Inspection on 24/08/05 for Shakti Lodge

This inspection was carried out on 24th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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

Shakti Lodge 15/03/10

Shakti Lodge 06/05/09

Shakti Lodge 30/05/07

Shakti Lodge 19/07/06

Shakti Lodge 06/02/06

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 208, 210 & 212 Princes Road Dartford Kent DA1 3HR Lead Inspector Nikki Gibson Unannounced 24th August 2005 at 9.00 am 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 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 H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shakti Lodge Address 208,210 and 212 Princes Road Dartford Kent DA1 3HR 01322 288070 01322 288109 care@shaktilodge.co.uk Shakti Lodge Limited 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) Ms Chan Teeluck Care Home 26 Category(ies) of Dementia - over 65 years of age (6) registration, with number Old age, not falling within any other category of places (20) Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2004 Brief Description of the Service: Shakti Lodge is registered to provide care and accommodation for twenty older people and six older people with dementia. Accommodation is provided on two floors which can be accessed via a shaft lift. A few bedrooms and a small lounge can only be accessed via a number of steps. The home has fourteen single and six double rooms, none have en-suite facilities. All bedrooms have a staff call system, washbasin and television ariel point. Residents have access to a pay phone or can use the homes cordless phone. The garden to the rear of the biulding is large and well maintained. Off road parking is available to the front of the building. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which lasted from 9.00 am to 7 pm. It was undertaken on this occasion by a Regulation Inspector from the Southend office of the CSCI. During the inspection there was a tour of the premises and records and documents were looked at. Time was spent in the lounge and dining room observing practice, and with a resident in their own room. Eight residents were spoken to about life at Shakti Lodge. Two visitors, a member of the District Nursing team, the manager and members of staff were also spoken with. The focus of this inspection was the requirements from the last inspection and the outcomes for residents. The manager, staff, and residents were most helpful and this was greatly appreciated. Discussion of the inspection findings took place with the manager and senior staff throughout and at the end the inspection, and guidance was given. What the service does well: Shakti Lodge was clean, bright, odour free and well maintained. It provided care in a relaxed and very informal atmosphere. A visitor said that she particularly liked the ‘touchy-feely atmosphere’ and her mother enjoyed all the hugs she received from the manager and staff. Shakti Lodge aims to provide a ‘home from home’. Staff sit and eat with the residents at meal times, very much like a family meal. Residents who needed help to eat their meals had one to one attention and were given appropriate covers to protect their clothes. The home has a stable staff team many of whom have worked at the home for several years. Residents described the staff as ‘caring’, ‘understanding’, ‘very nice’. Staff were heard joking and chatting with residents and one resident said, ‘even though staff are busy they always have time to chat with me’. Throughout the inspection the atmosphere in the lounge was busy and lively and the lounge was constantly supervised. Staff have received training and more is planned. All the residents were appropriately dressed and looked well groomed. Hair and nails were well attended to and several residents were proud to show their manicured and varnished nails. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 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. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 8 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 standard(s) 1 3 4 5.6 Prospective service users and their supporters do not always have correct information about the home so that they can make informed choices. The admission procedure does not include a sufficiently adequate assessment that ensures that service users needs can be met. The home provides a caring friendly environment where visitors are made welcome. EVIDENCE: Copies were taken and studied and in general the Statement of Purpose and Service User Guide provided detailed and useful information. However, shortfalls detailed in the last report of additional information which must be included have not been addressed. In addition under section ‘20.3.2 Services provided by the home’ it refers to the services of a trained nurse as registered manager. This is inappropriate as Shakti Lodge is registered as a care home and the manager is barred from providing any ‘nursing care’. The manager is fully aware of this, however the reference is misleading and must be removed. The Service User Guide contains a report from the Director which takes much of its style from the CSCI report format. This is inappropriate and misleading. A copy of the most recent CSCI report must be included in each Service User Guide. Both documents must be amended to provide a full and accurate picture of the service provided to assist prospective residents and families in Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 9 making informed choices. Guidance in this report and in the previous report dated 22 November 2005 need to be used to review and amend the documents and dated copies must be sent to the Southend CSCI office for agreement. The home’s preadmission assessment records were limited and did not provide evidence that a full assessment had been undertaken and that the home would be able to meet the residents needs. The areas which need to be covered before a home offers accommodation are listed in National Minimum Standard 3.3. These need to be covered in detail before the home makes a decision and advises the prospective resident whether their needs can be met by the home. Copies of such letters to recently accommodated residents could not be provided for inspection. On the day of inspection residents’ needs were assessed as being met. Time was spent observing residents and staff interactions. Staff were seen to have the skills and training to provide a good standard of care. Residents were relaxed and well groomed. Appropriate activities were taking place and the home was clean and well maintained The home is registered for six service users with