Inspection on 15/12/06 for Wolfeton Manor

This inspection was carried out on 15th December 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wolfeton Manor 11/12/08

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Wolfeton Manor East Hill Charminster Dorchester Dorset DT2 9QL Lead Inspector Val Hope Key Unannounced Inspection 15th December 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 Wolfeton Manor DS0000066937.V323691.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. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wolfeton Manor Address East Hill Charminster Dorchester Dorset DT2 9QL 01305 262340 01305 257915 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) Wolfeton Manor Healthcare Limited Mrs Pauline Daisy Stevenson Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2005 Brief Description of the Service: Wolfeton Manor provides 24 hour care and accommodation for up to 31 older people. The home is located on a hill overlooking the Cerne and Frome rivers to the south and west, one mile north of Dorchester and on the edge of Charminster village. There is ample car parking at the front of the Manor. Since the last inspection there has been a change of ownership; the home was registered to Wolfeton Manor Healthcare Limited on 31st May 2006 and the responsible individual is Susan Kathleen Adele Heybourne. Day to day running of the home remains the responsibility of Pauline Stevenson, the registered manager. There is a separate house adjacent to the home that contains two self-contained flats, which are not registered. The accommodation is arranged over three floors. Apart from 8 rooms, all accommodation is at ground floor level situated in the main house and in a north and west wing. There are 23 residential rooms all with en-suite facilities and 5 assisted living suites, a total of 3 of the rooms/suites may be used for double occupancy. The suites comprise a hall, bedroom, lounge, bathroom and hideaway kitchenette. The upper floors can either be accessed by stairs or by a lift which is suitable for wheelchair users. Information relating to weekly fees was provided by the proprietors on 24/11/06; these range from £595 to £725. Fees include all care and accommodation costs, including meals, laundry and activities. Additional charges are made for hairdressing and chiropody. People are expected to pay for their own personal items such as private telephone, toiletries and newspapers. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by the Commission as part of its regulatory duty to inspect all care homes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views and experiences of the service provided. The purpose of the inspection was to assess the home’s compliance with all of the key National Minimum Standards for Older People and to review the requirements and recommendations from the previous inspection report. The inspection was conducted on 15th December 2006 and took a total of 6 hours which included:• • • • • • • A review of the Commissions records; Examination of the Pre Inspection Questionnaire completed by the home; Planning the inspection; The premises were inspected including communal areas and most of the bedrooms; Sampling/examination of a range of the home’s records; Observing practice and general routines in the home; Talking with 14 residents and 3 members of staff; Reading, collation and analysis of 27 surveys and comment cards [3 General Practitioner, 1 health professional, 10 relatives/representatives and 13 residents]. On the day of the inspection there were 26 residents accommodated and the inspector was assisted throughout the inspection by Pauline Stevenson, registered manager. What the service does well: Wolfeton Manor continues to offer a high standard of care to its client group of elderly people with low to moderate care needs in elegant, spacious, well maintained accommodation. The provision of comprehensive information, detailed needs assessment prior to any admission and comprehensive care planning and risk assessment processes contributed to the provision of a level of care residents feel is very high. Comments received included: “The staff could not be better, I feel well cared for and am very satisfied with the help I get”, “There is always assistance if you need it which is a comfort”. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 6 Standards relating to daily life and social activities for the most part continue to exceed minimum standards. Social events, entertainment, contact with the local community was reported by residents to be very good. Wolfeton Manor has achieved and maintained a very high standard of catering provision and is again commended on exceeding this standard in all respects. An extensive menu of high quality, professionally prepared and cooked meals, which are extremely well presented and served is provided. The inspector was pleased to be invited to join residents for lunch; this afforded extra opportunity to further gather residents views upon their life within Wolfeton Manor and observe the serving of meals. Meals are an unhurried occasion, and it was observed that where necessary, assistance with meals was provided discreetly, minimising any loss of dignity. Soft, relaxing background music was played and dining tables were beautifully laid with good linen, cutlery and fresh flowers. Comments received included: “The food is always of a high standard, there is variety and you can have different if you want”, “Meals are more than adequate; we have a good varied menu each day and I have no complaints at all” and “Excellent food, always plenty of it and it is hot”. General comments received through surveys and discussion included: • • • • • • “I could not be more satisfied, the change over has gone smoothly”; “Everything is first class – same as always”; “Staff are very kind and respectful and will always help if you need it”; “I am very happy here I do as I please and am thankful that I am able to”; “There are no complaints, the buffet nights are missed though”; “It is expensive but you only get what you pay for don’t you?”