Inspection on 12/04/07 for Wolf House

This inspection was carried out on 12th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Wolf House 25/01/06

Wolf House 02/12/05

Wolf House 11/11/04

Wolf House 30/06/04

Wolf House 25/02/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Wolf House Wolf House Wolf`s Row Oxted Surrey RH8 0EB Lead Inspector Denise Debieux Unannounced Inspection 12th April 2007 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 Wolf House DS0000013835.V333098.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. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wolf House Address Wolf House Wolf`s Row Oxted Surrey RH8 0EB 01883 716627 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) Ms Yvonne B Gomes Ms Yvonne B Gomes Care Home 13 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (13) Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to two of the service users accommodated may suffer from either dementia DE(E) or a mental disorder MD(E). 25th January 2006 Date of last inspection Brief Description of the Service: Wolf House is a care home for older people providing personal care. Registration conditions include two places for older people with diagnosis of dementia or a mental health disorder. The service aims to foster an atmosphere of care and support, enabling and encouraging service users to live full, interesting and independent lifestyles as far as possible. The building is an adapted, detached residential house set in its own grounds. There is a small car park to the front of the premises with seating overlooking a pretty cottage garden. The home has a secluded rear garden with small patio area, set mainly to lawn. Though set in a rural location Wolf House is only a short distance from Oxted town centre. Here there is a wide range of shops and community amenities. Accommodation is arranged on three levels. Communal areas are on the ground floor, comprising of a lounge, interconnected dining room and small, pleasant sun lounge. Most of the bedrooms are single occupancy and two have en-suite facilities. The home has a chairlift between the ground and first floor. A small number of bedrooms are suitable only for ambulant service users who can safely manage stairs. Fees range from £330 - £650 per week. This fee does not include hairdressing, chiropody, toiletries, newspapers or magazines. This information was provided on 12/04/07. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This unannounced visit formed part of a ‘key’ inspection, took place over 7.5 hours and was carried out by Denise Débieux, Regulation Inspector. Ms Yvonne Gomes (Registered Provider/Manager) was present as the representative for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager and any information that CSCI has received about the service since the last inspection. A tour of the premises took place. On the day of this visit there were eleven service users living at the home. Ten of the eleven service users, one visiting relative and five on-duty staff were spoken with during the visit. Eleven service user survey forms and four staff survey forms were completed and handed in to the inspector on the day of this visit. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The home had completed a pre-inspection questionnaire and service user care plans, staff recruitment and training records, health and safety check lists, menus, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector would like to thank the service users, relatives and staff for their time, assistance and hospitality during this visit and the service users and staff who participated in the surveys. What the service does well: The staff work hard to ensure that service users’ needs are appropriately assessed and that their care is planned to ensure that these needs are met, whilst encouraging and enabling service users to maintain their independence where possible. Service users spoken with expressed their satisfaction with their quality of life at the home. Comments received from service users included: ‘It’s like home from home here’, ‘I’m pleased my family chose this home for me’ and ‘I feel very comfortable here, the staff are very caring.’ One visiting relative commented that ‘I have nothing but praise for the care my mother has received at Wolf House.’ Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 6 All interactions observed between the management, staff and service users evidenced that the home has a close and caring staff team. One member of staff commented that ‘the best thing about working here is having a good working relationship with the staff and manager, the good environment, being friendly and caring for residents in the best way.’ 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. The summary of this inspection report can be made available in other formats on request. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 7 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 Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the service user’s identified needs. The home does not offer intermediate care. EVIDENCE: The inspector was advised that, on the first enquiry from a prospective service user or their representative, the service user or their representative will be invited to visit the home. Following the initial visit to the home, and if the service user wishes to continue, the manager will visit the service user and carry out a pre-admission assessment to ensure that the home can meet the service user’s needs and wishes. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 9 Three care plans were sampled during this visit. In each case comprehensive pre-admission assessments had been carried out to ensure that the home could meet the service users’ identified needs. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Service users surveyed all felt they had received enough information prior to moving to the home. New regulations came into force last year that require additional information to be included in the service users’ guide and that all service users be given a full breakdown of their fees. These regulations were discussed with the manager during this visit and the inspector was advised that the home will be reviewing their documentation against the new regulations. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance was seen to be provided, where needed, in a respectful and sensitive manner. The home needs to ensure that care provided and measures taken to reduce risk are clearly documented in the service users’ care plans. Policies, procedures and practices are in place to ensure the safe administration of medication. EVIDENCE: The home has a small and close care team and the staff demonstrate an in depth knowledge of each individual service users’ needs, abilities and preferences in how they wish their care to be delivered, resulting in all service users stating that they always receive the care and support they need. One service user commented ‘I am very well looked after’ and another ‘I have everything I need’. The care plans sampled during this visit were all based on pre-admission assessments and had been drawn up shortly after each service user’s Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 11 admission to the home. These care plans set out the actions which need to be taken by care staff to meet the health, personal and social care needs of the service users. The care plans included initial risk assessments related to skin breakdown and manual handling. Falls risk assessments had been carried out, but not for all three service users and the home do not routinely carry out nutritional risk assessments. The risk assessments sampled had not been reviewed since they were first carried out. Care plans are reviewed on a monthly basis and daily notes are kept that reflect the care given. These daily notes demonstrated that any changes or new concerns are promptly acted upon, although not always added to the care plan. Requirements and a recommendation have been made that the home expand their care plan documentation to reflect their knowledge and the care actually being provided to service users. The lunchtime medication round was observed and the medication administration records, medication storage, policies and procedures were all sampled and found to be in order. During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and all interactions observed between staff and service users were seen to be caring and respectful. All service users stated that they felt their privacy was always respected. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provided by the home are individualised to each service user and include contact with the local community both within and outside the home. Contacts with family and friends are encouraged. Meals are well-balanced and varied with individual choices and preferences catered for. EVIDENCE: The routines of daily living are arranged to suit individual service user’s preferences and choices. This was confirmed by service users spoken with. The activity log/programme was sampled at this visit. Activities provided included: an exercise group; newspaper group; cookery; art; knitting; board games; reminiscence sessions. Activities within the local community include: local day centre; local walks; shopping; pub lunches and local drives. Ten of the eleven service users surveyed stated that there were always activities they could participate in, with one answering ‘usually’. One service user commented on how much she enjoyed the old time music. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 13 Service users are able to choose which activities they attend or participate in and their individual rooms were all seen to contain many personal possessions which were arranged to suit their individual wishes. There are no restrictions to visiting times and staff support and encourage service users to maintain family links and friendships inside and outside the home. Menus sampled showed that the home offers a varied and well-balanced menu, with service users able to choose alternatives if they do not want the dish that is on the menu on the day. The lunchtime meal was taking place during this visit, the food was well presented, the atmosphere in the dining room was pleasant and relaxed and there were ample staff available to offer help and assistance as needed. Of the eleven service users surveyed, all said that they always liked the meals at the home. One service user commented on how much she enjoyed the fish pie and another added ‘I am very happy here and enjoy the meals.’ Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure which includes timescales for the process. Policies and procedures are in place to protect service users from potential harm or abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users and their relatives and is also included in the service users’ guide. The Commission has received information concerning one complaint made against the service since the last inspection and judges that the regulations in relation to complaints have been met by the provider. All service users surveyed said that they always knew who to talk to if they were not happy, with one service user adding that: ‘the staff are very helpful.’ There is a whistle blowing policy in place and the home have a copy of the latest Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. Training in safeguarding adults is included in the home’s staff induction and all staff surveyed confirmed that they had received the training and were aware of the procedures to follow. All service users spoken with said that they felt safe at the home with one service user adding ‘very’ and another commenting ‘I feel very happy and safe here.’ Wolf House DS0000013835.V333098.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing maintenance and redecoration programme provides the service users with clean, pleasant and homely surroundings in which to live. EVIDENCE: Service users spoken with expressed their satisfaction with the accommodation provided at the home. Service users surveyed all said that the home was always fresh and clean. The home was toured during this visit. The maintenance and redecoration programme for the home was seen to be ongoing. Since the last inspection there have been many improvements to the communal and individual areas of the home. These improvements included the redecoration of six service users’ bedrooms, the upgrading of the kitchen and laundry areas and many carpets have been replaced throughout the home. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 16 Laundry facilities are sited on the ground floor with washing machines suitable for the needs of the service users at the home. On the day of this visit the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. Wolf House DS0000013835.V333098.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing numbers meet the needs of the service users currently accommodated at the home. The home has a staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times. Action must be taken to ensure that future staff recruitment procedures protect service users from the potential risk of harm or abuse. Staff induction training needs to reflect the home’s categories of registration and include the care of people with dementia and mental health needs. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the service users at the home. The morning (8am – 2pm) shift is covered by three or four care workers, two care workers cover the afternoon/evening shift (2pm – 8pm) and the night staff consists of one waking care worker and one sleeping on the premises and available if needed. Of the eleven service users surveyed, ten stated that staff are always available when needed and one answered ‘usually’. One service user commented that: ‘Staff are very supportive and nice.’ Of the seven care staff, three hold a National Vocational Qualification (NVQ) level 3 in care, with a further two currently undertaking NVQ level 2. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 18 During this visit the files of three recently recruited members of staff were sampled. All files were seen to contain proof of identity, two references, a completed application form and enhanced Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) list checks had been obtained. However, the home were unaware of new regulations that came into force in July 2004 and had not been verifying applicants’ reasons for leaving previous employment with vulnerable adults; had not been obtaining full employment histories and some gaps in employment had not been explained or explored. All staff surveyed confirmed they had been supplied with a copy of the General Social Care Council (GSCC) code of conduct and practice. The amended Schedule 2 of The Care Homes Regulations 2001 was reviewed with the manager and requirements were made for immediate action. It is positive to note that, following this inspection and on the evening of this visit, the manager had spoken with the three members of staff that had been employed since the new regulations came into force and had obtained the missing information. Evidence was faxed to the inspector that showed that the home had obtained full employment histories with any gaps in employment explained, the references had been determined appropriate and reasons for leaving previous