Inspection on 10/04/08 for Shakti Nursing Home

This inspection was carried out on 10th April 2008.

CSCI 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 Nursing Home 10/04/07

Shakti Nursing Home 27/01/06

Shakti Nursing Home 05/07/05

Shakti Nursing Home 09/03/05

Shakti Nursing Home 13/07/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Shakti Nursing Home 11 Forty Lane Wembley Middx HA9 9EA Lead Inspector Andreas Schwarz Key Unannounced Inspection 11:00 10 & 11th April 2008 th 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 Nursing Home DS0000022942.V361138.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 Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shakti Nursing Home Address 11 Forty Lane Wembley Middx HA9 9EA 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) 020 8904 7220 020 8903 1934 shaktihome@aol.com Mrs Urvashi Chudasama Evelyn Umamaheswaran Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16), Physical disability (0) of places Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Asian Adults in need of Nursing care, aged 50 years old and above. Minimum staffing notice applies. Date of last inspection 10th April 2007 Brief Description of the Service: Shakti Nursing Home is a registered care home providing accommodation, personal care and nursing care for up to 16 Asian elders; on the day of the inspection there were 16 people using the service. Mrs Urvashi Chudasama owns the home and the manager is Mrs Evelyn Umamaheswaran.The home is situated on a main road in Wembley Park, within easy reach of local facilities. There is parking for four cars on the forecourt. The home is a large converted three-storey house and was first registered under the Registered Home Act 1984 in August 1997. Accommodation for people using the service is provided on the ground floor and first floor, accessed by a through floor passenger lift; there is one shared and 14 single occupancy rooms. On the second floor there is an office for the registered provider and a staff room. There is a garden and patio at the rear of the property. The building is Grade 2 listed. The home is providing vegetarian meals for people who are of Hindu faith, but also provides care for people from different religions. Vacant beds can be used for respite care. Fees and charges can be obtained from the registered manager or responsible person. Shakti Nursing Home DS0000022942.V361138.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. This unannounced key inspection started on the 10th April 2008 at 11:00am. We visited the home on the 11th April 2008 to complete this key inspection. This key inspection lasted 8 ½ hours. We spoke to six people using the service with the help of a Gujarati speaking interpreter. We interviewed two members of staff, the registered manager and registered provider. Eleven service users surveys and three staff surveys have been returned to us. The home has returned a completed Annual Quality Assurance Assessment form within the given timescale and information from this document has been included in this report. We looked in-depth into the care of five people using the service. As part of this process we viewed care plans, health records, activity records, menus and other documents. We assessed nine staff files, training records and supervision records. We observed staff interacting and supporting people using the service. We would like to thank people using the service, staff registered manager and registered provider for supporting us during this unannounced key inspection. What the service does well: Shakti Nursing Home is providing care and support for Asian elders. Staff speak a range of Asian languages, i.e. Gujarati, Hindi, Tamil, Urdu, Swahili. All people using the service and visitors spoken to were very positive about the care and support provided by the home. The home is enabling people using the service to pray and regular Bhajan sessions are organised. One of these sessions is organised by the local temple. It was clearly evident that the home is enabling people using the service to make choices about their lives, for example one person choose not to eat solid food. The home arranged with the help of the General Practitioner, the person’s family and the person an Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 6 alternative, which is both healthy and nutritious and is meeting the person’s needs. Care plans are of good standard and are reviewed monthly, together with the person or their chosen representative. Meals are nicely presented, nutritious and reflect the religious as well as cultural identity of the people living at the home. Staff informed us that they feel supported by the registered manager and registered provider, both of whom are available regularly to support staff and people using the service. 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. The summary of this inspection report can be made available in other formats on request. Shakti Nursing Home DS0000022942.V361138.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 Nursing Home DS0000022942.V361138.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): We assessed standard 3 during this key inspection. