Inspection on 05/07/05 for Shakti Nursing Home

This inspection was carried out on 5th July 2005.

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

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

Other inspections for this house

Shakti Nursing Home 10/04/08

Shakti Nursing Home 10/04/07

Shakti Nursing Home 27/01/06

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 Middlesex HA9 9EA Lead Inspector Andreas Schwarz Unannounced 5 July 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shakti Nursing Home Address 11 Forty Lane Wembley Middlesex| HA9 9EA 020 8904 7220 020 8903 1934 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs U Chudasama Ms E Umameheswaran Care Home 16 Category(ies) of Old Age registration, with number Physical Disability of places 16 Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1.) Asian Adults in need of Nursing Care aged 50 years and above. 2.) Minimum Satffing notice applies. Date of last inspection 9th March 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.The home is owned by Mrs Urwashi Chudasama 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 G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in July 2005. The responsible individual (RI) Mrs U. Chudasama was available during the first one and half hours of this inspection and the manager Mrs E Umamehewaran was available during the end of this inspection. The inspector spoke to the residents with the help of an interpreter Mrs Gashu Hirami. The inspector was able to talk to two family members during this visit. Additionally the inspector sampled residents’ files and other documents made available to him. The inspector would like to take this opportunity thanking residents, staff, manager and RI of making him so welcome during this inspection. What the service does well: What has improved since the last inspection? The home complied with all requirements made in the previous inspection report. The manager reviewed activities for residents and increased the opportunities for residents attending Bhajan singing sessions as required by residents when asked in surveys. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3; 6 The home has a good assessment procedure in place and residents are involved in this process. The home does not provide intermediate care; therefore this standard was not assessed. EVIDENCE: The RI and manager informed the inspector that the registered manager conducts all assessments within the home. The manager is visiting prospective residents in the hospital or there home and establishes their suitability in moving to Shakti nursing home. The home has a detailed assessment policy in place and assessments viewed by the inspector are following this procedure. The manager informed the inspector that prospective residents are involved in the admission and assessment process; residents and their relatives the inspector has spoken to have confirmed this. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 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 standard(s) 7; 8; 9 Residents have detailed care plans in place, which are regularly reviewed with their input. Health care needs are assessed fully and form part of residents’ care plans. Residents’ medication is of high standards and residents are protected through policies and guidelines. EVIDENCE: The inspector sampled four care plans during this visit, all of which have found to be of good standard and regular reviews with service users input is evident. The registered manager on a monthly basis does review of care plans. All residents have a night care plan in addition to the care plans viewed this is judged as being good practice. Viewed care plans include reports from social workers, risk assessments, health information and important information for nursing staff providing care. There was no clear evidence if relatives are involved within care planning processes; the inspector recommends this. The home manager assesses residents’ health needs. All assessed health needs are well documented within care plans. There is currently no resident living at the home with the need of pressure care. Health care professionals visit the home regularly to support nursing and care staff in providing care Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 10 appropriate. Residents weight is documented at admission and consequently monitored depending on the health needs of the individual. All residents are registered with a local GP, the manager informed the inspector of having good relationships with GP’s visiting the home. The GP is visiting the home on a weekly basis. The inspector sampled residents’ medication records and procedures, which have all found to be of good standard. Qualified nursing staff administers medication at the home. The medication trolley is located in the lounge and is safely secured to the wall. The home is using the Nomad system. The home has an up to date medication policy in place, which adheres to Royal Pharmaceutical Guidelines. The MAR sheet were judged to be of good standard, however the manager must ensure to include residents allergies in residents MAR sheets. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 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 standard(s) 12; 15 Activities within the home have improved since being reviewed by the manager and residents are supported appropriately by the home fulfilling their interests. Residents have a nutritious, well-balanced vegetarian diet provided by the home. EVIDENCE: The manager has reviewed the homes activity programme following previous requirements. Residents the inspector has spoken were very positive about the activities in the home. The home listens to the request made by residents and has now Bhajan singing three times a week. Other activities provided are ball playing, massage sessions, religious prayers, card games, etc. One resident informed the inspector of having more opportunities of playing cards this has been raised with the manager following service users instructions. The inspector viewed the homes’ kitchen, which is in need for decoration. There are a number of missing and loose tiles, the draw bellow the sink needs attention The inspector viewed meal times, which are unrushed and residents are given enough time consuming their meals. The inspector was invited sampling lunch. Which was judged as being very good and nicely presented. All residents and relatives the inspector has spoken to confirm, that the food is very good and culturally appropriate. Fruits and snacks are available throughout the day. