Inspection on 06/05/09 for Shakti Lodge

This inspection was carried out on 6th May 2009.

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

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

Other inspections for this house

Shakti Lodge 15/03/10

Shakti Lodge 30/05/07

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 20/07/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Shakti Lodge 208-212 Princes Road Dartford Kent DA1 3HR Lead Inspector Robert Pettiford Key Unannounced Inspection 6th May 2009 7:15 DS0000049742.V375235.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shakti Lodge Address 208-212 Princes Road Dartford Kent DA1 3HR 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) 01322 288070 Shakti Lodge Limited Ms Chan Teeluck Care Home 26 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE) The maximum number of service users to be accommodated is 26. Date of last inspection 15th April 2008 Brief Description of the Service: Shakti Lodge is registered to provide care and accommodation for twenty-six older people. 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 residents 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 are £431, additional charges are made for hairdressing, chiropody, newspapers and outside activities. Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection took place at 7:15AM on 6th May 2009 We agreed and explained the inspection process with the manager. The focus of the inspection was to assess the home in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. We used a varied method of gathering evidence to complete this inspection, pre inspection information such as discussion and correspondence with the registered provider/manager was used in the planning process. This was to support us to explore any issues of concern and verify practise and service provision. The home had completed an annual quality assurance assessment questionnaire (AQAA). This provided us with information relating to What the agency considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. The judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Commission to be able to make an informed decision about outcome areas. Further information can be found on the Commissions website with regards to information on KLORAs and AQAAs. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other areas viewed included risk assessments, pre-admission assessments, rotas, and training records. In addition an environmental tour took place. We identified several residents for case tracking (a review of the level of care and support needed, and if it is being provided in a way that treats them with respect and dignity). What the service does well: The management and staff encourage residents to see the home as their own home. Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 6 Staff demonstrate their commitment to achieving best outcomes for residents. Staff stated they expressed job satisfaction and liked working in the home. Residents who spoke to us confirmed in their own words that they receive a good quality of care from staff that are courteous, respectful, communicate well, and deliver care in the way they prefer. Several residents spoke highly of the care staff and felt that they enjoyed the activities they participated in and liked the home they lived in. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Shakti Lodge DS0000049742.V375235.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 DS0000049742.V375235.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents know that their needs will be properly assessed prior to moving to the home and they receive comprehensive information about the home and services provided. Intermediate care is not provided. EVIDENCE: The standard relating to the assessment of residents prior to them moving into the home was met from the previous inspection. No evidence or intelligence would suggest that the process does not continue to meet with the required standard. Records showed that residents have an assessment, which identifies their individual needs prior to or on admission to the home. The AQAA states prospective residents can be referred through Social Services Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 9 or through private arrangement. From an initial enquiry, the home arrange to visit the prospective resident at his/her home or at another location at the request of a care manager or member of the family. In some circumstances, an Enquiry Pack is sent to the enquirer. Should an enquirer respond to this initial pack, the home arrange to meet with them to discuss future needs. The potential resident is always visited and assessed within his/her own environment, be it at home, in hospital or with a relative or friend as stated in the AQAA. At this initial meeting, the potential resident is invited to spend a day at the home to meet staff, residents and visitors in a relaxed atmosphere and without feeling under any pressure. This also gives us the opportunity to make a more in-depth assessment. Occasionally a prospective resident either cannot or does not wish to make an initial visit because of disability or other reason. The AQAA and discussions with the manager confirmed that if procedure is successful for both parties the prospective resident is invited to take up a fourweek trial period before a long-term arrangement is discussed. This is of a two way benefit, as it allows the resident to settle into the new environment and to assess whether the changes they are experiencing are beneficial to their quality of life. This trial period also allows the home to assess the success or difficulties of the placement and to reflect on whether it is providing the care and facilities required by the new resident. On admission care needs are discussed with the new resident and their relative or advocate in attendance and a ‘Care Plan’ established and agreed. Each resident is encouraged to bring personal items and to make their room as personal and homely as they wish. The home retains the right to refuse or accept such items on the basis of safety (and all electrical items are tested for safety). The assessment process as shown in the AQAA recognises cultural needs and the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. The home does not provide intermediate care. Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from having individual plans that identify there physical and medical needs and provide the support they need. Residents can feel confident that they are fully supported with their healthcare needs. Residents are treated with respect and dignity and their rights to make decisions about their lives and they have the opportunity to be consulted on, participate in, all aspects of life within the home as they wish or their capacity allows. Residents can feel confident that the homes policy and procedures with regard to the administration and dispensing of medication is sound. EVIDENCE: Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 11 The staff at the home are committed to supporting all residents including those to make informed decisions, understand the range of options, which are available to them and have the right to take responsible risks. Evidence of this was gathered through taking to the residents, staff, and the manager. We discussed with the manager the care records relating to several residents at Shakti Lodge. In the care plans viewed there were guidelines in respect to support needed. The home undertakes regular reviews. Formal reviews involving significant professionals where possible are also undertaken. The homes care plans do not wholly use a socially lead model. From the care plans viewed they were of a medical / clinical approach. The plan of care needs to better evidence social and personal goals including hopes, and aspirations where possible, to better evidence the current support given to residents at the home. It was therefore recommended that the home review this element of its care planning process. We viewed a sample of care records and specific health care records relating to several residents. Records viewed confirmed residents had access to a range of health care input as and when required and as part of regular health checks. This included access to their chosen G.P (where possible), Dentist(where possible), Optician and Chiropodist in addition to identified specialist health care input. The Home facilitates residents keeping hospital appointments and seeing their own GP. It is evident through talking to members of staff at the home that the wellbeing of the residents is of a high priority and that staff are pro-active in maintaining and supporting residents with their needs in order to maintain their quality of life. This was confirmed in discussions with many of the residents who lived at the home a relative and feedback received from comment cards returned. Risk assessments were reviewed within the home and discussed with the manager. Assessments seen detailed how to support residents to minimise risks for personal safety and had been updated and reviewed. However not all of the residents had a moving and handling assessment. The manager stated that this is reviewed. This she agreed to do and implement. We visited the home at 7:15AM. During the inspection we noted that residents up were seen making choices about their lives and were seen to be part of the decision process as their capacity allowed. A relaxed atmosphere was noted with the residents taking to staff. The AQAA states the home recognizes that for some older people confusion, forgetfulness and dementia are part of the ageing process. There are referrals to the mental health team, daily district nurse accessibility, medical Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 12 professionals input, individualised care plans, qualified staff on each shift trained to dispense medication, medication audits. Daily records were not wholly comprentaneous however in that they had gaps and full names of staff were not seen. It was recommended that the home follow the Nursing and Midwifery Council guidance: Guidelines for records and record keeping. We viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of Medication within the home. The manager confirmed that all staff that dispense medication have received the appropriate training. Medication was inspected and found to be administered correctly on evidence seen. It was also requested that any additions to the medication record sheet are signed and verified by two members of staff to ensure accuracy. It is recommended that the home at a frequency to be determined consults with a pharmacist and implements any suggestions with regard to the management of medication within the home. Shakti Lodge DS0000049742.V375235.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that they are offered a range of opportunities for personal development. Residents engage in a good level of activities, which are appropriate to their needs and capabilities. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The residents benefit from the appetising meals and balanced diet offered at the home. EVIDENCE: Discussion with staff and residents confirmed that the levels of activities were of a good quality and that they enjoyed a good level of stimulation through leisure and recreational activities. Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 14 Residents were observed participating and interacting with staff. Residents have been enabled to and encouraged to participate in activities, which they had an interest in. It was confirmed that residents are enabled to maintain contact with relatives and friends where they wished to do so. The AQAA showed that residents are encouraged to use all aspects of their home according to their ability and wishes. Residents undertake a wide variety of activities. The AQAA evidenced that the home continues to contract an activities organiser. She offers craft sessions, quizzes, music therapy, bingo and reminiscing. Staff also offer activities in the afternoon e.g. board games, cards, quizzes and general conversation. Local churchs visit regularly to provide spiritual support. The AQAA states residents have a variety of spiritual needs. Care staff help to provide for these through the care planning process according to the needs and preferences of each resident. The