Dementia. The actual number of residents with a diagnosis of dementia being cared for has been under dispute for sometime. The manager said that at the present time she had admitted six residents with a diagnosis of dementia and there were also two residents established in the home who were showing some signs of dementia. The CSCI do not wish to cause unnecessary upheaval but rather to confirm that relevant healthcare professionals have completed a thorough assessment and a diagnosis of dementia has been confirmed. It is important to ensure that other treatable conditions are ruled out. The home must demonstrate that they can meet the changing needs of all the residents. The home wishes to develop this area of care and training has begun. The manager said that a specialist Dementia Nurse visits the home on a monthly basis to give general or specific advice. Guidelines from the CSCI on registering to provide care for people with dementia has been sent to the home. When they feel able to meet the requirements they are advised to request a variation of registration form and their application will be duly assessed. In the meantime the manager is reminded when assessing new residents to remain within the home’s registration category and numbers. The manager said that all prospective families are strongly encouraged to visit the home before making a decision, and prospective residents who are able to visit, are also made welcome. Shakti Lodge does not provide intermediate care. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7 8 10 The lack of adequate assessments limited the homes ability to write detailed and clear care plans. Communication with healthcare professionals has improved and health needs were being met. EVIDENCE: The quality of the care plans varied and various formats have been tried. The manager and some staff have undertaken care plan training and this has engendered new ideas and interest. However, at the time of the inspection the care plans studied were confusing and lacked adequate assessments. Consideration needs to be given as to how risk assessment relating to falls and pressure sores etc, and a list of current medication are to be included. The lack of adequate assessments limited the homes ability to write adequate care plans. Most care plans did not fully cover issues of health, personal care and were particularly lacking in information on social needs and how they were to be met. The home has yet to introduce an adequate system for assessing the risk of pressure sores and recording the treatment and outcomes. Staff were interested to discuss how care plans could best be reviewed. A new system had been considered but not utilised and advice was given to ensure the system was effective, simple and that it did not become a ‘paper exercise’. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 11 Two members of the district nursing team were spoken with either in person or over the telephone. No concerns regarding resident’s health care were raised. They said that the home made appropriate referrals and communication had improved. They also said that any advice given by the medical profession was followed by staff unless the resident refused. The home has separate records for medical appointments for easy retrieval of information. During the inspection staff went about their duties in a manner which respected the resident’s privacy and dignity. A resident said that she was pleased to be able to have the same member of staff help her take a bath each week. She said the door was always kept closed and the member of staff went out of her way to maintain her privacy and independence. All bedroom, toilet and bathroom doors were fitted with appropriate locks. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12 13 14 15 A wider range of meaningful pastimes is now being offered which promotes mental and physical wellbeing. Links with families are good and contact is encouraged. The home provides home cooked food in ample quantities in a homely environment. EVIDENCE: A programme of activities was displayed on a white board and it was advised that it is written in a format that more residents could read. At the time of the inspection the Activity Person was on leave, normally she takes a lead but is supported by all staff. It was pleasing to note that throughout the day staff remained in the main lounge providing various group activities. One resident said she enjoyed the armchair exercises and discussions on items in the newspaper. The manager said that individual and small group activities were now being introduced since staff had attended Dementia training. This will be reviewed further if the home wishes to increase the number of residents with a diagnosis of dementia. The home may wish to obtain further advice on appropriate activities for the elderly from the National Association for Providers of Activities for Older People on 01376 585225 Email: tessatnapa@aol.com It was acknowledged that large group outings were not appropriate, however two small groups had recently gone out in cars to go strawberry picking. A resident said she had really enjoyed the trip and she also enjoyed the Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 13 entertainers and parties which are held. Details of the activities offered and taken up were recorded in the care plans. Visitors to the home were spoken with and they were very complimentary about the staff and the care provided. They said they were always made welcome and provided with a quiet area to sit. The home has an open visiting policy. Resident’s views about the home were very positive. Comments included, “Freedom to do what you like is the best thing, and I can’t think of a worst thing”. “No one orders you about here”. “This is a care free place” “You can say what you like here”. “If I had a problem I would speak to Chan”(manager) The menu for the day was displayed on a white board but not in a manner that many residents could read. The manager plans to introduce menu cards on each table. Meal times at Shakti Lodge are very social occasions and a member of staff sits at each table and eats with the residents. Some residents remained in their armchairs to eat and were assisted by staff in a sensitive and dignified manner. The cook said she is aware of likes and dislikes and these are catered for. However, a true choice is not provided at lunchtime and this should be considered, as it would improve the residents’ options and quality of life. One resident said that she would like Lasagne to be on the menu. The deputy manager said that fresh fruit is prepared in the afternoons and offered to the residents. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 18 The complaints policy was not accessible to residents and visitors to the home and a record of complaints was not available. The home’s Abuse Policy requires amendment. These are outstanding issues, which put residents at risk and have been raised at previous inspections. EVIDENCE: The home’s complaint policy as detailed in the Statement of Purpose and Service User Guide was clear and appropriate. However at the time of the inspection a copy of the complaints policy was not publicly displayed. The log of complaints and how they were investigated could not be found and was not available for inspection. The home needs to evidence that they take complaints seriously and deal with them appropriately. Again the home had difficulty locating the Adult Abuse Policy. The policy when found required development to ensure that all staff are familiar with the actions to be taken following an allegation of abuse. The importance of not undertaking an investigation before alerting social services, CSCI and possibly the police was discussed. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19 20 21 22 23 24 Shakti Lodge was clean, bright and well maintained and provided the residents with homely and comfortable surroundings. The premises are not specifically suited to residents with dementia, but improvements are being made with this group in mind. EVIDENCE: The home is located on a busy road in a residential area. The premises are well looked after and maintenance records were available. The rear garden was pleasant and accessible to residents. There is a popular main lounge-diner where activities take place and staff are stationed. This is the hub of the home and residents favour this room. A separate quieter small lounge was available, however it had low seating and was accessed via a short flight of stairs, which made it inappropriate for most residents. Staff reported that residents were reluctant to use the small lounge so in consequence the main lounge was over crowded. This crowded lounge with rows of chairs detracts from the otherwise domestic atmosphere of the home. The proprietor has given consideration to providing a conservatory, Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 16 which may address the problem if appropriately situated, staffed and furnished. Toilets had robust grab rails and were clearly marked, however the wheelchair symbol is inappropriate as they are not assisted toilets. Toilets and bathrooms contained liquid soap, paper towels and lidded bins and a good standard of cleanliness was maintained. The home does not have any hoists and this needs to be considered as resident’s age or be come more infirm or suffer a fall. It is also a significant issue, which must be born in mind when assessing residents before they enter the home. There are handrails in corridors, however there are areas of the home with steps that can only be accessed by the more able residents. The manager said that following dementia training the decorating programme has been reviewed to provide more calming colours. Bedroom doors are identified by large brass numbers, the manager said this had proven successful for the present residents, however alternative means of identifying rooms would be used if considered helpful. Room sizes are detailed in the service user guide. Only one resident was noted to use a wheelchair at the time of the inspection. Most bedrooms were inspected and each had been personalised and were clean, light and odour free. All but two rooms had the furniture expected and the manager stated the residents were free to request additional furniture if they wished. Two rooms however lacked any armchairs; the manager explained that these had been moved into the lounge as a temporary measure. She confirmed that additional armchairs would be purchased as a priority. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 29.30 An adequate staffing level was not being maintained throughout the day to meet the needs of the residents. Staff training had taking place, however there was no clear staff development programme. EVIDENCE: The staff rota was studied and advice given that for clarity it must contain full names and designation of staff. The manager was advised that all staff working in the home including her should appear on the rota so that it is an accurate document. Agreed staffing levels were not being maintained and at the end of the day the number dropped to an unacceptable level. Due to the lack of a teatime cook/domestic, senior staff were rostered to work in the kitchen. This took them away from the care of the residents and the supervision of junior staff. After tea one resident was observed having been left alone in a wheelchair in a corridor. She was distressed and vocal and remained waiting outside a toilet for several minutes. The manager agreed to review the staffing level and the following day informed the CSCI that a tea time cook would be employed and the level of four care staff including one senior would be maintained throughout the waking day. The manager’s role continues to be supernumerary. There is two awake staff at night. Staff are undertaking training and a record of planned training was seen. The manager said that she and six members of staff had attended a Care Planning and Risk assessment course. However the home did not have a simple way of checking that all staff had undertaken appropriate training or when that training was required to be updated. Recent training included two courses on the needs of people with dementia and challenging behaviours. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 18 Staff recruitment records were inspected, however these were disorganised and some documents took a long time to be found. Two written references are required including one relating to the persons last employment with vulnerable adults or children. The home was advised that Criminal Records Bureau checks are not transferable and the home must make itself aware of the correct procedure as detailed in the DOH Protection of Vulnerable Adults Scheme ‘A Practical Guide’ published July 2004. The recruitment procedure must be more robust in order to protect residents. The home has an appropriate induction programme and staff spoke with enthusiasm of the courses they had attended. The Statement of Purpose details considerable investment in training, which indicated there was a strong commitment to training, however the organisation of records was poor and did not provide good evidence. