Inspection on 02/06/06 for Little Oldway

This inspection was carried out on 2nd June 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Little Oldway 09/08/07

Little Oldway 01/11/05

Little Oldway 16/11/04

Little Oldway 10/06/04

Similar services:

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Fairfields Country Rest Home

Poldhu

Queensmount

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Little Oldway Little Oldway Torquay Road Paignton Devon TQ3 2TD Lead Inspector Rachel Proctor Unannounced Key Inspection 2nd June 2006 10:00 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 Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 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. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Oldway Address Little Oldway Torquay Road Paignton Devon TQ3 2TD 01803 527156 01803 663670 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) Mr Barry Michael Privet Mrs Jacqueline Ann Privet Vacant Mrs Jacqueline Ann Privet Care Home 35 Category(ies) of Dementia - over 65 years of age (35), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (35), Old age, not falling within any other category (35), Physical disability over 65 years of age (35) Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: Little Oldway is a large, listed building, which provides accommodation for up to 35 service users on two levels. The home is surrounded by a large, level attractive garden, and is adjacent to Oldway Mansion and its grounds. The home provides personal care for elderly service users with or without a physical and/or mental health frailty. The fee range on 21.07.06 was stated as from £294 to £360. The inspector was told the fee charged depended on the care needs of the individual and the way funding is agreed. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which covered the key standards for older people. The inspection took place over three weeks. Information was obtained from feedback/comment cards, discussion with professional who visit service users at the home, the staff who work at the home, relatives and the residents themselves. The homeowners and manager also took part in the inspection. A pre inspection questionnaire was provided prior to the visit to the home. A tour of the home was completed and some records were inspected. What the service does well: What has improved since the last inspection? 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. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 6 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 Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 7 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): 3 The residents have access to information, which enables them to make informed choice about the home. The assessment process in place ensures individuals care needs are assessed prior to their admission. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The five residents comment cards returned all indicated that they received enough information about the home before they moved in, which had enabled them to decide if it was the right place for them. Each residents room entered during the inspection had a copy of the service uses guide and statement of purpose in the room. This gave information about the home, its facilities and the staff. The complaints policy and procedure, which included how to contact the commission was also contained within this folder. The inspector saw contracts for two of the residents, which had been provided by social services. Four a five comment cards received from residents indicated that they had received a contract. The home has introduced a new care planning system since the last inspection. This uses an easy to follow template, which covers personal care, health care, social care and health and Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 8 safety. Copies of the initial assessments undertaken by social services prior to admission were available for those residents admitted under their scheme. The manager advised that where possible new residents are encouraged to visit the home and meet the staff prior to their admission. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 9 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, 9, 10 On the whole the way residents care is monitored and managed is good. Some attention to ensuring all residents reviews and medication returns are documented would ensure the residents continue to receive the care they need. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new care planning system had been introduced for individual residents since the last inspection. This follows on from the initial assessment of needs completed on admission. Three of the four care plans viewed had been reviewed monthly. The care plans included falls risk assessments and the action staff needed to take to prevent them. Each of the four care plans had a page to record monthly observations. These included the residents weight, however not all had had their weight recorded regularly. The owner and the manager advised that they were in the process of purchasing suitable scales, which would enable them to weigh residents who are unable to stand. Two GP comment cards received both indicated that they were satisfied with the service and over all care of their patients at Little Oldway. The four residents case tracked had a section within their care plans that recorded GP visits and Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 10 the action staff should take. One district nurse spoken to during the inspection said that staff are always helpful and any instructions they give are followed. One resident told the inspector that the district nurse was visiting regularly to complete the dressings they needed on their leg. Case tracking also highlighted that where residents have specialist health care needs specialist nurses had been contacted for advice and support. One resident’s plan of care indicated that the Parkinsons disease specialist nurse had visited to review the progress with the treatment regime in place. On the day of the visit to the home one resident was accompanied by staff to a hospital appointment. This resident commented that the staff are always helpful and ensure they got to the appointments they needed to. Medication is stored in a lockable trolley within locked room. This locked room is used as storage for the resident’s medication. The medication records for the four residents case tracked were seen. These had been signed and completed as expected, where medication had been refused or not given a code had been put in place to indicate why. The controlled drug records were checked for one resident who had left the home. Although the medication returns book indicated that the medication had been returned to the pharmacy this had not been recorded in a controlled drug book. The record of return medication was clear indicating which resident’s medication was being returned and the type and dose of the medication. The manager confirmed that only staff who had received medication training were responsible for giving the residents their medication. Three residents, comment cards received indicated that they always received the medical support they needed; two others indicated that they usually receive the medical support they need. The feedback received from all the comment cards indicated that the residents are treated with respect and their right to privacy upheld. Five of the residents spoken to said the staff are always friendly and helpful towards them and one said they never grumble. The inspector observed members of staff talking to the residents during the lunchtime meal. The residents were being addressed by their preferred name in a friendly manner. They were given time to respond to questions and make choices about their meal. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 11 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, 14, 15 The residents have access to activities that take into account their personal preferences and choices. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents spoken to during the inspection told the inspector they were satisfied with the activities provided for them. There are two lounges within the home and those residents who dont want to take part in activities are able to go to a small lounge or conservatory. A list of activities is provided for the residents. One activity provider was visiting during the inspection. The residents asked said they had enjoyed taking part in the mornings activities. A written record of the activities is provided for the home manager. One resident commented that if they asked the staff would take them shopping or alternatively collect the things they wanted from the shop. The comment cards received indicated that there are activities arranged by the home that they can take part in. Two of the residents spoken to during the inspection said they really enjoyed the garden. A conservatory area with level access to the garden is available for the residents. Six residents were using this area during the inspection. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 12 Visitors were coming and going during the inspection, they were seeing their relatives/friends in the privacy of their own rooms or one of the communal areas in the home. The statement of purpose and service uses guide available in each of the resident’s bedrooms gives information about the homes policy on maintaining relatives and friends involvement with the residents. The way the environment is set out with three key communal lounge areas and a dining-room allows residents to choose where they wish to sit. Each of the residents rooms entered had been personalised with items of their choice. The four care plans viewed as part of the Case tracking had space for the residents to sign the care plan. The manager confirmed that those that are able and encouraged to sign and participate in the development of their care plan. The residents asked said they were consulted by the staff about their care needs and preferences. The mealtime observed during the inspection was unhurried with the residents eating their meals at their own pace. The residents were given the opportunity to have second helpings if they wished. The staff assisting the residents who needed help to cut their food were doing this in a friendly supportive way. Two residents the inspector shared lunch with said the food is always good and theres always plenty to eat and they look forward to mealtime. One resident spoken to said the food isnt always what they would like. One commented that if they didnt like what was on offer they could ask for an alternative. The five residents comment cards received indicated that they always or usually liked the food provided for them. Very little wastage was seen the lunchtime meal. The Cook told the inspector that the food is always freshly prepared and where possible fresh vegetables are used. Preparation for the evening meal was underway in the afternoon. The inspector was told the residents had been asked their preferences before the meals are prepared. A cold water dispenser was available in the dining room, which residents could help themselves if they were able. The day of the inspection was very hot, the provider had bought ice creams for the residents in the afternoon. He said we all like treats occasionally and he felt the residents should have this too. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 13 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 residents can have confidence that any concerns they have will be dealt with by a staff team who have their best interests at heart. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One complaint has been received since the last inspection. This related to the way a resident was cared for. The majority of the recommendations made following the complaint investigation had been put in place. There is a clear complaints policy and procedure available for the residents and visitors. Copies of the complaints procedure were freely available in the resident’s rooms with the statement of purpose and service users guide. This included the name and contact number of the Commission. The five comment cards received from residents indicated that they knew how to make a complaint and felt that staff listen to and acted on what they said. One resident spoken to during the inspection said they discussed any concerns they had with the home manager or owner. They also said they felt their concerns were listened to and acted upon. Two residents said they had been enabled to vote. The owner confirmed that she make sure either postal voting is organised for the residents who want this or provides transport and escort to take residents to the local polling station. The manager advised that she had introduced a new training programme for adult protection. Copies of the course contents and questionnaires two members of staff had completed were provided. The manager uses a training matrix to indicate when staff had completed the mandatory training, which included adult protection. This was available for Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 14 inspection. At the last inspection a requirement was made that all staff have a CRB check completed before starting work. During the inspection four staff files were viewed all had an up-to-date completed CRB form on file. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 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): 19, 26, The homes environment continues to be pleasant, fresh and welcoming for the residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home was completed. The home was clean and fresh in all areas the residents have access to. Ongoing repairs and renewals and redecoration have continued since the last inspection. There are two lounge areas, a conservatory and a dining room available for the residents use. All these areas were being used during the inspection. The large lounge provides space for entertainment and activities for the residents. The small lounge and conservatory provide a quite space for those residents who prefer this. The gardens surrounding the home are attractively presented. A variety of summer flowering plants were in hanging baskets and the flower borders for the resident’s enjoyment. Several of the residents commented how much they liked the gardens and watching the birds and the squirrels. The owner Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 16 confirmed that since the last inspection all the radiators that the residents have access to had been covered. The environmental risk assessment completed by the homes manager was available for inspection this had been reviewed this year. The drying area for the laundry had been de-cluttered and cleaned and the laundry person had access to space to fold clothing once it had dried. The handyman/gardener also share the space where the laundry is dried. The home was fresh and clean in all areas entered during the inspection. The comment cards received from residents and visitors indicated that the home is always fresh and clean. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 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, 29, 30 The acting manager uses a robust system to ensure staff receive the training they need to provide care for the residents. The residents can have confidence that the staff team who care for them understand their care needs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has provided a rota, which shows the number of staff on duty and in what capacity, they are employed. She further commented that when the resident’s needs are increased, staffing is adjusted to meet their needs. The staff spoken to during the inspection felt that there are enough staff on duty to meet the needs of the current residents. The rota indicated that more staff are on duty at peak times. One relatives comment card received indicated that in their opinion they were always sufficient numbers of staff on duty. Both GP comment cards indicated there was always a senior member of staff for them to talk to and the management/staff take appropriate decisions when they can no longer manage the care needs of the residents. Both indicated they were satisfied with the overall care provided within the home. The owner, the manager and two of the staff team were spoken to during the inspection visit. Two staff members spoken to said they felt supported to do their work and had access to training and development to help them do their work better. Both said they liked working at the home and felt supported by the management team. The owner advised that they are aiming to have a high number of staff with NVQ level 2 or above, which is 60 at present. The Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 18 manager advised that as part of the recruitment process staff had to agree to complete an NVQ award if they dont already have one. The manager has clear records of the training completed for the staff team. She had developed a system, which enabled her to ensure that all staff and receive mandatory training. The manager had been part of a pilot scheme set up by the local Health Care Trust to provide training for staff in relation to health care. This included infection control, wound care and nutrition. The manager advised that staff who had completed this course including her had found it beneficial for their own development as well as the care of the residents. A requirement made at the last inspection regarding recruitment had been met. Four staff files viewed had up-to-date CRB’s available. The owner and the manager confirmed that staff had CRBs applied for before they start work at the home. The homes recruitment process includes a completed application form, two references, and confirmation of proof of identity as well as CRB checks. The four staff files seen had a statement of terms and conditions on file, which had been signed by the staff member. A copy of an induction programme completed by one staff member was provided. The manager advised how the induction process is completed and how the staff member is supported during their induction period. The manager confirmed that staff receive a minimum of three paid days training a year and have an individual training and development assessment completed. Examples of the training and development plans provided for staff were given. The manager was able to demonstrate that she was committed to ensuring staff have the training they need to care for the residents. All staff had completed their mandatory training. Training relevant to the care of older people in relation to health care had also been completed. The manager advised of other courses the staff team had signed up to. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 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, 35,36, 38 The acting manager has continued to improve the way care is delivered and directed for the residents. However the slow response to the fire officers report could have put residents at risk. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager has been at the home for several months, however an application has not been received by the Commission to enable process registration of the manager to start. The Commission has provided an application form and the completed form is awaited. The manager has several years experience working within care homes and has kept herself up to date with current practice. Job descriptions for the manager and staff who work at the home are provided. There are clear lines of accountability within the home. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 20 During the visit to the home there was an open, positive and inclusive atmosphere. Those residents asked said they liked living a Little Oldway. One resident commented that feels this is a very homely place to live, where staff are considerate of peoples expectations and needs. A quality audit system is in place and residents and relatives questionnaires are available. However an analysis of the recent quality audit had not been completed. The manager advised that she was awaiting the return of some of the relatives and residents questionnaires before completing the audit. Two visitors and seven residents questionnaires were provided for the inspection. The minutes of the last residents meeting on the 14th November 2005 recorded that the residents had been asked for ideas for the forthcoming Christmas celebrations. The manager advised that she had reviewed the policies and procedures. A new policy relating to how to prepare residents personal belongings for collection by relatives have been introduced. This inspection confirmed that requirements made the last inspection had been completed. The manager advised that the majority of the residents have the finances managed by their relatives or supporter. One resident who had asked the manager to manage the pocket money had records of expenditure. The resident has signed this record. Records of staff supervision were provided. The manager provided the matrix that showed when staff had received supervision and when it was due. The staff spoken to during the inspection confirmed that they had regular meetings with the manager. The manager was able to provide evidence that staff had received health and safety training, which included manual handling, fire safety, food hygiene and first aid. Copies of the certificates staff had received for the training they had completed were available with the staff files. First aid training certificates and manual handling certificates were also displayed on the wall in one of the reception areas of the home. The two staff spoken to confirmed they had received mandatory training. A risk assessment of the environment had been completed. The manager confirmed that equipment and lifts had been serviced. The manager confirmed that checks have been implemented to reduce the risk of legionella. The completed checklist for water temperatures was provided. The tour of the home revealed that the chemicals used had been securely stored and staff had access to policies and procedures for COSHH. (Control of Substances Hazardous to Health). Accident records were available for inspection. A system for reporting injuries, diseases and dangerous occurrences regulations (RIDDOR) 1985 was in place. A fire officers report from April 2006 had required the owner to make improvements to maintain fire safety in the home. None of the requirements made by the fire officer had been implemented at the time of the inspection. The owner advised that these would be completed by the end of July 2006. At the second visit to the home some of these requirements made by the fire officer had been met and others were in the process of being completed. Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Little Oldway DS0000018389.V292424.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement The controlled drug record must reflect the prescribed medication amount held by the home. Returns must be recorded in the controlled drug book as well as the drug returns book Requirements made by the fire officer in April 06 must be implemented to ensure adequate precautions against the risk of fire are in place. Timescale for action 07/06/06 2 OP38 23(4)(a) 31/07/06 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 2 3. 4 Refer to Standard OP7 OP8 OP31 OP33 Good Practice Recommendations All service users plans should be reviewed monthly Suitable scales should be provided to enable staff to weigh service users who are unable to stand. The new manager should complete the commissions fit person processes The results of quality audits should be available for the service users and the Commission. DS0000018389.V292424.R01.S.doc Version 5.2 Page 23 Little Oldway Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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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