Vicar of Christchurch provides a service each month. He regularly drops in to meet with residents. If they express a wish in this regard, they are supported in attending their church. On Sundays, many service users watch or listen to morning service and, in the evening, “Songs of Praise”. The stated the home has previously been featured on a radio religious programme. A Catholic lay visitor provides Communion to residents. The AQAA states the home has traditionally provided services that meet the needs and preferences of people from ethnic minority groups (eg. Food and religious preferences). At Christmas, the Vicar of Christchurch arranges for a 45 strong choir from a local girl’s school to provide a concert for staff and residents. The Commission had the opportunity to speak with the Catholic lay visitor who expressed her views and opinions of the home. During the discussion she spoke of the good quality of care offered and the dedication of the manager and staff. From observation, records viewed it was evident that residents were offered a choice of menus that meet their dietary needs and individual preferences. Meal times are flexible to suit the residents activities and schedules. Residents are able to choose where to eat, and also and have drinks and snacks for themselves. Residents on evidence seen have had been involved in planning and choosing what to eat where possible. This was additionally confirmed following discussion with one resident. However another resident wished to have more choices at mealtimes. Shakti Lodge DS0000049742.V375235.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can feel confident that their concerns and complaints are taken seriously. Residents are protected from the risks of abuse. EVIDENCE: A copy the complaints procedures was reviewed. The procedure included details of how to complain, timescales for response and information for referring a complaint to the service provider. However the complaints procedure needs to refer to the ability to make a complaint to the Commission and Social Services at any time. Residents within the service have an understanding of how to make a complaint as their capacity and understanding allows. Any complaints that have been received from information contained within the AQAA on evidence seen were dealt with appropriately to achieve the best outcome for the complainant. The homes Policy for the Protection of Residents and staff Whistle blowing procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training has been provided for staff, evidence of this was seen within the staff files and training record. Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 16 Further evidence and the AQAA showed the Complaints procedure is displayed at the main entrance to ensure it is made visible for everyone to see. Residents and families are giving a copy of the complaints procedure on admission and they are also verbally informed about the procedure by the manager. The majority of staff trained in NVQ 2 have covered a module of adult abuse and also have attended a study day on abuse. The Commission identified a very small number of staff that had not received such abuse training. The manager is aware of this shortfall and confirmed that it would be addressed as a priority. The Commission is confident that this will be the case and has not made a requirement at this time. The manager stated robust policies and procedures are in place as well as having good practice documentation in place such as the Kent and Medway Adult Protection procedures. However the homes copy at time of inspection was not available. The manager stated that it was borrowed by a member of staff and not returned. The manager was concerned about its whereabouts and confirmed that a new copy would be ordered as a priority. The manager speaks to the residents daily when working as this gives the residents an opportunity to express any concerns or anxieties. Communication is effective and residents and families feel comfortable to raise concerns or worries. The manager stated that Criminal Record Bureau Checks (CRB) had been obtained for all staff. The Commission saw evidence of this. Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a generally well maintained environment, which provides a homely warm atmosphere. However some areas are in need of refurbishment. Residents are protected by the homes infection control procedures and policies EVIDENCE: It was apparent that the individual and collective needs are being met in a generally comfortable environment. The standard of internal decoration and fixtures and fittings are maintained and of a generally good quality. Some areas, furniture and furnishings however would benefit from a degree of refurbishing. The manager is aware of this and confirmed that it forms part of the homes action plan. Evidence was seen at the time of the inspection that new chairs had Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 18 been ordered for the residents rooms thus confirming the homes commitment to improve the environment. An environmental risk assessment has been carried out to maximise the safety of residents. The management and staff encourage residents to see the home as their own home. It provides a safe comfortable, home which has all the specialist equipment and adaptations needed to meet individual residents needs. The home is planning shortly to build a conservatory to further improve the environment for the residents. This was seen a major investment for the home and a mark of the providers commitment to improve the experience of residents living within the home. Evidence seen and the AQAA showed that the layout of the home is suitable, accessible and well maintained for the residents to meet their needs. It is kept hygienically clean to a high standard. Bedrooms have been personalised to suit individual tastes. They are encouraged to bring personal belongings and furnishing to aid transition and ensure that they will be comfortable in the care home with their own personal belongings. Access to patio area leading to a mature garden is kept clean and tidy. Fire risks assessments have been carried out and contractors check all fire systems regularly. Door guards are in place. Staff carry out weekly fire alarm testing and monthly emergency light checks. The home is very well lit, tidy and smells fresh. The premises are kept clean, hygienic throughout and the manager stated systems are in place to control the spread of infection. However the home was requested to seek the views of an Infection Control Nurse to ensure that the transportation of dirty linen / clothes within the home meets current guidance. The laundry area consists of an industrial washing machine and tumble dryer.. Policies, procedures and risk assessments are in place. Water pipes have been fitted with thermostatic valves to ensure water safety. Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents care, social and emotional needs are promoted by the employment of caring staff in such numbers to support their needs that put the interests of the residents first. Residents can feel confident that they are supported by staff that have been employed by the home using sound recruitment procedures and that they are trained to a good standard overall. EVIDENCE: From discussions with the manager, observations and reviewing the staff rotas sufficient staff were on duty at the time of inspection to meet the residents needs. Staff are receptive to residents needs and work together as a team. The manager stated staffing levels are always under review to ensure the needs of the residents are met. Risk assessments have been prepared both for the residents as individuals and the environment. The staff training records indicated planned and undertaken training in all the key areas. Core training in Infection control, moving and Handling, Basic Life support, fire training, food hygiene, and Adult protection has been provided. The manager evidenced that individual and group staff training needs had been identified. Core courses are undertaken by staff to maintain current Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 20 qualifications and for protection of residents. Staff have achieved NVQ qualifications in Care to level 2 or above, thus meeting with the required standards. However the manager needs to ensure that all staff providing personal care have the required training to meet the needs of the residents. It was evidenced that a few staff had not received all the training to enable them to perform their role. The manager confirmed that the home has a development programme for all new staff, which meets Sector Skills Councils workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users, and that all members of staff receive induction training to specification. The inspection of the recruitment files at the previous inspection evidenced that the required checks had been carried out and that the standard was met. Upon reviewing a sample of recruitment file the standard continues to be met. All required information was contained within the files and all checks of identity have been carried out. All staff have a CRB (Criminal Record bureau Checks). Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are currently being met and can be confidant that the home is managed appropriately by a competent experienced manager and that the quality assurance of the service is monitored. However the quality assurance visits of the provider could be improved. Residents can feel confident that their health and safety is protected. EVIDENCE: The manager is actively involved in the day-to-day management of the home and works with staff and residents. She has many years of experience caring for others and is a Registered Nurse. Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 22 Outcomes for the quality of care are good. Residents expressed a great deal of satisfaction of the care provided and the staff are very supported of the manager and have a positive ethos. There is strong evidence that the ethos of the Home is open and transparent. The views of both residents and staff are listened to, and valued. Quality assurance was discussed and the views and opinions of many of the residents and stakeholders sought. The residents and visitors spoken with confirmed a great deal of satisfaction of the quality of care offered within the home and residents felt confident that their views and opinions were valued by both staff and management. The registered provider of the home does regularly visit the home. Completion of what is known as a Regulation 26 visit takes place. This requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. We recommended to the manager that the visits additionally need to focus more on outcomes for residents with regard to quality of care, staffing, adult protection, recruitment, audits of policies and procedures, staff training, activities in addition to health and safety. The home has a full range of policies and procedures to promote and protect residents health and safety. There is full and clearly written recording of all safety checks and there is no evidence of a failure to comply with other legislation. There is a good understanding of risk assessment and this is taken into account in all aspects of the running of the home. The quality assurance system confirms that the findings from risk assessments have been actioned. The manager however needs to ensure all staff are trained in health and safety matters and have regular planned updates at the required frequency. Shakti Lodge DS0000049742.V375235.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 x x 3 x x x 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 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP30 Regulation 18(1) Requirement The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users— (a) Ensure that at all times suitably qualified, competent and experienced persons are working at the care home and that they receive training appropriate to the work they are to perform. To ensure that residents are supported with their needs by suitably trained staff Timescale for action 06/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shakti Lodge DS0000049742.V375235.R01.S.doc Version 5.2 Page 25 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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