Bhakti Shyama Care Centre

Updated 18 May 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was conducted by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Bhakti Shyama Care Centre is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Bhakti Shyama Care Centre is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager, two care workers, the activities co-ordinator, three people and seven relatives. We reviewed a range of records. This included three care records, two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including complaints, incident forms, policies and procedures were reviewed.

Updated 18 May 2022

About the 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.