person must ensure that the Home is conducted so as to promote and make provision for the health and welfare of the residents. This includes mandatory training in: Fire safety, moving and handling and infection control. That all furniture is of a good standard. That all residents have access to a call bell facility at all times. That COSHH chemicals are kept safely locked away at all times. 20/09/06 20/09/06 20/09/06 20/09/06 8. OP38 OP22 12 20/08/06 Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP9 OP36 OP27 Good Practice Recommendations The Registered Person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. Care staff should receive formal supervision at least six times a year. It is recommended that the rota is demonstrates staff designation Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Shakti Lodge Ltd DS0000049742.V303956.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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