CQC report explained · a residential care home
What the CQC found at Shakti Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People felt safe and there were enough staff, with suitable infection control arrangements. However, topical medicine records were incomplete, liquid medicines were not dated when opened, and fire safety actions were not complete during the inspection.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- The home had audits and action plans, but actions did not always solve problems or remain effective. Accident analysis also needed more detail to support learning and improvement.
What inspectors found, June 2021
Rated Requires Improvement; inspectors found improvements, but medicines records, fire safety follow-up and quality checks still needed attention.
This was an unannounced focused inspection on 27 April 2021. Inspectors spoke with people, staff and relatives, observed care, and checked medicines, care records, staff files and management records.
The home had improved since the previous inspection and was no longer in breach of regulations. However, topical medicine records were not completed, liquid medicines were not dated when opened, and fire safety actions were still unfinished during the visit.
People said they felt safe and feedback about staff and management was positive. There were enough staff, infection prevention arrangements were satisfactory, and risks to people were generally understood and managed.
The overall rating remains Requires Improvement. This means inspectors found some important improvements, but there was not enough consistent assurance that the home was always safe and well managed.
Enough staff
Inspectors found staffing levels were above those calculated from people's needs. People told inspectors staff helped them and that there were enough staff.
“There were enough staff to meet people's needs.” from the report
People felt safe
People and relatives said they felt safe. Staff understood safeguarding procedures and concerns had been referred appropriately.
“People told us they felt safe.” from the report
Infection control
Inspectors were assured that the home followed infection prevention measures, including safe visiting, protective equipment, testing and outbreak planning.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Positive relationships
Feedback from people, relatives and staff was positive. Inspectors saw people who appeared happy and engaged, and staff said they felt valued and supported.
“Feedback from people living at the service, relatives and staff was positive about the care and management.” from the report
Communication with relatives
Relatives said they were told promptly about incidents and received positive communication, including during the pandemic.
“All relatives told us that when an incident had happened, they had been contacted immediately and informed of actions that were taken.” from the report
Medicine records
needs fixingTopical medicine administration records were not completed during the inspection. Liquid medicines also did not show when they had been opened.
“Topical medicine administration records (TMARs) were not completed at the time of the inspection.” from the report
Fire safety follow-up
seriousRepeated fire safety reviews had identified problems, including gaps around fire doors. The action plan was not complete during the inspection, although later checks found the home compliant.
“There was an action plan in place however actions had not yet been completed during our inspection.” from the report
Quality checks did not always work
needs fixingThe home had introduced audits and action plans, but these did not always resolve problems or keep improvements in place. Accident analysis also lacked enough detail to identify patterns.
“However, the actions implemented did not always achieve good outcomes.” from the report
- 01How do you now check that topical medicine records are completed every day?
- 02How do you record the date that liquid medicines are opened, and who checks this?
- 03What fire safety work was completed after the inspection, and when was it checked by Kent Fire and Rescue Service?
- 04How do you make sure actions from audits are completed and remain effective?
- 05What are the current ratings and recent findings for Effective, Caring and Responsive?
This was a focused inspection of Safe and Well-led, including infection control; the other key question ratings from the previous comprehensive inspection were carried forward. This explanation was written from the published report of 4 June 2021 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, October 2019
Requires Improvement; inspectors found kind, responsive care, but medicines safety and quality records were not reliable.
This was a planned, unannounced inspection on 9 September 2019. Inspectors spoke with people, relatives and staff, observed care and lunch, and checked care, medicines, staffing and management records.
The main safety concern was medicines. Checks were not strong enough to find errors quickly. A medicine was missing from stock, and a medicines trolley was left unlocked and unattended. Records about food, drinks and personal care were also not always accurate.
People described staff as kind and said they felt safe. Staff were available, trained and knew people well. Healthcare support, activities and personalised care were viewed positively. Effective, caring and responsive were rated Good, while safe and well-led were rated Requires Improvement.
Kind and respectful staff
Inspectors saw caring relationships and respectful support. People and relatives spoke positively about how staff communicated with them.
“Staff supported people in a way that was respectful and upheld their dignity throughout the inspection.” from the report
Enough staff
Inspectors found enough staff to support people when they needed help. The home usually used its own staff, which helped provide consistent care.
“There were enough staff available to support people in their home.” from the report
Good healthcare support
People were supported to see healthcare professionals when needed. Inspectors also found strong working relationships with outside health and social care professionals.
“People were supported to access health care services such as their doctor when they were needed.” from the report
Personalised activities and choices
Staff knew people's interests, preferences and cultural or religious needs. Activities included music, games, entertainers and trips out.
“The activity coordinator provided a structured programme of activities from Tuesday to Saturday including music and games.” from the report
Medicines were not always safe
seriousChecks did not reliably identify medicines errors. One tablet could not be accounted for, and a medicines trolley was left unlocked and unattended near people's rooms.
“There were not safe systems for the management of medicines which put people at risk of harm.” from the report
Care records were not reliable
seriousFood and drink records were incomplete or written down late. Care notes did not always show whether people had received personal care or had declined it.
“There were not effective systems to assess, monitor and improve the quality and safety of the service, nor to maintain accurate records of people's care and treatment.” from the report
End-of-life wishes were not fully discussed
needs fixingThe report said there had been limited consultation with people about their wishes for the end of their lives. The manager recognised this needed improvement.
“There had been limited consultation with people about their wishes at the end of their lives.” from the report
- 01What changes have been made to medicines checks since the inspection, and how do you now identify missing or incorrect medicines quickly?
- 02How do you make sure medicines are never left unlocked or unattended?
- 03How are food and drink records checked each day, including the amount each person needs to drink?
- 04How do care records show when personal care was offered, provided or declined?
- 05How do you now record and discuss each person's wishes for end-of-life care?
This was a planned, unannounced inspection that looked at the premises, care provided and all five CQC questions. This explanation was written from the published report of 25 October 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 Shakti Lodge
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- June 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2019
Registered with the Care Quality Commission on 21 August 2019.
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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