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. To ensure the home is able to meet the needs of new prospective people the manager is undertaking detailed assessments. People using the service and or their representatives are involved in the assessment process. The home is not providing intermediate care. EVIDENCE: We assessed five care plans. One of the care plans assessed was a person being admitted to the home recently. The registered manager undertook the assessment. The assessment provides information about the persons needs, likes and dislikes. Information gathered during the assessment process is included in the persons care plan. The home has a referral and assessment Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 9 policy. We asked people using the service if they remember an assessment being undertaken, but none of the people was able to tell us. A visitor however told us that he could remember the manger doing an assessment of his mother at the beginning of her moving into Shakti Nursing Home. During the assessment the registered manager is assessing the compatibility of the new resident and if the home can meet his/her cultural needs. The home does not provide interim care; standard 6 was therefore not assessed. Shakti Nursing Home DS0000022942.V361138.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. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 7-10 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are written with the individual, or their representative, and include a range of information that is important to them. People receive personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. People using the service have access to healthcare and remedial services. The home has a medication policy which is accessible to staff. Medication records are generally up to date for each person and medicines received, administered and disposed of are recorded to ensure people using the service are safe. EVIDENCE: Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 11 We assessed five care plans during this key inspection. The home has introduced a new care-planning format at the time of the last key inspection. The new format is now fully implemented. Care plan information is based on the initial needs assessment, which is undertaken prior or during admission to the home. All people using the service have key workers and co-key workers allocated. All five care plans have been reviewed monthly. People using the service their family and placing authority are involved in the care planning process and annual placement reviews are undertaken. During monthly reviews any changes are recorded and care plan objectives are updated. We viewed individual night care plans for people who present challenges during nighttime or have specific needs such as changing of incontinence pads or needing to be turned due to the risk of developing pressure sores. People using the service told us that their family is dealing with the care plans. Care plan objectives are achievable. Staff told us that they have read care plans as part of their induction. We have viewed personal records, which demonstrate that people using the service are supported to wash, shave, dress, etc. All staff records showed that staff receives an induction prior to supporting people using the service. The registered manager informed us that currently none of the people living at the home have any pressure sores. If people are likely to develop pressure sores this is recorded in their care plan and appropriate intervention such as turning regularly, use of pressure mattresses, or cushions are provided. We viewed detailed health records and visits to and from health care professionals are clearly documented. The home is recording people’s nutritional intake and dieticians or General Practitioners are involved if there is reason for concern. We viewed falls assessments, manual handling assessments, use of bedrails assessment and consent during this key inspection. All records are of good standard and have been regularly updated. All people living at the home are registered with a local General Practitioner. Registered nurses administer medication. The controlled drugs cabinet is fixed to the wall, we sampled records of two people, which were all in order. The home is using the Nomad system. Medication Administration Sheets are of good standard; we noted that one of the Medication Administration Sheets assessed did show that during the morning of the 08/04/08 one dose of antibiotics was not administered. This was discussed with the registered manager. We informed the registered manager that she must investigate this and send a report to the Commission for Social Care Inspection. The registered manager is checking medication weekly and the Medication Administration Sheet monthly. This is clearly recorded. The medication policy has been reviewed in February 2008. One of the people case tracked is receiving liquid medication, the bottle has not been signed after opening, and this is required. Overall the medication standards are judged as good and regular auditing and monitoring is evident. None of the people living at Shakti Nursing Home is selfmedicating. Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 12 People using the service told us that staff is treating them with dignity and respect. One person told us; “They know me very well and know what I need”. We observed during this inspection, that when using the hoist staff is using a blanket to cover people up, this ensures nothing is exposed. We observed the registered manager giving mail unopened to people using the service. People using the service informed us that they wear their own clothes, which was judged as age and culturally appropriate. People’s preferred form of address is recorded in their care plan. Shakti Nursing Home DS0000022942.V361138.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. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 12-15 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to develop and maintain important personal and family relationships. People using the service are involved in meaningful daytime activities of their own choice and according to their individual interests. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. Care staff are sensitive to the needs of those people who find it difficult to eat and give assistance with eating their meals. EVIDENCE: Visitors told us that they could visit the home whenever they want, staff inform them about issues relating to their parents or relatives, and the home involve them in care plans and activities organised by the home. The home receives weekly visits from the local temple for prayer meetings, which was observed during this visit. The home is offering activities such as ballgames, walking Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 14 exercise, reading of books, play cards, etc. Peoples participation is recorded. Daily activities are displayed on a notice board in the lounge. A large number of people living at the home do not speak English as their first language and it is recommended to display the activities in English and in Gujarati. Staff told us that people using the service would benefit from a wider range of community-based activities. We informed the registered manager that this should be explored and discussed with people living at the home. People told us that they could meet visitors in their rooms, but they prefer to meet them in the shared lounge. We viewed records of monies held by the manager on behalf of the people using the service. Records have improved since the last inspection and people using the service and relatives are encouraged to sign for the money. All people spoken to informed us that they could bring their own possessions, which was seen in rooms visited during this key inspection. The home has a confidentiality policy and people’s files are safely stored in a lockable cabinet. The home offered for us to sample lunch during this key inspection. The meal was nicely presented and was suitable for people living at the home. The home is providing a vegetarian Asian menu. People using the service told me that they enjoy the meals provided. Meal times were relaxed and staff support people who require help around eating their meal very patiently. The registered manager informed us that menus are reviewed every three months and the cook is meeting people using the service regularly to discuss the meals provided. The home has three cooks employed, who work during different times of the day. All cooks hold a valid Food Hygiene certificate. One person told me that she can eat meat, but this is provided from her family. The statement of purpose states that Shakti Nursing Home is a vegetarian home. We thought that people using the service would benefit to have the daily menu displayed on a notice board. Shakti Nursing Home DS0000022942.V361138.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. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 16 and 18 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows people using the service to express their views and concerns in a safe and understanding environment. The service has a complaints procedure that is clearly written and easy to understand. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. EVIDENCE: The home has received two complaints since the last key inspection. We viewed complaints records and both complaints have been well documented and recorded. The registered manager followed up each complaint and the complainant has been informed about the outcome. The homes complaints policy is available in Gujarati. We informed the registered manager to include the new Commission for Social Care Inspection contact details in the complaints policy. People using the service and visitors told us that they know how to complain and who to approach. Staff told us that they would record complaints and tell the registered manager to deal with them. Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 16 The home has a safeguarding adults policy in place and training records show that all staff have recently attended safeguarding adults training. We informed the registered manager to include the new Commission for Social Care Inspection contact details in the safeguarding adults policy. The home did not receive a safeguarding adults referral since the last inspection. Staff demonstrated good understanding of safeguarding adults procedures and how to respond and report safeguarding adults allegations. Shakti Nursing Home DS0000022942.V361138.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. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 19, 20, 24 and 26 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. People using the service are encouraged to personalise their bedrooms. All the home’s fixtures and fittings meet the needs of individuals and can be changed if their needs change. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. The home is well lit, clean and tidy and smells fresh. EVIDENCE: Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 18 The home is located on Forty Avenue in Wembley and has easy access to bus stops, which are a short walk from the property. The nearest tube station is Wembley Park, which is a short bus ride away. The closest supermarket is ASDA, which can easily reached by bus or foot. The home has a Close Circuit Television camera on the entrance door, to prevent unauthorised access. The home was visited by the Local Environmental Health Department last year and recommendations made have been complied with. The home has a large garden and car park, which are kept clean and tidy, and are fully accessible for people using the service. The home has an ongoing problem with subsidence. The registered provider informed us in writing that this is in the hand of their insurers and the claim has been authorised. During the day of this inspection the registered provider had a meeting