CQC report explained · a nursing home
What the CQC found at Bhakti Shyama Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe. Inspectors found suitable recruitment checks, enough staff, risk assessments, safe medicines systems and appropriate infection-control arrangements.
- Effective?
- Requires improvement
- Staff were trained and people received suitable health and dietary support. However, the environment needed attention, including pest-control work, worn carpets, bedroom arrangements and information that was not available in formats most people could understand.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Their religious, cultural and personal preferences were taken into account.
- Responsive?
- Good
- Care plans were personal, current and reviewed monthly. Activities met cultural and religious needs, but inspectors said the range should include more outdoor walks and trips.
- Well-led?
- Good
- The manager had good oversight through audits, meetings and checks of staff practice. Resident meetings and relatives' questionnaires had not restarted after the pandemic.
What inspectors found, May 2022
Rated Good overall; inspectors found safe, kind and personalised care, but the environment and activities needed improvement.
The inspection was unannounced and took place on 11 and 13 April 2022. One inspector and an Expert by Experience spoke with people, relatives, staff and a visiting professional. They also checked care records, staff files, medicines records, complaints, incidents and management records.
People and relatives said they felt safe and were treated kindly. Inspectors found suitable staff checks, safe medicines practice, risk assessments, regular care plan reviews and good support with health, food, culture and religion. The home also worked well with healthcare professionals.
The overall rating improved from Requires Improvement to Good. Safe, Caring, Responsive and Well-led were rated Good. Effective remained Requires Improvement because some parts of the building and activities did not always meet people's needs.
Safer recruitment
Staff files showed the required checks had been completed, including identity, right-to-work, references and DBS checks. Inspectors also found enough staff on duty during the day and night.
“Staff files included a new starter checklist confirming that all the necessary pre-employment recruitment checks had been carried out to a satisfactory level.” from the report
Safe medicines
Staff administering medicines were trained and competent. Records, consent checks, as-required medicine guidance and controlled-drug checks were in place.
“Medicines were checked against the Medicine Administration Record (MAR) chart and people were asked for their consent before medicines were given.” from the report
Kind and culturally suitable care
People's religious and cultural needs were respected. The home supported religious practices and provided vegetarian food in line with people's beliefs.
“People's religious and cultural needs were being met by the provider.” from the report
Personalised care planning
Care plans covered individual needs and preferences, including mobility, personal care, nutrition, medicines and end-of-life care. They were reviewed monthly.
“Care plans were individual to people and covered areas that were relevant to them.” from the report
Environment and pest-control work
needs fixingPest control had made recommendations after rodents were seen, but the home had not acted on all of them at the time of inspection. Some carpets were worn and the main lounge needed modernisation.
“Although the provider had been proactive in calling in pest control, they had not acted upon a number of recommendations made in the report.” from the report
Limited stimulation for some people
needs fixingInspectors were concerned that some people left in their bedrooms might not be able to see or control the television. They recommended improving bedrooms and communal areas to encourage more interaction.
“It was difficult to see whether the people were given enough stimulation from this, had the ability to change the channel or could even see what was being shown.” from the report
Activities and outdoor access
minorThe activity programme was culturally relevant, but people and relatives wanted more outdoor visits and trips. Inspectors said this should be followed up at the next inspection.
“The service would benefit from a more wide-ranging activities program, including incorporating more outdoor walks, especially for those people that spent the majority of time in their bedrooms.” from the report
Visiting arrangements
minorVisitors were asked to meet relatives in a small area near reception. CQC signposted the home to guidance about allowing visits in bedrooms or the lounge when requirements were met.
“We have signposted the provider to resources to develop their approach and to align these more closely to government guidance and to allow visits in people's individual bedrooms.” from the report
- 01What work has now been completed following the pest-control recommendations?
- 02Have the worn carpets and main lounge been refurbished, and how have bedrooms been improved for people who are nursed in bed?
- 03What outdoor walks, trips or visits are now available, especially for people who spend most of their time in their bedrooms?
- 04Can visiting take place in a person's bedroom or in the lounge, and what requirements apply?
- 05Are the food menus and activity information now available in languages or large print formats that people can understand?
This inspection covered all five key questions and included infection prevention and control, as well as care, premises, staff and management records. This explanation was written from the published report of 18 May 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2019
Rated Requires Improvement; inspectors found kind, culturally appropriate care, but important checks, records and oversight were not reliable.
Inspectors visited on 11 and 17 June 2019. The first day was unannounced. They spoke with people, relatives and staff, and checked care, medicines, staff files and management records.
People and relatives were generally happy with the care. Staff were kind, respected privacy and dignity, and provided food, activities and support suited to the Gujarati community. People said they felt safe and staff were available when needed.
The inspectors found problems with recruitment checks, staff induction records, incident records and care plans. Some care was not delivered as the records said. The home's systems did not identify these problems, and some significant incidents were not reported to CQC.
The overall rating fell from Good at the previous inspection to Requires Improvement. Caring stayed Good. Safe, effective, responsive and well-led were rated Requires Improvement.
Kind and respectful staff
People and relatives described staff as friendly, courteous and caring. Inspectors saw staff supporting people sensitively and respecting privacy during personal care.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Culturally appropriate support
The home provided care, meals, celebrations and activities suited to the Gujarati community. People and relatives valued staff who understood their culture and language.
“The providers vision and culture, to provide specialised, dedicated care to the Gujarati community was known and understood by people, relatives and staff.” from the report
Food and drinks
People were happy with the food. Inspectors found it appetising, well presented and suitable for people's dietary needs, with staff encouraging people to drink.
“The food looked appetizing and was well presented.” from the report
Healthcare support
Records showed that staff monitored some health needs and made referrals to outside health professionals when needed.
“There was evidence that appropriate referrals were made to external healthcare professionals such as the GP and community therapy teams.” from the report
Recruitment checks
seriousSome recruitment files lacked a complete employment history or the required employer reference. This was a breach because the home had not operated recruitment procedures effectively.
“We found some inconsistency in the recruitment files that we looked at.” from the report
Incomplete incident records
seriousRecords of falls did not always show observations, action taken or management sign-off. A fracture after a fall was also not notified to CQC.
“Although incidents were recorded, there were a number of records we saw where information was missing.” from the report
Care plans not followed
seriousSome records did not match the care people received or professional advice. This included personal hygiene, mobility exercises and support for safe wandering.
“Some of the records we saw were not in line with what staff had told us or with the care that was being delivered.” from the report
Weak oversight
seriousThe home's audits and governance systems did not detect the problems found by inspectors. Records of residents', relatives' and staff meetings were also limited.
“We found the governance systems in place had failed to identify the issues we found during our inspection.” from the report
- 01What changes have you made to ensure every new staff member's employment history, references and induction are fully checked and recorded?
- 02How do you now review falls and other incidents, including recording the action taken and notifying CQC when required?
- 03How do you check that care plans match people's current preferences and that staff deliver the care recorded in them?
- 04What support is now provided to people who spend time away from the main lounge, including people who may wander or become agitated?
- 05What regular meetings and feedback processes are now in place for residents, relatives and staff, and how are actions recorded?
This was a planned inspection covering all five CQC questions, the premises and the care provided; the first day was unannounced and the previous ratings were considered. This explanation was written from the published report of 19 July 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bhakti Shyama Care Centre
4 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 11 November 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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