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 12 Residents informed the inspector that non-vegetarians food can be consumed, but is not provided by the home. This is documented within contracts and service users guide of the home. Fridge and freezer temperature checks are up to date and food is dated and labelled in the fridge following food hygiene guidelines. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 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 standard(s) 16 Residents and their relatives are listened to when complaining about the services received by the home. EVIDENCE: The inspector viewed the homes complaints policy, which is of good standard. All residents the inspector has spoken to confirmed of knowing whom to complain to. The complaints policy is displayed in the home and is made accessible to residents. The last complaint received was in 2004 and has been investigated by the manager, however it was not reported to the CSCI. The home must report serious complaints to the CSCI. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 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 standard(s) 19; 26 Residents are living in a well-maintained environment and previous requirements have been complied with. The home is clean, pleasant and odour free. EVIDENCE: The home is located close to shops and transport links. The responsible individual showed the inspector around the home. The home is nicely decorated and has a homely feel to it. Previous requirements made in regards to the environment have been complied with. Residents’ rooms are located on the ground and first floor of the building, which can be reached via a passenger lift. The home has different policies relating to residents Health & Safety in place. The laundry area is located on the first floor. The floor and wall coverings are washable. The washing machine and dryer is of semi professional nature and a sluicing facility is available. The home was clean and free from any offensive odours on the day of this inspection. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 15 Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27; 30 A skilled and well-trained staff team supports residents. Staff is competent doing their jobs. EVIDENCE: The overall numbers supporting residents is judged as being appropriate. One registered nurse and three care assistants for the morning, one registered nurse and two care assistants for the afternoon and one registered nurse and one care assistant during the night shift. Staff confirmed that this is an adequate number of staff and residents can be supported to high standards. The manager informed the inspector that a Gujurati speaking staff is available during each shift, residents the inspector has spoken to confirmed this. The manager informed the inspector that the responsible individual is willing to increase staffing numbers if residents needs suddenly change. The inspector viewed residents training records, it was evident that staff receives regular training in mandatory training such as Manual Handling, First Aid, Food Hygiene, etc. Two staff have achieved the NVQ in Care L3 qualification, four staff have achieved their NVQ in Care L2 qualification and five staff working towards achieving this qualification. Staff the inspector has spoken to informed the inspector of receiving good training and of being very happy working at the home. The home has regular handovers and staff is encouraged attending staff meetings to discuss issues relating to residents care. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 17 Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33; 38 Residents are involved and consulted in the running of the home. Residents live in a safe environment and their Health & Safety is protected. EVIDENCE: The inspector viewed the homes’ annual development plan and service users surveys. It was evident that service users wishes are listened to, for example a number of residents requested to have more opportunities of singing Bhajan; the manager has implemented this. Family members confirmed to have received a questionnaire about the home. Additionally all relatives confirmed to be listened to by the manager and changes are implemented. The inspector viewed the following certificates, which were all up to date. Portable Appliances, gas certificate, passenger lift servicing, Electrical wiring, Legionella, nurse call, etc. Fire safety documentation was judged as being of good standard with the exception of regular fire drills. The home must have four fire drills per year one Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 19 of theses must be a night drill. The home was visited in June 05 by the fire brigade and all was found to be satisfactory. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x 3 x x x x 2 Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. Standard OP9 OP15 OP15 OP16 OP38 Regulation 13(2) Requirement Timescale for action 31/08/05 31/08/05 31/08/05 31/07/05 31/07/05 Residents allergies must be included in MAR sheets. 16(2)(g) The missing and broken tiles in the kitchen must be repaired. 16(2)(g) The draw under the sink must be repaired. 37 Serious complaints must be reported to the CSCI. 23(4)(c)(ii The manager must ensure i) documenting regular fire drills. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA7 YA15 Good Practice Recommendations The manager should involve relatives within care palnning processess. The kitchen should be redecorated. Shakti Nursing Home G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex 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 G62 G11 S22942 Shakti NH V234603 050705 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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