We carried out a review of the data available to us about Bhakti Shyama Care Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Bhakti Shyama Care Centre, you can give feedback on this service.
Bhakti Shyama Care Centre provides accommodation for up to 25 people who require nursing or personal care in one adapted building. It is specifically designed to meet the needs of older people from the Asian Community. At the time of our inspection there were 20 people using the service.
People’s experience of using this service and what we found
The provider had made improvements in relation to the areas of concern we found last time including recruitment checks for new staff, person centred care and governance procedures.
People using the service and their relatives were satisfied with the care they received from staff. They told us they felt safe at the service and care workers treated them with kindness. Risks to people were assessed and plans were in place to reduce the risk and keep people safe from harm. People received their medicines from staff who were trained and competent to do so. There were robust checks in place which meant that only staff who were safe and competent to work with people were recruited. The provider followed safe infection control procedures, although we signposted them to develop their guidance around visiting rights.
Staff received training and supervision which meant they were able to carry out their roles effectively. People were admitted to the service safely and received good support in relation to their ongoing health and dietary needs.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People were treated with respect and in line with their religious and cultural needs. Care plans were person centred and staff supported them in a way that protected their privacy and dignity.
Care plans were reviewed on a regular basis which meant they were in line with people’s current support needs. People and their relatives told us they would raise any concerns with the registered manager if needed.
Robust governance procedures were in place which meant the registered manager had good oversight into all aspects of the service. These included regular audits, clinical meetings and observations of practice.
We have made recommendations to the provider in relation to the physical environment and access to outdoor activities.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 19 July 2019) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
At our last inspection we recommended more robust incident and accident reporting, and staff induction training records. At this inspection we found the provider had acted on these recommendations and had made improvements.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bhakti Shyama Care Centre on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Bhakti Shyama Care Centre is a nursing home for up to 25 people, specifically designed to meet the needs of older people from the Asian Community. There were 19 people living at the service at the time of our inspection.
The home is arranged over three floors, each bedroom has en-suite facilities.
People’s experience of using this service and what we found
People and their relatives were happy with the care and support they received from staff. They appreciated the fact that the provider and the staff were providing dedicated care to the Gujarati community.
However, we found that the service was not always safe, effective, responsive or well-led. This was because staff recruitment checks were not robust and staff induction training records and other records such as incident monitoring forms were not always complete. We also found that some aspects of care were not delivered according to the records in place and the provider’s governance systems were not robust enough to pick up the issues we identified during the inspection.
People told us they felt safe living at Bhakti Shyama and there were enough staff available to help them when needed. Risks to people were identified along with the action needed to keep them safe from harm. Where incidents such as falls had occurred, although these were documented, the records were not always completed with the action that had been taken. The environment was clean and regular infection control audits took place.
We have made a recommendation about incident reporting records.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were happy with the food that was available which was culturally appropriate and met their needs. People were supported to access healthcare services and appropriate referrals were made to external professionals such as physiotherapist and diabetic nurses if needed.
We have made a recommendation about staff induction training records.
People were cared for by staff who were caring and compassionate. Staff respected people’s privacy and carried out personal care in a discreet manner, respecting their dignity.
Care plans were easy to follow and included ways in which staff could support people. End of life wishes were discussed with people and their relatives, where appropriate. Culturally appropriate activities were available and staff engaged with people well during these. Any formal complaints that were raised were investigated and responded to.
There was a long-standing registered manager in place who people and staff respected and was well liked. The staff team worked well together. However, there were areas where more meaningful engagement with people and staff could have been conducted. There were some incidents which the provider did not notify the CQC about.
We have made recommendations about the providers responsibility with respect to notifying CQC of any significant events and ways they can engage in a more meaningful way with people, relatives and staff.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Good (published 13 December 2016).
Why we inspected
This was a planned inspection based on the previous rating.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report.
Enforcement
We have identified three breaches in relation to recruitment of staff, care planning and governance systems. This was because we found that staff recruitment checks were not robust and care plans did not always reflect people’s preferences. We also found the governance systems were not effective in identifying the concerns we found during the inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
We undertook this comprehensive inspection to check that they had followed their plan and to confirm that they now met the legal requirements in relation to the breaches found.
There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Bhakti Shyama Care Centre is a care home with nursing for up to 22 people, specifically designed to meet the needs of elderly people from the Asian Community. There were 20 people living at the service at the time of our inspection.
At our previous inspection we found that there were not always enough staff at the service to meet people’s needs, the provider did not follow safeguarding procedures, infection control practices were not always adhered to, covert medicines were not administered in line with accepted guidelines, the provider was not adhering to the principles of the Mental Capacity Act 2005 and care plans did not always reflect people’s current needs.
At this inspection, we found that improvements had been made in all of these areas.
The Care Quality Commission had received statutory notifications from the provider where allegations had been made and the local authority had been made aware of these concerns.
People using the service and their relatives did not raise any concerns about staffing levels within the home. The provider was using a formal tool to calculate staffing levels based on people’s dependency needs.
The concerns that we found at the previous inspection regarding overflowing bins and some rooms not being maintained to a good standard had been addressed.
Although no one was receiving their medicines covertly at the time of the inspection, the provider had introduced new records which were used to record when people were to be administered medicines covertly. We saw examples where someone needed to be given their medicines covertly and lacked the capacity to make a decision about this, best interests meetings had taken place.