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 34 36 37 The manager has a vision for the running of the home, which is not always fulfilled. Poor administrative organisation has lead to ongoing shortfalls. Improvements have been made since the last inspection and these need to be built on for the smooth running of the home. EVIDENCE: The manager is trained and experienced in the care of the elderly and has worked as the manager at Shakti Lodge for eleven years. She takes a practical role in the care of the residents and residents said they found her affectionate and approachable. Issues regarding the number of residents with a diagnosis of dementia have arisen in the past and led to a formal written caution from the Commission for Social Care Inspection. At the time of the inspection it was noted that a high proportion of residents demonstrated some level of confusion. However, apart from the issues already highlighted in the report there was no evidence that in general their needs were not being met. The home is increasing its knowledge and understanding of the needs of Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 20 residents with dementia and environmental changes are taking place. The manager is undertaking further training to increase and update her knowledge and she is currently undertaking NVQ level 4 in Management. Residents, relatives and staff said that they felt able to approach the manager. One member of staff said it was the ethos of the home to give the residents whatever they wanted. Staff morale was good and the manager said she had an excellent relationship with the registered proprietor, whose first aim was to put the residents’ needs and wishes first. There was nothing to indicate that the home was not financially viable. The registration certificate and Public Liability Insurance certificate were both displayed. The manager said that formal supervision of staff had lapsed in recent months therefore records were not inspected. This is a standard that has been met in the past and needs to be got back in line. The manager said that the registered proprietor’s regulation 26 inspections and reports had not taken place in recent months. A report dated March 2005 was faxed to the home during the visit. Copies must be sent to the manager and CSCI on a monthly basis. The manager was given written advice on how to obtain guidance on Regulation 37 notifications from the Internet. For the present time both these documents should be sent to the Southend Office of the CSCI Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 3 2 3 2 x x STAFFING Standard No Score 27 1 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 3 x 3 x 2 x x Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 22 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 1 Regulation 4(1) Requirement Timescale for action 14.10.05 2. 1 5(1) 3. 3 14(1) 4. 3 14(1) The Registered Person must produce a Statement of Purpose which meets the requirements of this regulation and submit it to the CSCI. (Previous timescale of 30.12.04 not met) The Registered Person must 14.10.05 produce a Service User Guide which meets the requirements of this regulation and submit it to the CSCI (Previous timescale of 30.12.04 not met) The Registered Person must not 14.10.05 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 indepth preadmission assessment (Previous timescale of 10.01.05 not met) The Registered Person must not 14.10.05 provide accommodation until they have confirmed in writing to the resident that having regard to the assessment the care home is suitable for the purpose of meeting the resident’s needs in Version 1.40 Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Page 23 5. 7 15 6. 16 17(2) 7. 18 13(6) 8. 20 23(h) 9. 24 16(2)(c) 10. 27 18(1)(a) respect of his health and welfare. This refers specifically to having copies of such letters available for inspection on the residents files. (Previous timescale of 10.01.05 not met) The Registered Person must prepare a written plan (“service user’s plan”) with consultation with the resident as to how their needs will be met. This refers specifically to further developing the care plans(eg Risk of Pressure sore assessment) and the monthly review. The Registered Person must maintain a record of all complaints about the operation of the Home and the action taken. (Previous timescale of 30.12.04 not met) The Registered Person must make arrangements to prevent residents from being abused. This refers to policies and procedures being in place and known to staff. (Previous timescale of 30.12.04 not met) The Registered Person must provide communal space suitable for the needs of the residents. This refers specifically to not over crowding the main lounge. The Registered Person must provide in rooms occupied by residents adequate furniture and equipment suitable to the needs of the resident. The Registered Person must ensure that at all times there are suitably qualified, competent, and experienced persons working at the Home in such numbers as are appropriate for 14.10.05 14.10.05 14.10.05 14.10.05 14.10.05 14.10.05 Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 24 11. 29 19 12. 36 18(2) 13. 37 17(2) 26 37 the health and welfare of the residents. (Previous timescale of 10.01.05 not met) The Registered Person must ensure that robust recruitment procedures are in place, and applied consistently. All records required by regulation in respect of staff recruitment must be obtained prior to a staff starting work The Registered Person must ensure that persons working in the Home are appropriately supervised The Registered Person must ensure that the records required by legislation are maintained. This includes, Regulation 26 reports and Regulation 37 notifications. 14.10.05 14.10.05 14.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 15 22 14 36 Good Practice Recommendations It is recommended that residents are made aware of the full extent of the options available to them at each mealtime and a real choice should be offered. It is recommended that the provision of a hoist is reviewed in light of the changing needs of the residents. It is recommended that service users, relatives and friends are given details of an advocacy service who will act in their interests. Care staff should receive formal supervision at least six times a year. Shakti Lodge H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend-on-Sea Essex, SS2 6BG 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 H56 I06 S49742 Shakti Lodge V250390 240805 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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