employment had been verified. The inspector was also advised by the manager that a checklist has been devised to ensure that all future recruitment complies with the new Schedule 2 of The Care Homes Regulations 2001. Staff induction is in line with the new, mandatory Skills for Care common induction standards and the inspector was advised that staff are supervised until they have completed their induction. Staff are booked on additional training and updates as the courses become available. It was seen from the files sampled, and the schedule of booked training, that the three newest members of staff were booked on a course for caring for people with mental health needs but had not yet received training or been booked on a course in the care of people with dementia. From the rota it was seen that these three staff members routinely cover the night shift between them. Whilst their staff induction involved the care required specifically by each individual service user currently at the home, staff should receive additional training specific to the registration categories of the home, prior to being left in charge. Of the eleven service users surveyed, ten said that the staff always listened and acted on what they said with one answering ‘usually’. Additional comments made included: ‘I am very well looked after’ and ‘the staff are very helpful and friendly.’ One member of staff commented that she was ‘very happy with the level of training’ provided by the home. Wolf House DS0000013835.V333098.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the clear management approach at the home providing an open, positive and inclusive atmosphere. The home has an effective quality assurance and monitoring system in place that is based on seeking the views of the service users. Policies and procedures are in place to protect service users’ financial interests. Staff now receive formal staff supervision at least six times per year. All policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: The manager is currently undertaking her Registered Manager’s Award and expects this to be completed by the end of this year. Her management style is inclusive and the service users benefit from the ethos, leadership and clear management approach of the home. The home has recently refurbished the Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 20 office, has purchased a new computer system and expects to be connected to the internet within the next two weeks. This should enable the home to keep up to date with the latest guidance in the provision of care and any changes to legislation that relate to the running of a care home. A total of four care staff questionnaires were returned to the inspector on the day of this visit. From observations made on the day and from comments made on the staff questionnaire it is clear that the home have a close and happy staff team. To the question ‘What is the best thing about working here?’ answers included: ‘the homely atmosphere and good team of staff and giving care to the residents and supporting their families’ and ‘having a good working relationship with staff and manager, good environment, being friendly and caring for residents in the best way.’ The home has an effective quality assurance and monitoring system in place that is based on seeking the views of the service users and their relatives. The inspector was advised that the home carry out yearly service user and relative surveys, correlate the responses and then formulate an action plan to address any issues that are raised. Policies and procedures are in place to protect service users’ financial interests. The manager stated that the home does not handle the financial affairs for service users. At the previous inspection a requirement was made that the staff receive formal supervision in line with the national minimum standards of six times per year. Staff surveyed confirmed that they receive formal, documented supervision and evidence was seen in individual staff member’s files. In discussion with the manager the inspector was advised that the staff have a formal 1:1 supervision session four times a year plus group supervision in the form of staff meetings at least twice a year. The previous requirement has been met. Health and safety monitoring check sheets were sampled and found to be wellmaintained and up to date. All staff have received required safe working practice training and updates. Staff were observed to be following appropriate health and safety practices as they went about their work. In November 2006, the manager commissioned a fire safety risk assessment of the home, in line with the new Regulatory Reform (Fire Safety) Order 2005. In the report seen at this visit, a number of recommendations had been made that have yet to be implemented, these recommendations included the fitting of tumescent strips to all doors and concerns regarding the need for the front door to be fitted with a lock that can be opened without needing to find the staff member holding the key. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 21 It is important that the manager implement the recommendations of this report and a requirement has been made. All interactions observed between the staff and service users were inclusive, caring and respectful. Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 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 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 23 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 OP7 OP8 Regulation 13(4)(c) Requirement Timescale for action 12/05/07 2 OP30 18(1) (c)(i) 3 OP30 18(1)(c) The registered person must ensure that comprehensive risk assessments are carried out for all service users. The risk assessments to routinely include, as a minimum: falls, skin breakdown, manual handling and nutrition. Additional risk assessments (i.e. use of bed rails, self medication etc. ) to be included when appropriate. Following carrying out the risk assessments, any necessary preventative measures must be put in place and clearly documented in the care plans. The risk assessments should be reviewed at least monthly as part of the service user’s care plan review. The registered person must 12/06/07 ensure that staff responsible for carrying out individual service user risk assessments have received appropriate training. The registered person must 12/06/07 ensure that training specific to the care of people with dementia and mental health needs is included in the home’s staff DS0000013835.V333098.R01.S.doc Version 5.2 Wolf House Page 24 4 OP38 23(4A)(b) induction programme and is provided prior to a member of staff being left in charge of the home. The registered person must 12/06/07 ensure that the recommendations made, following the November 2006 fire risk assessment of the home, are fully implemented in compliance with the Regulatory Reform (Fire Safety) Order 2005. 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 Refer to Standard OP7 OP8 Good Practice Recommendations It is recommended that the registered person expand the service user care plans to include: • More in depth staff actions to be taken to meet individual service user’s needs • Service user preferences in how they would like their care delivered • Service user/representative signature to indicate their involvement and agreement with the care plan • All staff to sign and date all entries Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Burgner House 4630 Kingsgate Cascade Way Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. Extracts may not be used or reproduced without the express permission of CSCI Wolf House DS0000013835.V333098.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!