Inspection on 27/01/06 for Shakti Nursing Home

This inspection was carried out on 27th January 2006.

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

The inspector 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 10/04/08

Shakti Nursing Home 10/04/07

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 Unannounced Inspection 27th January 2006 07:30 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.V278282.R01.S.doc Version 5.1 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.V278282.R01.S.doc Version 5.1 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 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.V278282.R01.S.doc Version 5.1 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 5th July 2005 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 service users in the home. 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 the service users 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 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 vegetarian for people who are of Hindu faith. Vacant beds can be used for respite. Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in late January 2006. The registered manager was available throughout this inspection. The inspector spoke to five service users with the help of an independent interpreter. In addition to this one family member and two members of staff gave their time talking to the inspector. The registered individual was available to ask questions, in addition to this the inspector sampled care plans, staffing files and other relevant documentation. The inspector would like to take this opportunity thanking everybody involved helping the inspector making a judgement about this service. What the service does well: What has improved since the last inspection? What they could do better: Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 6 The inspector made four requirements during this inspection and is confident the home will comply with these. The home must explore a variation of registration to be able to cater for residents with dementia. Financial records will require extra work to achieve full compliance Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 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.V278282.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9; 10 Residents are safely supported with the administration of medication. Staff is treating residents with respect and a culturally appropriate environment is provided. EVIDENCE: Medication was fully assessed during the previous inspection to the home and the home complied with National Minimum Standard outstanding requirements have been assessed during the inspection and the home has fully complied with these. All service users the inspector has spoken to confirmed to be treated with respect by staff. The home has a payphone and hands free, which can be taken to their room if residents wish to do so. The registered manager informed the inspector that all rooms have telephone points, but only three residents expressed interest in having their own phone. Residents have been dressed appropriately during this visit and confirmed that the clothes they are wearing are their own. None of the residents told the inspector of clothes being mixed up, but informed the inspector that the home is laundering their clothes and they are satisfied with this. Mail is given to residents unopened. Residents Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 10 confirmed that they can meet relatives in their room and staff closes the doors if they are assisting residents using the toilet or having a bath. Staff told the inspector that they are told in their induction on how to treat residents with respect and staff handbooks examined by the inspector confirmed this. Staff have been observed supporting residents unrushed and with respect. Residents confirmed that the home allows residents maintaining their cultural identity and religious prayers are provided three times a week by volunteers from the temple. The inspector observed this during this inspection. Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13; 14; 15 Residents have regular visits from friends, families and volunteers. Residents manage their own finances with staff support and are able to bring their own possessions. The home is providing a healthy cultural appropriate diet. EVIDENCE: The inspector observed a number of family members visiting their relatives. One daughter the inspector has spoken to confirmed that she can come whenever she wants to see her mother and the home informes her always of changes or events in regards to her mother. The home has a visitor’s policy in place and there are no restrictions to visiting times, except that visitors are asked if they could avoid visiting at busy times such as the morning or during mealtimes. The policy also clearly states that residents can refuse to see visitors if they wish to do so, but none of the residents spoken to had any issues. Volunteers from the local temple visit the home regularly for Bhajan and residents confirmed that they could go out if they wish to do so. The home has an access to records policy and service users records are safely stored in a lockable cabinet in the nurses’ station. Service users said that they don’t want to see their files, but the policy confirms that this is possible if they wish to so. The family member the inspector has spoken to confirm that she has had a look at her mothers file in the past. The registered manager informed the inspector that family or the Next of Kin manages service users Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 12 finances. The registered manager explained that monies brought to the home are recorded and expenditure is document. The inspector viewed these records and noted that they are of poor standard and informed the registered manager that they need to improve as a matter of having more transparency. Service users confirmed that they can have bring their own possessions to the home. The home provides a vegetarian diet and mealtimes observed are unrushed and appropriate time is spent with each service user. Breakfast consisted of a choice of cereals and a cook prepared lunch during this visit. The inspector did not sample any meal during this visit, but residents expressed full satisfaction with food received in the home. A menu plan is available. Residents confirmed that they can have meat if they wish, but this is not provided by the home and should not be consumed in the lounge, as this would be disrespectful to the other service users, this is clearly documented in service users contracts. Previous requirements around maintenance issues have been complied with. Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16; 18 Appropriate policies and procedures enable service users and/or their representatives voicing their dissatisfaction regarding the service received from the home. The homes policies and guidelines provide protection from abuse. EVIDENCE: The homes complaints policy is compliant with National Minimum Standards. The complaints policy is available in Gujurati.The home has received two complaints since the last inspection, both complaints have been dealt with appropriately and outcomes have been communicated with the relevant people. The home has a Protection of Vulnerable Adults policy in place; the inspector noted that the policy should be updated giving clear guidance of what to do if suspected abuse is witnessed. The home did not have any allegations of abuse since the last inspection. All staff has attended appropriate Protection of Vulnerable Adults training. The home has Protection of Vulnerable Adults guidelines from other funding authorities in place. The proprietor received a Protection of Vulnerable Adults poster from Ealing which is displayed in the home and is available in Gujurati. Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The home is well maintained and requirements are complied with EVIDENCE: The home is clean and safe, previous requirements in regards to the kitchen have been complied with. The inspector raised the issue around the need of redecorating the kitchen and continued recommending this. The inspector noted the white board between kitchen sink and worktop has gaps, which must be repaired. The registered manager informed the inspector that some residents developed age related dementia and must apply for a variation of registration to be able meeting the changing needs of residents. Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28; 29 A well-trained and qualified staff team supports and protects residents. Appropriate recruitment practices support service users from unsuitable staff. EVIDENCE: All staff working at the home has either completed or is in the process of completing their Health and Social Care NVQ Level2, which is commendable and exceeds the required 50 . The home does not employ staff under the age of 18 or student and/or adaptation nurses. The inspector sampled three recruitment files, which were all of good standard, and documents were compliant with National Minimum Standards. The inspector raised the issue of one CRB check missing, which was promptly send to the Commission for Social Care Inspection office and has been destroyed in line within data protection. The home has a clear recruitment policy in place. Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31; 35; 38 A qualified and experienced nurse manages the home. Appropriate policies and insurances protect service users financial interests. Service users health and safety is protected appropriately. EVIDENCE: The registered manager Mrs Evelyn Umamaheswaran is a qualified registered nurse with over thirty years experience. The registered manager informed the inspector of having completed her Registered Managers Award. Staff the inspector has spoken to gave very positive feedback regarding support given by the manager. Observations made during this inspection confirmed this and relationships are judged as friendly and with a good sense of humour. The registered manager is fully involved in residents personal care and has one day allocated for admin duties. Staff and residents demonstrated knowledge and understanding of who is responsible and accountable in the home. Residents Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 17 confirmed that the manager is involved in care and very positive feedback was received. The home has a valid public liability insurance displayed meeting National Minimum Standards. The registered provider showed the inspector monthly accounts, which are clear and transparent. The inspector has viewed the business plan for the current year; the responsible person documents on the plan once proposed actions have been met. This functions as a continues review and the evidence is used for the business plan of the following year. The inspector did not fully assess standard 38, but the last inspection provided evidence of compliance. The previous inspection raised the issue of the lack in recording of fire drills, which has been complied with. Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 X 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 19 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. 2. 3. Standard OP14 OP18 OP19 Regulation 17(1)(a) 13(6) 12(1)(a)& 16(1) 13(4)(c) Requirement The registered manger must improve financial records for service users. The registered manager must up date the Protection of Vulnerable Adults policy. The registered manager must apply for a minor variation of registration to meet registration requirements. The gap between kitchen sink and worktop must be repaired. Timescale for action 28/02/06 28/02/06 28/02/06 3. OP19 15/02/06 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 OP19 Good Practice Recommendations The kitchen should be redecorated. Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shakti Nursing Home DS0000022942.V278282.R01.S.doc Version 5.1 Page 21 - 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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