Inspection on 23/02/06 for Shivam Nursing Home

This inspection was carried out on 23rd February 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

Shivam Nursing Home 08/03/07

Shivam Nursing Home 27/09/05

Shivam Nursing Home 25/10/04

Shivam Nursing Home 17/07/04

Shivam Nursing Home 05/02/04

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 Shivam Nursing Home 12 Chaplin Road Wembley Middx HA0 4TX Lead Inspector Julie Schofield Unannounced Inspection 10:45 23 February 2006 rd 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 Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 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. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shivam Nursing Home Address 12 Chaplin Road Wembley Middx HA0 4TX 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 8903 6878 020 8795 3738 Chaplin Care Home Limited Mrs Maria Theresia De Silva Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15), Physical disability (0) of places Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 15 Adults over the age of 40 in need of nursing care Date of last inspection 27th September 2005 Brief Description of the Service: Shivam Nursing Home is a care home providing both personal and nursing care, and accommodation, for up to 15 people over the age of 40. The home is one of several care homes owned by the proprietors. Shivam Nursing Home accommodates Asian residents. The home is situated in a residential area of Wembley and is a few minutes walk from the shops and facilities on Ealing Road. It is within easy reach of public transport links and the nearest underground stations are Wembley Central and Alperton. Parking restrictions apply on the roads outside the home but there is a car park, which provides spaces for approximately 8 cars. The building consists of ground and first floors and has a passenger lift. Bedrooms are situated on both floors. Two bedrooms have ensuite facilities and 2 bedrooms are shared rooms. There are bathing and toilet facilities on both floors. The communal space is situated on the ground floor and there is a small garden to the rear of the property. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 visits to the home. The first visit was made on the 23rd February and started at 10.45am and finished at 12.40pm. On the second visit the Inspector was accompanied by an interpreter who spoke with residents in Gujarati. The second visit started at 10.15am and finished at 1.40pm. The manager was present during both visits and the proprietor was present during the first visit. The Inspector would like to thank the management, staff and residents who took part in the inspection. During the inspection a site visit took place, records were examined, discussions took place with management, staff and residents, the preparation of a meal was observed and residents were observed taking part in activities. What the service does well: What has improved since the last inspection? During the previous inspection in September 2005, 5 statutory requirements were identified. Three of these are now met. The manager will carry out a pre-admission assessment of each prospective resident, which is recorded and a copy kept on file. The plan of care includes an identification of the social care needs of service users. The home displays a valid insurance certificate for Employer’s and Public Liability cover. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 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. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 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 Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 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): 3, 6 Prior to admission, information is received about the prospective resident and the manager carries out an assessment to ensure that the needs of the resident can be met within the home. EVIDENCE: During the previous inspection a statutory requirement was identified that the manager carries out a pre-admission assessment of each prospective resident, which is recorded and a copy kept on file. The manager said that this would be done. The home does not provide and intermediate care service. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 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): 7, 9, 10 Assessing the needs of residents and identifying these in a care plan, which is tailored to meeting the individual needs of the resident, enables the resident to receive a quality service. Supporting residents to take their prescribed medication helps the residents to maintain a healthy lifestyle. The home demonstrates this through accurate recording of the administration of medication to residents. Discreet and caring support is given to residents by staff so that the privacy and dignity of the resident is respected. EVIDENCE: During the previous inspection a statutory requirement was identified that the plan of care includes an identification of the social care needs of service users. This is now in place and will form part of the review process. The identification of social care needs includes religious and cultural needs. Medication in use is kept in a locked trolley, which is attached to the wall, when not in use. Inside the trolley the storage of medication was orderly and each resident had a named tray. The administration of medication is from the Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 10 bottle. Bottles were appropriately labelled and tubes or bottles of liquid recorded the date of opening. Records were inspected and were up to date and complete. Residents are called by the name of their choice. Residents confirmed that they are given respect and that carers treat them as they would treat a parent. The manager said that staff are instructed to knock on the bedroom before entering, even if the resident is unable to respond. Residents confirmed this. If the carer is assisting a resident with personal care in the resident’s room and there is a knock on the door the carer will call out and ask the person to wait until it is appropriate to enter. She said that it is important to ask the resident when assisting them “is this what you want”. Residents have access to a telephone where calls can be made and received in private and some residents have their own mobile telephones. Consultations with the GP take place in the privacy of the resident’s bedroom and the resident can also entertain their visitors in private. Rooms that are shared by 2 residents have screening to protect the privacy of the resident. Mobile screening was used when a hoist was used to transfer a resident who was seated in a communal area. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 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): 14, 15 Opportunities for choice enrich the quality of life of residents and they said that they were able to do what they wanted. However opportunities for activities both inside and outside the home are necessary. Residents have a varied and balanced diet, which respects their cultural and religious needs, and which they found enjoyable. Standards 12 and 13 were inspected during the previous inspection in September 2005. EVIDENCE: A discussion took place with the manager regarding the opportunities that residents have to exercise choice in their day-to-day lives. The examples given by the manager included use of their own rooms or the communal areas, whether they wished to see a visitor or not, where they entertained visitors, whether to take part in activities, observing their religious practices and bringing personal items into the home to make their rooms more “homely”. Residents said that they were able to decide what to do and one resident said that she preferred to sit quietly and that she enjoyed her own company and this was respected. Another resident said that that she was able to choose what clothes she wanted to wear each day and that there was a choice of activities. A resident said that they were able to use their room during the day Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 12 when they wished. One resident said that the owners were good and that they came and spoke to residents and asked them about what they wanted. Several residents said that they would like to go out for a walk or for an outing but would need an escort or transport. The preparation of the midday meal was observed. It appeared appetising and wholesome. It consisted of curried vegetables, dhal, salad, roti, poppodoms, rice, yoghurt, lassi and pickles. Kedgeree was also being prepared for 2 residents who wished to eat this later in the day. The cook said that 2 residents sometimes liked to help with the preparation of the vegetables. Food hygiene certificates for the catering staff were on display. The manager said that she had just completed a training course in relation to the new food hygiene regulations. All the residents who took part in the inspection said that the food served in the home was good. A resident said that if there is anything that they want to eat they tell the staff and then it is prepared for them. One resident said that if he wanted to eat his midday meal later in the day because he wasn’t hungry yet this was possible. A resident said that they were pleased to be served fresh Asian meals each day. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 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): Standards 16 and 18 were inspected during the previous inspection in September 2005. EVIDENCE: Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 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, 26 Residents live in a safe and well-maintained environment, which is “homely” in appearance. The clean and hygienic environment promotes the health and safety of residents. However, all staff need to complete infection control training so that the systems in place to control the spread of infection are understood. EVIDENCE: A site visit took place during the inspection although the bedrooms were not inspected as this had been done on the previous inspection. The home is furnished and decorated in a “homely” manner and respects the religious and cultural needs of the residents. A programme of routine maintenance is in operation. During the inspection the gardener was tidying the small garden and the parking area. It was noted that all areas inspected were clean and tidy and free from offensive odours. The laundry room is separate to any part of the home where food is prepared, stored or consumed. Appliances are commercial machines Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 15 and the washing machine has a sluicing cycle. Inside the room are facilities for washing hands. Clothing is marked to identity its owner. It was noted that residents were smartly dressed and that clothing had been pressed. A resident said that the laundry service was quick and efficient. The proprietor said that 5 carers have enrolled on a distance-learning course for infection control while the other carers have completed this training. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 NVQ training builds upon the induction and foundation training already undertaken by carers. The home needs to ensure that staff complete their NVQ training so that the quality of care provided to residents is enhanced. The safety and welfare of residents is promoted and protected through recruitment practices, which include carrying out all the required checks. However the home did not have evidence on file that 2 references had been received for each member of staff. Standards 27 and 30 were inspected during the previous inspection in September 2005. EVIDENCE: During the previous inspection a statutory requirement was identified that 50 of carers achieve an NVQ level 2 qualification. A new timescale has been set. The manager said that 5 of the 9 carers have commenced training. Although staff personnel files are kept centrally the proprietor arranged for the files selected by the Inspector to be on site. These were examined and it was noted that an enhanced CRB disclosure, pova first check, proof of ID, application form, statement of terms of employment and passport details were available. The files did not contain copies of the references. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 17 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): 33, 34, 35, 38 Quality assurance systems need to encompass feedback from all parties interested in the development of the service so that it can continue to meet the changing needs of residents. Comments from the placing authorities are needed to ensure that feedback is comprehensive. In the event of an accident or incident occurring in the home the displaying of a valid certificate of insurance reassures the residents, members of staff and visitors that their safety is protected. Maintaining and servicing equipment used in the home promotes the safety of residents and staff and there are certificates to demonstrate this. Fire precautionary systems and equipment help safeguard residents, staff and visitors and these have been maintained and serviced to a satisfactory standard. Training for staff in safe working practice topics promotes the health and safety of both staff and residents. Standard 31 was inspected during the previous inspection in September 2005. EVIDENCE: Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 18 During the previous inspection a statutory requirement was identified that written feedback from placing authorities is obtained on an annual basis and is used in planning the development of the service. The timescale for compliance has not expired. The proprietor said that although they have sent satisfaction questionnaires to the placing authorities no responses had been received yet. During the previous inspection a statutory requirement was identified that the home displays a valid insurance certificate for Employer’s and Public Liability cover. A valid insurance certificate was on display in the entrance hall. The proprietor said that the home has no involvement in the financial affairs of any resident. She said that the home does not hold any money, or receive the personal allowance on behalf of a resident. There were certificates to demonstrate that systems and equipment in the home were checked and serviced on a regular basis. These included documents for the wheelchairs, the assisted bath, hoists and weighing scales. There was a current Landlord’s Gas Safety Record, electrical installation wiring certificate, P.A.T. certificate, and chlorination of the water certificate. The fire extinguishers, fire alarm system, emergency lighting etc had all been checked and serviced. A discussion took place with the manager in relation to training for staff in safe working practices. Infection control training for staff and health and safety training was underway. Food hygiene training is planned for carers although the catering staff have already completed this. All staff have completed manual handling training and fire safety training. All the nurses and some of the carers have completed first aid training. A fire risk assessment and a health and safety assessment for the building were in place. A record is kept of any accidents that may occur in the home and the book was available for inspection. Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 2 STAFFING Standard No Score 27 X 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 3 N/A X X 3 Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 20 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 OP14 Regulation 16.2 Requirement That discussions take place with residents about their wishes to go out of the home either for a walk or for an outing. That all staff receive infection control training. That 50 of carers achieve an NVQ level 2 qualification. That staff files contain evidence of 2 satisfactory references being obtained, prior to employment. That written feedback from placing authorities is obtained on an annual basis and is used in planning the development of the service. Timescale for action 01/05/06 2 3 4 5 OP26 OP28 OP29 OP33 13.3 18.1 19.1 24.1 01/07/06 31/12/06 01/05/06 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 21 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 Shivam Nursing Home DS0000022943.V269506.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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