The provider had introduced a mental capacity assessment form and care records included assessments of people's capacity to make decisions. Records for people assessed as not having capacity to make certain decisions about their care and support included best interests meetings. Applications had been made to the local authority when people were subject to restrictions to their freedom.
Care plans were clearly laid out and reviewed regularly. Where recommendations had been made, we found that staff followed these and maintained accurate records.
People told us they felt safe living at the home and we found that where concerns had been raised, the provider had investigated and acted upon recommendations made.
People we spoke with said that staff treated them well and were caring. They told us their healthcare needs were met by staff. Staff demonstrated a caring attitude towards people, during mealtimes and when assisting them around the home.
Care workers told us they were happy with the quality of the training they received. An accurate training matrix was maintained which allowed the provider to plan and book training that was expiring. Care workers told us they felt supported and the registered manager was approachable.
The provider carried out regular audits on medicines, wound care and infection control. A quality assurance manager visited the home regularly which helped to ensure standards were maintained and improvements made.
This inspection took place on 21 and 24 April 2015 and was unannounced. At the last inspection on 16 May 2014 we found the service was meeting the regulations we looked at.
The registered manager had left the service in July 2014, however, an application to cancel their registration with the Care Quality Commission (CQC) had still not been submitted at the time of our inspection. The clinical lead for the service had submitted an application to register with the CQC as the registered manager and was awaiting the outcome of this at the time of our inspection. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Bhakti Shyama Care Centre is a care home with nursing, specifically designed to meet the needs of older people from the Asian Community. The majority of the people living there are Gujarati speaking. This is reflected in the staff team at the home, who are all Asian and are able to speak Gujarati. It can cater for up to 22 people, at the time of our inspection there were 19 people using the service. It is based in Balham, and is located next to The Radha Krishna Temple Shyama Ashram temple.
The home is arranged over four floors and there is a lift available at the home. There is a kitchen, laundry room and staff room located on the lower ground floor. Bedrooms are arranged on the ground, first and second floor. The main lounge is on the ground floor which leads out onto a courtyard. There are smaller lounges on the first and second floors. All bedrooms have an ensuite bathroom.
Although people told us that they felt safe and that staff treated them well, we found that the provider did not follow safeguarding procedures in terms of notifying the local authority of any concerns relating to potential abuse.
We observed staff during the medicines round and saw that people were supported to take their medicines safely, however we found that where people were given their medicines covertly, there were no clear guidelines about the method of administration and how the medicines were to be disguised.
We found that where people did not have the capacity to consent to certain decisions related to their care and treatment, the provider was not following the requirements of the Mental Capacity Act 2005 (MCA). Where people may have been restricted of their liberty, consideration had not been given as to how this may impact on people’s lives and applications to lawfully impose restrictions on people in their best interests were not always submitted in a timely manner.
We observed staff speaking to people in a friendly way and speaking to them in a culturally appropriate manner.
Staff attended training that was relevant to the needs of people and were regularly supervised. Staffing levels were stretched at certain times of the day and we saw some instances where staff did not always have enough opportunity to engage with people and attend to their individual needs.
People spent a lot of time sitting in the lounge or in their bedrooms and there was a lack of meaningful activities for people to engage in that met their individual preferences.
Care plans were in place and updated at regular intervals. However, there were gaps in these records that meant staff did not always have the information they required to meet people’s individual needs effectively. For example, there was a lack of guidance about how to support people’s emotional wellbeing.
The manager of the service had applied to be formally registered with the CQC at the time of our inspection. She had identified areas of improvement and staff that we spoke with felt that she was a good appointment.
The service monitored the quality of service by conducting health and safety checks, audits and feedback surveys from people using the service, relatives and visitors. A quality manager also carried out monitoring visits.
During this inspection we found that the provider was not meeting the requirements of the regulations in relation to safeguarding people, adequate staffing levels, management of medicines, some aspects of hygiene, control and restraint and care planning. You can see what action we told the provider to take at the back of the full version of the report. We also made a recommendation in relation to caring for people living with the experience of dementia.
Is the service safe?
The provider conducted regular audits to ensure the safety of the premises and the equipment used. Staff had all had training in moving and handling. There were appropriate checks completed on all staff before they were employed. All staff received a comprehensive induction before they commenced work with people who used the service.
Is the service caring?
People were supported by professional and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. A relative said, "I come here nearly every day, the staff are great". People's preferences and interests had been recorded and care and support had been provided in accordance with people's wishes.
Is the service effective?
People's health and care needs were assessed with them or their relatives, and they were involved where possible in writing their plans of care. Visitors confirmed that they were made welcome, able to see people in private if they wished and that visiting times were flexible.
Is the service responsive?
People enjoyed a range of activities both in and outside the home. The home encouraged activities and we saw many activities happening during the inspection, both collectively and on a one to one basis with individuals.
Is the service well led?
The provider had systems in place which ensured the service was responsive to change. There was evidence the service was modified when appropriate. Staff we spoke with were complimentary when asked about management.
The majority of people who use the service speak Gujarati or Hindi and staff spoke one of those languages as well as English. We spoke to family members and when needed they interpreted for us. Several people and their families we spoke with told us, 'This is home from home' or 'Home to home'. Staff speaking their own language and catering for their cultural needs, especially diet was a priority for everyone we spoke with. We observed that visitors to the home greeted each person in turn and took time to speak to them.