Inspection on 27/09/05 for Shivam Nursing Home

This inspection was carried out on 27th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shivam Nursing Home 08/03/07

Shivam Nursing Home 23/02/06

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 27th September 2005 09:15 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.V253108.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.V253108.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.V253108.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 25th October 2004 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, which specialise in the care of Asian service users. 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 parking for 8 cars in the onsite car park. 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 facilities on both floors. The communal space is situated on the ground floor and there is a garden to the rear of the property. Shivam Nursing Home DS0000022943.V253108.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 unannounced visits to the home. The first visit started at 9.15 am and finished at 1.15 pm. The manager was on duty and a proprietor called to the home. The second visit started at 9.30 am and finished at 11.45am. The manager was on duty and the other proprietor called to the home. The Inspector would like to thank the manager and proprietor, staff and residents who took part in the inspection. During the inspection records were inspected, the serving of the midday meal was observed, a partial site inspection took place and discussions took place. What the service does well: What has improved since the last inspection? Since the last inspection the service users’ guide has been amended to include a copy of the complaints procedure. Carers have undertaken either in-house or externally organised training courses in adult protection procedures. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 6 The home has developed a more comprehensive activities programme for residents. 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.V253108.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.V253108.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): 1, 3, 5, 6 Residents and their relatives are assisted in the choice of care home by the provision of information about the home, in a suitable format. Carrying out an assessment of the resident prior to their admission ensures that the needs of the resident can be met within the home and a record of this assessment must be kept on file. Residents and their families are involved in the process of choosing a care home that can meet the needs of the resident and make their decision after an introductory visit to the home. EVIDENCE: A discussion took place with the manager about documents used in the admission process for residents. She said that many of the residents spoke Gujarati but were unable to read or write Gujarati. Family members supporting them were able to read the documents, which were printed in English, and explained the content to the prospective resident. It is recommended that an audio tape is prepared, in Gujarati, which covers the statement of purpose, the service user’s guide and contract so that residents may hear first hand what the home offers. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 9 The case files for 3 residents, who have recently been admitted to the home, were inspected. Each file included pre-admission information from the placing authority. One file contained a copy of the pre-admission assessment form completed by the manager when she visited the prospective resident in the hospital. The manager had carried out a pre-admission assessment of the second resident but had not recorded this. The manager had not assessed the third resident but the pre-admission information provided by the placing authority included information from the previous care home. Two files had evidence of the family providing information as part of the pre-admission process. A resident said that they had visited the home prior to admission, with their sons. Their first impressions of the home was that it was “very good”. The manager said that where a pre-admission visit by the resident had not been possible a family member had been encouraged to make a visit, on behalf of the resident. The manager said that a pre-admission visit usually took place if the resident had been living in his or her own home or in another care home. Pre-admission visits by the prospective resident did not take place if they were in hospital. The home does not provide an intermediate care service. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 A comprehensive care plan assessment ensures that the individual needs of residents are identified and met and the home’s assessment must include the social care needs of the resident. Evaluating care plans on a regular basis ensures that changes in the needs of residents are identified and can be addressed. Residents’ health care needs are met through access to health care services from the community and from support by staff in the home. EVIDENCE: The case files of 3 residents were inspected. None of the care plans inspected addressed the social care needs of the resident. Each care plan had been evaluated on a monthly basis. Staff assist residents with personal care and oral hygiene. Equipment is provided to promote tissue viability although the manager said that none of the residents have pressure sores at present. The home contacts the continence adviser, as necessary. McMillan nurses have previously supported residents living in the home. A member of staff said that they encourage residents to walk, as a form of exercise. Two residents said that their mobility had improved since their admission to the home and they had progressed from Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 11 using a wheelchair to walking with a zimmer frame. Residents confirmed that they had access to health care facilities in the community including flu jabs, their GP, the optician and the physiotherapist. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 12 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): 12, 13, 15 Providing activities for residents offers residents an opportunity to develop their social and communication skills and to enjoy an interesting and stimulating lifestyle. The support of staff enables residents to maintain family contact. Residents have a varied and balanced diet and said that they enjoyed the meals served in the home. EVIDENCE: Residents confirmed that religious festivals are celebrated in the home and that prayers are said. During the second visit a lady was sitting in the lounge and was reading religious tracts aloud to a resident. Residents said that they enjoyed the activities and during the second visit they were preparing cotton wall balls for use in religious ceremonies. The activities co-ordinator is also encouraging residents to develop and/or retain their numeracy and literacy skills. A resident said that they had done counting yesterday and pointed to the activities co-ordinator and said “she’s very nice, my teacher”. During the inspection visitors came to the home and residents confirmed that their visitors were made welcome and were offered refreshments. There were photographs of the most recent celebration of a festival in the home and these Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 13 included residents, staff and visitors. When residents entertain visitors they either do this in the lounge or in their own room. Residents said that the meals were good and that the food was spiced and seasoned to their taste. One of the proprietors brings fresh vegetables to the home and residents are given a choice of these when curries are prepared. She said that a different dhal is served in the home each day. A resident described their favourite dish and said that this was served in the home. Pureed food is served to residents who have difficulty swallowing. A monthly record is kept of the weights of residents. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 14 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 The welfare of residents is promoted and protected by having a complaints procedure in place. Residents said that they were confident to use this, if the need arose. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. EVIDENCE: The manager said that no complaints have been recorded since the last inspection. The home has a complaints procedure and a copy of this is contained in the service users’ guide. The procedure advises the complainant of their right to contact other agencies, including the CSCI. Residents said that they would be able to speak to some one in the home if they had any comments or concerns. The manager said that no allegations or incidents of abuse have been recorded since the last inspection. The home has a copy of the interagency guidelines from the London Borough of Brent in respect of adult protection. The adult protection policy includes a reference to whistle blowing. Since the last inspection training in the protection of vulnerable adults had taken place in house and some staff had taken part in PoVA training, which had been organised by the local authority. The manager said that the home does not practice restraint. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 15 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): 20, 24 With access to a comfortable lounge/dining area or to their bedroom, residents had a choice of socialising or enjoying their privacy. Residents were pleased that they were able to practice their religious observances in their rooms or, as part of a group of residents, in the lounge. Residents said that the size of their bedroom and the furniture and fittings met their needs. EVIDENCE: One of the residents said that rather than spending time in their room they preferred to sit in the lounge “for company”. Communal space consists of an open plan lounge/dining area and there are also chairs in the hallway where one or two residents like to sit. The communal areas are comfortably furnished and decorated and there are facilities for religious observances. The television in the lounge had been turned on and it was tuned to an Asian channel. A member of staff said that when residents wanted a change the television was switched off and music was played instead. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 16 Some residents spoke to the Inspector in their rooms and they said that the rooms were comfortable and warm. Rooms were personalised with photographs, grand children’s drawings, religious objects etc. Some residents said that they liked to watch the television in their rooms. Each room contained furniture, sufficient for the needs of the resident, and was in a good state of repair. Rooms also contained a wash hand basin. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 17 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): 27, 28, 30 The rota demonstrated that there were sufficient staff on duty to support the residents. 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. EVIDENCE: The rota for week commencing 26th September was available. The hours of the manager were supernumerary. There was a 1st level nurse on duty on each shift. In addition there were 3 carers on duty in the morning, 2 carers on duty in the afternoon/evening and 1 carer on duty at night. Domestic staff were on duty each day and catering staff were on duty from 9 am to 2 pm and from 5 pm to 7 pm each day. Residents said that the staff were kind and helpful. It was observed that there was a good rapport between staff and residents. During the previous inspection in May 2005 a statutory requirement was identified that 50 of the staff team achieves an NVQ level 2 qualification by 31 December 2005. The manager reviewed the staff team’s progress and said that 5 carers had started their NVQ level 2 training although at the moment the course is in abeyance as the college is making changes to the curriculum. She said that as the staff team would not complete their studies by the end of 2005 the home would not achieve a target of 50 of the staff team having an NVQ level 2 qualification by this date. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 18 There was a record of 9 carers attending a TOPSS induction and foundation training programme in July 2005. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 19 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, 33, 34 The registered manager continues to develop her knowledge through the successful achievement of an RMA training qualification and this contributes towards understanding the needs of residents and staff. 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. The valid certificate must replace the out of date certificate, which is on display. EVIDENCE: The manager is a registered nurse and has had many years experience of working at and managing nursing homes. She has completed the NVQ assessors’ course and has successfully completed her RMA training. The certificates for each of the 9 modules of the RMA course were shown. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 20 A discussion took place with the manager regarding the ways in which the home encouraged feedback from those receiving care (or their relatives) and from those providing the care and how this information is used in planning the development of the service. Quality assurance systems included staff questionnaires and staff appraisals. Questionnaires were also sent to relatives although only 1 response was received. Relatives have been canvasses about setting up a relatives committee to discuss issues relevant to the running of the home but only 1 expression of interest was received. Residents are encouraged to give comments to the manager on a daily basis or to the proprietors when one visits the home each Thursday. Written feedback from professional visitors to the home e.g. representatives from the placing authority, has not been obtained. A statutory requirement was identified during the inspection in October 2004 that a copy of the insurance certificate for Employer’s and Public Liability cover is available for inspection. The certificate on display in the home was for the period 1/9/04 to 31/8/05 and was not valid. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 21 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 3 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X 3 X X X 3 X X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 2 X X X X Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14.1 Requirement That the manager carries out a pre-admission assessment of each prospective resident, which is recorded and a copy is kept on file. (Previous timescale of 01 April 2005 not met). That the plan of care includes an identification of the social care needs of service users. (Previous timescale of 01 April 2005 not met). That 50 of carers achieve an NVQ level 2 qualification. (Previous timescale of 31 December 2005 not met). That written feedback from placing authorities is obtained on an annual basis and is used in planning the development of the service. That the home displays a valid insurance certificate for Employer’s and Public Liability cover. Timescale for action 01/01/06 2 OP7 14.1 01/01/06 3 OP28 18.1 31/12/06 4 OP33 24.1 01/04/06 5 OP34 25.2 01/01/06 Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 23 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 OP1 Good Practice Recommendations That an audiotape, in Gujarati, is produced which explains the contents of the statement of purpose, the service users’ guide and the contract. Shivam Nursing Home DS0000022943.V253108.R01.S.doc Version 5.0 Page 24 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. 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