Inspection on 30/05/07 for Shakti Lodge

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 19/07/06

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 Graham Cummings Key Unannounced Inspection 30th May 2007 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.V339040.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.V339040.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.V339040.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 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 on admission a 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. The garden to the rear of the building is large and well maintained. Off road parking is available to the front of the building. Intermediate care is not provided. Residents have access to a pay phone or can use the homes cordless phone. Fees charged as from 1 April 2007 range from £410 to £450, which includes toiletries, additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection under Inspecting for Better Lives (IBL). The inspection consisted of looking through previous inspections and information held including a completed AQAA. A site visit took place where discussions with the Manager, staff, people using the service, relatives and visitors occurred. A tour of the property and viewing documentation completed the inspection. The home is registered for 26 people and the occupancy on the day of the site visit was 23. The evidence gathered showed the home to be providing good quality care and support that allowed people living at the home to be as independent as possible in a supportive environment. Comments from people living at the home and relatives spoken to included; ‘I have no concerns about the care my mum receives’ ‘We are treated excellently, very good’. What the service does well: What has improved since the last inspection? The recording and paperwork required has improved and the home has responded positively in addressing the requirements made at the last inspection. A new pre admission assessment form has been implemented recently and this will be put in use over the next couple of weeks when possible new admissions are assessed. The home has almost completed making a new office with the furniture on order and awaiting delivery. The home has also purchased a new fridge and freezer. The plans are now in place for a conservatory to be built across the rear opf the house that will increase the communal space within the home. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have been given the information they require and an opportunity to visit the home before making a decision. Assessments of need had been carried out to minimise the risk of the placement failing. EVIDENCE: The home has a Statement of Purpose and Service User Guide that is given to prospective admissions and their families when a referral is made. All prospective admissions and their friends and relatives are invited to visit the home and meet staff and existing residents. Intermediate care is not provided. The Manager receives an assessment from the funding local authority as well as carrying out their own assessment of need to ensure that the home can meet the individuals needs. The home has got a new Pre Admission Assessment form that will be put to use when assessing to fill the three current vacancies, this includes where the information was gathered and who gave it as suggested in the last inspection. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have their individual needs set out in a care plan and are treated with respect and dignity. They have their health needs met, but nobody currently self medicates. EVIDENCE: The Manager and Head of Care complete care plans. Information is used initially from the local authority assessment and the pre placement assessment. After two weeks information is gathered from staff about the actual care that is required and a new care plan is made that is then reviewed every month. Evidence seen in three care plans confirmed that evaluations take place, however not all of the paperwork was signed and dated. The manager takes responsibility to get answers to any questions raised by staff from previous carers or family. All of the people living in the home are registered with a local doctor and dentist, an optician visits the home regularly, a chiropodist visits the home every six to eight weeks. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 10 Medication is ordered and checked by the manager and a record of returns was also available. None of the current people living at the home self medicates, the home has a policy for this should it ever be required. The care plans viewed had information about the individuals routines for the morning regarding what time they wanted to be woken, with or without a cup of tea, the personal care required and how the individual wanted it provided. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service lead a lifestyle that allows them to exercise choice and that enables them to have their needs met. They have unrestricted contact with family and friends and a choice of meals on a daily basis. EVIDENCE: Wherever possible people living at the home live a lifestyle of their choice that keeps them safe. The home has good external relationships with agencies and on Sundays a small service and hymn singing is available and on Fridays Holy Communion can be accessed if required. The home employs an Activities Co-ordinator that works 3 days a week from 10am to midday and 2 days of 8am to 4pm. The activities include Monopoly, Snakes and Ladders, Cards, Hangman, Who Wants To Be a Millionaire, Dominoes and Connect 4. Other games are ‘Words Beginning With’ ‘Countries Beginning With’ and someone then choose a letter. On the day of the site visit one person was going out for lunch and then going on to see the show ‘Sound of Music’. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 12 A board is placed in the dining area that is completed every evening with the following days menu, during the morning people are asked for their choice. The individuals likes and dislikes are also recorded in the care plan. The home employs three cooks who work at different times. On the three files seen it was noted that there was minimal information in the ‘past events’ section and this should be looked into and improved. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home and their relatives feel their concerns or complaints would be acted upon and people are protected from abuse. EVIDENCE: The home has a copy of the complaints procedure on display and all people living at the home are given a copy when they arrive at the home. The procedure gives telephone numbers for CSCI, Dartford Social Services and Citizens Advice Bureau if people living at the home felt unable to speak to the Manager or staff. Staff training includes recognising signs of abuse and are aware of the Social services Safeguarding Adults document and Protection of Vulnerable Adults. The homes uses their yearly quality assurance document to raise the issue of concerns and complaints and the procedures to follow should any incident need to be raised. A visitor to the home spoken to was aware of the complaints policy but had no reason to use it. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service live in a safe, clean, comfortable and well-maintained environment. Communal space is being increased to compliment peoples personal space. EVIDENCE: The home has plans in place and work is due to start by August 2007 for a large conservatory area at the rear of the property connected by a covered walkway. Although the home has a small and large lounge, the small lounge is not used on a regular basis, this is because people using the service choose and want to be in the large lounge in each others company. On the day of the site visit, two visitors and a resident were using the small lounge. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 15 The home was clean, tidy and well-maintained. The home employs a cleaner, three cooks and maintenance person. The bedrooms viewed were well decorated and furnished. The rooms seen were individualised with personal belongings on display. Shared bedrooms had curtains to provide privacy when washing and changing. All bedroom doors were fitted with automatic door closures. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service have their needs met and are protected by a well trained and competent staff team and the homes recruitment process. EVIDENCE: The home has four carers on duty from 7am to 8pm, between 1pm and 3pm six staff are on duty when a handover takes place. An Activities Co-ordinator working five days per week, 2 days 8am to 4pm and 3 days of 10am to 12pm. From 8pm to 8am there are three waking night staff on duty. The Manager and Head of care are also on duty and cover 7 days a week and supernumerary to the care rota. The home also employs a cleaner, cook and maintenance person. All staff have, or are completing their NVQ level 2 or higher in care. The Manager has an NVQ 4 and RMA with the Head of Care having an NVQ level 3 and just starting their RMA. Other training completed in the last year includes Dementia care, Manual Handling, Safe handling of Medication, safe handling of Vulnerable people, Infection Control, Nutrition and Health, Health and Safety, Food Hygiene, Care Planning, Loss and Bereavement and First Aid. Courses are held at Bexley, Orpington and West Kent College and Aset training. A lot of the courses are run over 13 weeks and are competency based with the certificate valid for three years. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 17 Staff recruitment process is in line with good practice and when starting they have a period of two weeks shadowing staff and supernumerary on the rota, they also complete a 13 week induction program. Three staff files were viewed and found to contain all of the recruitment requirements set out in Schedule 2 of the Care Home Regulations 2001 including Identification, interview notes, contract, CRB, 2 references, health declaration, job description and induction. Staff supervisions were not complete, and there is a need to carry out individual formal supervisions a minimum of six times per year. Some of the records seen were not dated or signed and the Manager and staff need to make sure this is carried out. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home that is managed by a person who is able to discharge their responsibility fully and run in their best interest of the people living there. The health and safety of people living at the home is promoted and protected but supervision and recording of information could be improved. EVIDENCE: The Manager of the home has been in place since 1996 and has the NVQ 4 and Registered Managers Award. They have also completed the RVQ in Dementia Care. During discussions with the Manager it was apparent that they were dedicated to providing a good quality of care outcomes for the people living at the home. The Manager believes in an approach that promotes teamwork and creates an open positive and inclusive atmosphere. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 19 The home does not handle peoples finances, any expenses incurred on their behalf has a receipt and invoiced monthly to the individuals finance controller. Staff have received their yearly appraisal, but, on the three files viewed not all of them contained six formal supervision notes over the last year. Some of the documentation viewed was not signed and dated, the Manager is going to review the paperwork in use and make sure there is a space for the date and signature it was completed, evaluation dates were in place. The Manager is responsible for the health and safety of the building, there is a maintenance book that any jobs or work need completing are written and the maintenance person looks at daily and carries out the work. Any serious or dangerous issues are dealt with immediately by outside agencies if it is outside of the skills of the maintenance person. Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 20 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 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 3 3 Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 21 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 OP12 Regulation 16(2)12(3 ) Requirement 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. Timescale for action 20/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP36 Good Practice Recommendations Care staff should receive formal supervision at least six times a year. That documentation is signed and dated 2. OP37 Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shakti Lodge Ltd DS0000049742.V339040.R01.S.doc Version 5.2 Page 23 - 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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