. Extensive efforts have been made to reduce any anxiety relating to the change of ownership of the home earlier in the year. From contact with residents this has been much appreciated by the residents. What has improved since the last inspection? No significant changes were noted, the management has concentrated on ensuring a smooth hand over of ownership for the benefit of residents. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 7 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. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 8 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 Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 9 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): All the above were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive information is supplied to assist prospective residents in making an informed choice when considering Wolfeton Manor as a suitable home for them. Pre admission assessments of care needs are undertaken to ensure the home will be able to properly meet them and prospective residents are assured in writing their care needs can be met by the home. Prospective residents and/or their representatives are encouraged to visit the home in advance of admission to assist them in making an informed choice. A formal signed agreement relating to the terms and conditions of residence safeguards and provides clarity for residents. The home does not provide intermediate care. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home’s Statement of Purpose has been amended to reflect the change of ownership of the home. The care records of recently admitted residents were examined. There was evidence that assessments of need had been conducted prior to admission and that residents were assured in writing that as a result of the assessment, the home was able to meet their care needs. Prospective residents are encouraged to visit the home and a trial period is agreed. Each resident has entered into a formal written agreement, signed by them or their relative/representative. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 11 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. Care plans are detailed ensuring staff have the information they need to satisfactorily meet resident’s needs. The health needs of residents are well met and good multi disciplinary working takes place on a regular basis promoting and maintaining (where possible) good health. Systems in place for the management of medication are clear however actual practice needs to be accurate and in line with policies and procedures for resident safety and to ensure residents medication needs are fully met. Residents are treated with respect and their privacy and dignity is promoted, enhancing their quality of life. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 12 EVIDENCE: A sample of 4 care plan files were examined and found to be well organised. Residents have been involved in the development of the care plan designed to meet their assessed care needs, which is dated and signed by the resident. There was some evidence that not all care plans had been subject to monthly review as one of the care plans viewed had not being reviewed since 30th October 2006. A method of recording that routine personal care tasks have been carried out is in a tick box format. The content and frequency of recording in hand written case notes, relating to the general well being of residents, would benefit from improvement. It was noted that in one resident’s records there was a gap between 11/11/06 and 27/11/06. On the 27th November it was recorded that there had been a health problem that day and the previous day [26/11/06] and the entry noted “will keep an eye out”. However, there were no more entries in the records until 11/12/06 so there was no evidence that the situation had actually been monitored and the health problem had been resolved. The home must be able to demonstrate that identified health problems are monitored effectively and any action necessary is recorded through to conclusion/ satisfactory outcome. Case notes/care records should accurately reflect the health and well being of residents, providing a historical and timely record. Care plans include risk assessments and sufficient instruction to staff on how each individuals care needs are to be met. Residents are enabled to access NHS services and hospital appointments and domiciliary visits of health professionals were recorded appropriately. Satisfactory policies and procedures relating to medicines are in place. A Boots blister-pack system is used in the home and staff have received accredited training in the Administration of Medication. The main medication cupboard and medication trolley were well organised, well lit, clean and tidy. The records of administration of medication were up to date, legible and appropriately signed. Photographs of residents were in place for identification purposes. However, a shortfall was identified in relation to the management and administration of Controlled Drugs. Examination of the Controlled Drugs register and the actual stock held established that one resident had not had a Fentanyl patch for pain relief administered as prescribed on 8th December. It is required that all medication is administered as prescribed and it recommended that a routine monthly audit of medicines is implemented. Contact with residents through surveys and discussion found that they are treated with respect and that assistance provided with personal care is provided sensitively and in a manner which protects dignity. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 13 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): All the above standards were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Social, cultural and recreational activities are dependent on individual preferences and the resident’s capacity for involvement. The activities provided by the home are varied, interesting and provide mental and physical stimulation for residents. Residents are supported in maintaining contact with their friends, family and the community and they are helped to exercise choice and control over their lives promoting independence. An exceptionally good wholesome varied diet is provided, meals are appetising and of good quantity and quality, assisting with the promotion and maintenance of health. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 14 EVIDENCE: According to residents it remains the case that there is a very good programme of social events and activities on offer that they find interesting and stimulating although several residents spoken to said that the standard of activities had declined since the home came under new ownership. However, further discussion with residents ascertained that the only actual changes to the programme had been the lack of provision of the special buffet and drinks parties ‘theme’ nights that had been run by the previous management team. These had taken place on occasion, on particular celebration days i.e. St George’s Day, St Patrick’s Day, VE Day. During discussions residents then said they could understand this as at one time, in addition to Mrs Stevenson, there were four others in the management team present in the home on an almost daily basis. Mrs Stevenson explained to the inspector that it was her intention to try and re instigate the celebration theme days when it had been possible for the recruitment of a deputy manager to assist her in the day-to-day management of the home. Residents said that they are consulted with regards to how they would like to spend their leisure time and that their wishes are respected if they do not want to join in anything. Comments were received praising the home for the welcome and hospitality that is given to residents’ visitors and this is clearly very much appreciated. Good links have been forged with the local community and local groups visit the home for concerts, carol singing and other occasions. The standard of catering remains of an extremely high standard. Trained chefs and up to date commercial catering equipment contribute to the high standards achieved. The menu of the day was on display in the dining room showing there was a choice of two hot main courses with selection of five different vegetables to choose from. In addition there was a choice of salad. The sweet trolley offered choice of a range of hot and cold desserts; residents commented that this is always the case. There was evidence to demonstrate that residents are offered an informed choice on all the three full meals provided each day. Where assistance with eating was required it was observed that help was given in a sensitive and unobtrusive manner that promoted dignity. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 15 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. Complaints are managed properly and residents are confident their concerns are listened to and taken seriously. Staff members’ knowledge and understanding of Adult Protection issues provides a safe environment to protect residents from abuse. EVIDENCE: Appropriate policies and procedures and complaint records are in place. Since the last inspection there has been one complaint; the records were able to demonstrate that the complaint had been dealt with in line with the home’s policies and procedures and the complainant was satisfied with the conclusion and outcome of the complaint. Residents spoken with were very complimentary about the manager and said they felt able to refer any issues to her, confident that appropriate action would be taken to address any issues. Staff spoke of receiving training in adult protection/prevention of abuse and were knowledgeable about the subject . Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 16 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): All the above standards were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. On-going investment in both interior and exterior of the property ensures that residents live in an attractive and well-maintained environment. There is ample indoor and landscaped outdoor space creating a relaxing and comfortable environment for residents. More than sufficient toilet, washing and bathing facilities are in place to meet the needs of residents. Residents have the specialist equipment they require to maximise their independence and live in attractive, elegant, comfortable surroundings with their own belongings around them for their comfort. An exceptionally high standard of hygiene is maintained promoting both dignity and health. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 17 EVIDENCE: There was evidence to demonstrate that the home is suitable for its stated purpose. An occupational therapist’s assessment of the premises was undertaken on 9 May 2003. Aids are provided according to assessed needs. The property is set in attractive landscaped gardens that are accessible to residents, which even at this time of year, are very well kept. Communal areas consist of a lounge, large sun lounge, generous sized dining room with another smaller dining room adjacent and a conservatory. Level access is available to all bedrooms, bathrooms and communal areas by means of a 7passenger shaft lift and a wheelchair platform lift to overcome the change in floor level between the main building and the west wing. There are 23 bedrooms, 8 of these are large enough to accommodate 2 people; 3 are actually registered as twin bedrooms. There are 5 ‘suites’ located in the west wing. Each suite has its own private internal entrance, patio doors to a terrace, bedroom, a lounge with mini kitchen built into a cupboard and an assisted shower room. All suites are of a generous size. The heating, lighting, water supply and ventilation of residents’ accommodation meets the relevant environmental health and safety requirements and the needs of individual residents. There are 3 assisted bathrooms, 1 assisted shower room and 12 en suite bath/shower rooms, several of which have assisted facilities. An extremely high standard of cleanliness was found throughout the home, residents said that this is always the case. Residents are able to bring their own favourite furniture where practicable and all the rooms viewed were well personalised and made homely by residents own belongings. A high standard of cleanliness was evident in all areas of the home, residents said that this is always the case. Laundry services are well managed and to the satisfaction of residents of the home. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 18 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): All the above standards were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs enough staff to meet the needs of residents and to ensure their safety and comfort and the good condition of the premises. Recruitment and employment practices, designed to minimise the risk of unsuitable staff being employed, have been implemented. Staff training is ongoing ensuring residents receive a good standard of care is delivered by a caring and competent staff group. EVIDENCE: 22 care workers and 10 ancillary workers are employed within the home. Since the last inspection a staffing review has been conducted and night staffing arrangements have been changed to 2 wakeful night staff. The records of 2 recent recruits to the staff team were examined. There was evidence that a robust recruitment process has been consistently deployed. It was noted however that there was no record that the reasons for gaps in employment had been explored for 1 recruit. In addition to ongoing induction and foundation training a rolling programme of staff training covering a wide range of relevant topics has continued to be implemented including infection Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 19 control, manual handling and medication training. 18 members of staff have received emergency aid training and 10 have achieved the National Vocational Qualification in Care at level 2. Future training planned for the next few months includes training upon the identification and action to take in the event of abuse, Food Hygiene and health and safety refresher courses. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements of the home support good care practices for residents. Residents are assured of sound management of their financial interests. Management practices deployed promote and safeguard the health, safety and welfare of residents. The systems for consultation with residents in this home are good and residents’ views are sought and acted upon. EVIDENCE: Mrs Stevenson has achieved NVQ level 4 in management and care. The change of ownership has meant that in effect, where there were once 5 people in the management team, there is now only Mrs Stevenson. She is however, supported by a management company with expertise in key areas such as Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 21 health and safety and human resources. The newly implemented post of deputy manager is at present vacant, recruitment is currently in progress. All financial management is undertaken by the owning management company. Residents commented that they do not see as much “visible management” as they used too; further discussion did find though that they have not felt any lowering of standards in any of the services provided, other than the loss of their special theme buffet evenings as previously reported upon in the Daily Life and Social Activities section [standard 12] of this report. The home has no involvement with the financial affairs of residents. Residents manage their own finances or have a relative or representative to do so on their behalf. Quality assurance is undertaken, residents meetings are routinely held and residents said that they are consulted with and feel their views are taken into account. Contact with residents and staff established that there is an honest, open and inclusive culture within the home; residents feel well cared for and staff feel valued for their efforts. One requirement was made in relation to the recording of visual inspections of the hand held fire fighting equipment; the last record of this was dated 20th April 2006. Other fire precautionary measures including servicing, tests and training were satisfactory. There are a variety of health and safety policies to support the training programmes and a General Health and Safety Policy which includes the various hazards arising from electrical apparatus, fire, kitchen equipment, obstructions, personal injury and infection. There was evidence that policies and procedures have been subject to review and that routine servicing of systems and equipment has been carried out. The home complies with Control of Substances Hazardous to Health (COSHH) regulations and Reporting of Injuries, Diseases and Dangerous Occurrences Regulations(RIDDOR) 1985. Wolfeton Manor DS0000066937.V323691.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 3 4 4 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 Regulation 12[1][a] Requirement The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. Timescale for action 15/12/06 2 OP9 13[2] Action: The home must be able to demonstrate that identified health problems are monitored effectively and any action necessary is recorded through to conclusion/ satisfactory outcome. Case notes/care records should accurately reflect the health and well being of residents, providing a historical and timely record. The registered person shall make 15/12/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Action: Where the home is responsible for the administration of residents’ medication it must be administered exactly as prescribed by the prescribing General Practitioner. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 24 3 OP27 19 Schedule 2[6 The registered person shall not employ a person to work at the care home unless he has obtained the information and documents specified in paras 1 to 9 of Schedule 2. 15/12/06 4 OP38 23[4][cv] Action: A full employment history together with a satisfactory written explanation of any gaps in employment must be obtained. The registered person shall make 15/12/06 adequate arrangements for reviewing fire precautions, and testing fire equipment at suitable intervals. Action: The home must be able to demonstrate that visual inspections of hand held fire fighting equipment have been carried out at the required monthly frequency. Not met from 16/12/05 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 Refer to Standard OP7 OP9 Good Practice Recommendations Care plans should be reviewed on a monthly basis. It is recommended that a monthly audit of medicines is undertaken and documented. Wolfeton Manor DS0000066937.V323691.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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. 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