with the Insurance Company to discuss the upcoming refurbishment. The work will affect the kitchen, the lounge and some of the bedrooms. We asked the registered provider to forward a work schedule and risk assessment to the Commission for Social Care Inspection. The home has a large lounge, which is used as a dining room. People using the service informed us that they could meet visitors in their room, but prefer to meet them in the shared lounge. The home has a large well-maintained garden, which can be accessed by people using the service. The communal rooms are airy and well lit. Furnishing in communal areas is worn, but the registered provider informed us that these would be replaced during the planned refurbishment. Five people using the service allowed me to view their rooms. All rooms were spacious and nicely decorated. Pictures and other personal possessions were on display and all rooms were clean and tidy. The home was clean, tidy and free from any offensive odours. Two domestic staff are employed during the morning. The domestic staff is also responsible for washing laundry. The home sluice room is clean. There is a washing machine and dryer in the laundry room. The flooring and walls can easily be cleaned. The ironing board cover is very worn and we recommend purchasing a new cover. Shakti Nursing Home DS0000022942.V361138.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. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed all the above National Minimum Standards during this key inspection. People using the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The recruitment of good quality carers is seen as integral to the delivery of an good service. The service is proactive rather than reactive in its staffing, recruitment and training, with planning for the potential needs of people who use the service. Management prioritise training and facilitate staff members to undertake external qualifications beyond basic requirements. The service ensures that all staff within its organisation receives relevant training that is targeted and focused on improving outcomes for people using the service. Staff has the skills to communicate effectively with all people. EVIDENCE: We viewed staffing rotas during this inspection. The home has three early, three late and two night staff on duty every day. On certain days the home has additional staff on duty, to facilitate hospital appointments or planned activities. We observed staff interacting with people using the service and we never had the impression that staff is rushed of their feet, or people using the service had to wait long for support. People using the service told us that there Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 20 is enough staff on duty, but during busy periods in the morning or during the evening they have to wait a little longer for staff. The home has two domestic staff and four cooks employed. The home has one registered manager, seven Registered Nurses, three senior carers, ten carers and one care assistant employed. All staff has the necessary National Vocational Qualification in Care, with the exception of the care assistant, who recently started employment. The registered manager told us that the care assistant is currently attending an English course, before starting her National Vocational Qualification in Care. We assessed nine staffing files during this inspection; all files contained the required documents such as Criminal Records Bureau checks, references, application form, passport photo, visa status, and Nursing and Midwifery Council registration. Staff told us having received a statement of terms and conditions; copies were viewed in their files. The home has a recruitment policy in place, which has been followed. Staff recruited reflects the cultural and ethnic background of people living at the home. The majority of staff speaks Gujarati and/or Hindi. A family member told us that life for his mother has improved since the home employed a Tamil speaking member of staff. One member of staff told us that she has been working in the home for almost eleven years and has learned to speak Gujarati, which helps her to communicate more effectively with people using the service. The home has detailed training records of all employees in place. Copies of certificates are kept in a separate folder. Staff informed us that they are happy with the training provided by the home. All staff receives food hygiene, first aid, manual handling, safeguarding adults training. Some staff is currently attending a Dementia course provided by Harrow College. Shakti Nursing Home DS0000022942.V361138.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. JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 31, 33, 35, 36 and 38 during this key inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. The service has sound policies and procedures, which the manager effectively reviews and updates. The home works to a clear health and safety policy. All staff is aware of the policy and are trained to put theory into practice. Regular random checks take place to ensure they are working to it. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. The home has a consistent record of meeting relevant health and safety requirements and legislation, and closely monitoring its own practice. Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager Mrs Evelyn Umamaheswaran is a qualified registered nurse with over thirty years experience. The registered manager informed us of having completed her Registered Managers Award. Staff we have spoken to gave very positive feedback regarding support given by the manager. Observations made during this inspection confirmed this and relationships are judged as professional, friendly and with a good sense of humour. The registered manager is fully involved in personal care and has one day allocated for admin duties. Staff and people using the service demonstrated knowledge and understanding of who is responsible and accountable in the home. People using the service confirmed that the manager is involved in care and very positive feedback was received. We viewed a robust quality assurance policy during this key inspection. The home has undertaken service users and family surveys in November 2007, which were overall very positive. Information from these surveys has been included in the annual development plan for 2008. The development plan is regularly updated and achieved actions are recorded, with the date. The registered manager does regular medication audits and Health and Safety checks. These tasks have been allocated to staff. The previous Commission for Social Care Inspection report was available in the home for people to access. The home does not act as an appointee for any of the people living at the home. We viewed the resident’s finance policy, which is judged as robust. Financial records have improved since the last inspection. The person using the service or their representative now signs for Expenditure and Income. A valid public liability insurance is displayed. Service users monies are safely locked away, and can be accessed by the registered manager or Registered Nurses. The money is currently kept in individual envelopes, but we noted that money fell out of the envelopes during this inspection and it is recommended to provide better facilities to safe keep people’s individual monies. The home is providing supervisions to staff, we noted however that the minimum requirement of six supervisions per year has not been met. We discussed this with the registered manager, who informed us that she finds it difficult at times to provide regular supervisions to staff. We advised the registered manager to look into different ways and forms of supervisions, which can be provided. Staff informed us that they think, they would benefit from regular supervisions, but they are very happy with the support they receive from the registered manager and registered provider. Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 23 Staff receives fire training as part of their induction and regular refreshers are provided. A robust fire policy is in place. Signs to direct people to fire exits are in English and Gujarati. Fire points are tested weekly; the last fire drill was undertaken on 27/03/07. The fire alarm was serviced on the 08/01/08 and a very detailed fire risk assessment is in place. The home has undertaken regular services of lift, hoist and nurse call. The water is tested for Legionnaires Disease annually. The Portable Appliances Test Certificate expires in June 08, the Landlords Gas Safety Certificate expires on 28/02/09 and the electrical installation certificate expires on 23/11/08. The home has a contract with the local council to remove clinical waste. Robust Health and Safety policies, Infection Control Policies are in place, which have been reviewed by the registered manager. Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 24 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 2 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 X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement The registered provider must investigate and send a report to the Commission for Social Care Inspection regarding the member of staff omitting one dose of antibiotics. The registered provider must ensure that liquid medication bottles are signed once opened. This is to ensure that only medication, which is not expired, is administered to people using the service. The registered provider must ensure to include the new contact details for the Commission for Social Care Inspection in their complaints policy to provide complainants with the necessary information. The registered provider must include the new contact details for the Commission for Social Care Inspection in their safeguarding adults policy. Timescale for action 15/05/08 2. OP9 13(2) 01/05/08 3. OP16 22(6)(a) 01/05/08 4. OP18 13(6) 01/05/08 Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 26 5. OP36 18(2) The registered provider must provide a minimum of six supervisions per year, to discuss people’s performance, conduct, development and understanding of the work. 15/05/08 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 OP7 Good Practice Recommendations The registered manager should provide care plans in a user-friendly format. The registered manager should provide the activity plan in a user-friendly format and language. The home should discuss with people using the service about the provision of a wider range of community-based activities. The weekly menu should be provided in a user-friendly format and should be displayed in the lounge or any other communal area. The registered person should forward a work schedule and risk assessment to Commission for Social Care Inspection in regards to the planned refurbishment. The registered person should replace the worn ironing board cover. The registered person should provide better storing facilities for peoples monies. 2. OP12 3. OP12 4. OP15 5. OP19 6. 7. OP26 OP35 Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 27 8. OP38 A minimum of four fire drills is recommended to ensure people are aware of what to do in case of a fire or emergency. Shakti Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Nursing Home DS0000022942.V361138.R01.S.doc Version 5.2 Page 29 - 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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