Inspection on 28/02/07 for Elysian Villas

This inspection was carried out on 28th February 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elysian Villas 18/01/06

Elysian Villas 25/07/05

Elysian Villas 06/01/05

Elysian Villas 28/07/04

Elysian Villas 29/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Elysian Villas 21a King Street St George Bristol BS15 1DL Lead Inspector Ashley Fawthrop Key Unannounced Inspection 28th February 2007 09:30 Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 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 Elysian Villas DS0000020356.V331240.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 Adults 18-65. 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. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elysian Villas Address 21a King Street St George Bristol BS15 1DL 0117 9619977 0117 9619933 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Ms Sarah Cryer Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Staffing Notice dated 28/08/2001applies Manager must be a RN on parts 5 or 14 of the NMC register May accommodate up to 13 persons with learning disabilities aged 18 and over who are ambulant and may have a mental disorder. 18th January 2006 Date of last inspection Brief Description of the Service: Elysian Villas is operated by Aspects and Milestones and comprises three houses accommodating thirteen residents needing social or nursing care. The residents have learning difficulties or a dual diagnosis including mental disorder. The villas are set in secure grounds and the home is situated in a residential area that is close to local amenities and a main bus route. Each house has four or five single rooms including one bed sit, a lounge and dining room, bathroom, kitchen and laundry. The home is not considered a home for life as some residents may move to less supported environments in the future or become more physically frail. The fees levied to the 28 February 2007 were £1770.00 to £1873.12. Extra charges are levied for hairdressing, chiropody, toiletries, holiday trips, transport, hobbies and reflexology. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector over the course two days. This was due to the home moving back into it’s renovated premises and it was reasonable to split the inspection over two days so that the process would not be too intrusive as the people using the service and the staff were settling in. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, the action plan submitted following the previous inspection, and reports from other agencies, i.e., the Fire Officer. This information was used to plan the inspection visit. The inspector case tracked three people using the service. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Pre inspection information was received before the visit was done and on the day of the inspection the staff were open and helpful throughout. The inspection included looking at records such as care plans and reviews of the care for people using the service and other related documents. The inspector also read policies and procedures relating to the protection of vulnerable adults and health and safety. The views of the staff and people using the service were gathered either by face- to- face discussions or by surveys. What the service does well: The manager and staff continue operating the home in an increasingly person centred way and seek to empower and motivate the residents to engage more fully with life in and out of the home. The staff have the skills and experience to identify and provide therapeutic interventions and manage the clinical and social care needs of the people. The home offers a range of activities and opportunities to the people. Care plans were written in a way to promote independence, privacy and dignity of residents and detailed their personal preferences. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 6 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. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People wishing to use the service and their families are given good information in written or verbal form about the home. They know if the home can meet their needs before moving into the home. Contracts and terms and conditions of services are provided to all residents. EVIDENCE: The Statement of Purpose and Service User Guide continue to hold good information and give full information to people wishing to use the service. A photographic version of the guide, which will be more accessible to people wishing to use the service has been produced. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 9 All people wishing to use the service are referred through the community learning disability team and all have a pre admission assessment before moving into the home. This gives the staff the opportunity to start the care plan as soon as the person moves in. There are a diverse range of needs and abilities amongst the people who live there. The home employs a number of Registered Nurses (RN’s) who have knowledge and experience in relation to both learning disabilities and mental health needs. Many of the support staff are very experienced with the resident group and all will be training toward NVQ level 3. All the people have standard Trust terms and conditions and licence agreements in their case files. The staff read the provisions to the residents; some of who are able have signed or marked the documents. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People continue to be are involved with the assessment and care planning/goal setting and review process as much as they are willing and able. The homes philosophy promotes each person’s individual development and self-direction and empowerment. EVIDENCE: Three peoples care plans were case tracked. Full and detailed assessments are carried out on people prior to admission written by home staff qualified to do so. Assessments by social workers, nurses and other health care specialists are available. Elysian Villas operates a team working and key working system. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 11 Each person has a named RN and support worker who co-ordinate their care planning and reviews of the care package. There are monthly villa meetings to evaluate care plans and a small number of people play some part in this process although all are invited to do so. The people who live there are in general unable to or do not wish to make a significant contribution to the management of the home in a formal sense. Staff continue to share information and seek to empower people in making decisions and participating in choices related to day-to-day life. The home continues to uses a person centred approach to care planning: The development of essential lifestyle planning to enable a more holistic approach to service provision has been discussed but not implemented at present. There was evidence to indicate that most care plans and risk assessments are reviewed at regular intervals and that people and the multidisciplinary team are involved in this process. Records seen on the villas were in general written to a good standard. Nurses have a free day each month in part to ensure care documents and risk assessments are kept up to date. Staff handovers take place on the villas in the morning and evening. The midday handover is held in the main office to maintain a team ethos and up to date awareness as to what is happening on each villa. People have a diverse range of needs and some are more independent than others. Independence is promoted through the risk assessments and staff seek to broaden experiences where possible. Risk assessments and care plans document reasons for any limits to resident’s rights or related to management of behaviours that challenge. People are involved as much as they are willing or able in making these judgements. Each villa has a bed sit for people who are developing more independent living skills and one of the long term aims of the home will be to prepare some people to move to the minimal support flats that have been built in villa three. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15,16 and 17 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who live in the home have opportunities to take part in a range of community and leisure activities. The recreational and occupational arrangements in the home are well organised individualised and varied. The menus are varied, offer balanced diet and include individual choice. EVIDENCE: The level of activities has been maintained for those residents who enjoy active lifestyles. These are meaningful and where possible chosen by the individual. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 13 People continue to go out to make use of community leisure facilities such as pubs, walking, swimming and cinemas. A bi-weekly bowling club has been established and various day trips and short breaks arranged. The home continues to be set within a secure perimeter and has a key coded lock. The majority of residents on villa three are able to go out into the local area independently. Other residents’ ability to access community facilities varies some need more support to do so safely and others 2:1 escort. Three day care workers attached to the home four days per week working with individual residents or small groups either in or out of the home. Care plans and risk assessments are in place, which detail weekly activities. A number of the people attend local churches periodically. People are helped to maintain links outside the home with family and friends. There are some strong family links in place and all residents have some level of contact with their relatives, which include some home visits for several of them. A number of relatives are involved with care reviews. A number of the people have severe problems in creating relationships or lack social skills. These are risk assessed and the staff work to improve these. The home has a commitment to healthy eating. The dietician has visited and given advice to enhance the balance of the diet. Menus continue to be devised on a four weekly rotational basis other than on villa one where the menu is planned on a day-by-day basis. The records show that people eat a balanced diet with a good variety of meals on offer. There is one culturally sensitive diet and a number of diabetic diets provided. Three people have tea and coffee-making facilities, microwaves and fridges in their bed-sits. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The staff provide appropriate personal and nursing care in a sensitive manner to maintain each persons health and well being. Appropriate arrangements are in place for residents to access primary and secondary healthcare services if need be. The staff properly manages and administer medication. EVIDENCE: The home does not cater for people with major physical disability but where possible will manage some levels of short-term ill health. Those people whose mobility or general health significantly deteriorates and have a need for additional facilities may need be to transfer. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 15 Care plans also detailed support needed for personal care including continence, bathing, dressing and help at night. All the people continue to be registered with the same GP practice and generally see Dr Goyder who carries out health reviews and is considered very supportive. Many of the people attend community opticians, chiropodist, and dentist. In general all residents need staff support to access medical and paramedical services. Nurses administer medication in each villa and a nominated Nurse is responsible for the upkeep of the system. All the Villas operate a monitored dosage system. Records are kept in relation to the storing, administering and disposal of drugs. On inspecting the medication administration sheets I noted that there were some gaps in the recording There is a system in place for stock control of medication given on a PRN basis. The Trust has medication policies available. In addition to this there are individual medication profiles. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are robust and comprehensive policies in place to manage complaints or allegations of abuse. There are good arrangements in place for staff training and awareness of POVA matters. EVIDENCE: Aspects and Milestones continue to have an established complaints procedure that details actions taken if concerns are raised, within set down timescales. All the people living at the home have access to a copy of the organisations complaints procedures, which include the contact details of the CSCI and Trust officers. There is a pictorial version of the complaint procedure. It is unlikely that the residents could or would make use of formal procedures and in general would rely upon staff or other significant people advocating on their behalf. The manager has maintained a complaints logbook. There have been no complaints received since the last inspection. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 17 Aspects and Milestones continue to have a Protection of Vulnerable Adults policy and there is a copy of Bristol City Council’s “No Secrets” guidance that would be followed in the event of suspected or alleged abuse. There are no issues pending. There is a policy titled “Doing the right thing” which encourages staff to report bad practice without fear of being discriminated against. Nurses are aware of the NMC codes of conduct. Copies of the GSCC code of practice have been issued to care staff. Aspects and Milestones also have a code of conduct. Elysian Villas accommodate a number of people who display complex and sometimes challenging behaviour and there is a “ Behavioural Risk Management policy” in place. This outlined trigger points, which may lead to challenging behaviour, escalation points and strategies to reduce the likelihood of this occurring. All staff have received “Positive Response Training” (PRT) which incorporates theory and the law and some restraint techniques, which may need to be used as a last resort if residents’ behaviour becomes physically challenging. Staff updates occur bi-monthly. There are no recent records of restraint being used. A PRT review and update forum has been set to which all staff are invited. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is generally well maintained clean, safe and comfortable. One villa has developed facilities to enable two people to live more independently. Bedrooms bathrooms and communal areas suit the needs and tastes of the people who live there. EVIDENCE: The home comprises three purpose built houses, which are suitable for their purpose and well laid out. Each villa has a bathroom, dining room and lounge area. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 19 The villas are set in quite large and well-presented grounds, which are fenced and secure to which people have unlimited access. A number of the people are able to use the keypads, which secure the villas and gates. People’s rooms are decorated and furnished individually making sure the person has individual space and ownership of that space. One person’s room continues to be in a state of disrepair due to their current mental state and will be upgraded as the situation is stabilised. A number of people have recently acquired new bedroom furniture. Each house is appropriately furnished and decorated. There are proper arrangements in place to maintain and repair the houses and the standard of décor is generally good. There continues to be suitable laundry facilities and well-equipped kitchens in each villa. The Environmental Health Officer inspected the site prior to the inspection visit and they raised no concerns. The carpets in the lounge areas are marked and although cleaned are not greatly improved and replacement is now required. There is only one dining room where smoking is allowed on villa 1. No adaptations are required other than the fixed hoist fitted in one bathroom and a number of grab rails. All the people living at the home are ambulant although one person uses a rollator. All three villas were clean and in good order. People are encouraged to take care of their own rooms where they are able. All doors have locks with thumb turns and a small number of people are able to use a key. A copy of the Infection control manual is available. There are proper arrangements in place to dispose of clinical waste. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is adequately staffed with appropriately trained and experienced staff. Proper training arrangements are in place for care staff and clinical updating for RN’s. Staff supervision and appraisal continue to takes place. EVIDENCE: The staffing levels continue to be enhanced above the minimum levels on a monthly basis to allow RN’s to concentrate on supervision, appraisal and evaluation of care documentation or attend training. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 21 Staff morale is continuing. The introduction of the villa management structure has raised staff commitment and job satisfaction. There continues to been limited use of agency and bank staff and in general are able to maintain continuity of supply. This reduces the number of new staff in the home. Aspects and Milestones have a robust and established recruitment procedure. CRB /POVA and NMC checks are carried out by the personnel department. The four assistant team leaders to deputise for the villa managers are now in post. The trust has a satisfactory induction and orientation programme, staff work through the LDAF induction process prior to completing NVQ level 3. Records of such are kept. A detailed in-house induction programme has also been produced. The majority of the support staff have now commenced or are part way through NVQ level 3 courses. Those waiting to undertake NVQ’s are completing Trust competency training. The staff supervision and appraisal process is in place. The Trust’s community manager makes monthly visits for supervision purposes and as required by regulation 26.however the annual personal development plans (PDP)process is not fully operational. There are regular team meetings and RN meetings. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management arrangements continue to be effective and there are clear lines of accountability. There are various methods and systems in place to obtain people’s views. There continues to be appropriate arrangements in place to service and repair plant and equipment. The home has good Health and Safety arrangements. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 23 EVIDENCE: As written in the last inspection the registered manager and has many years of experience managing a nursing home for people with learning disabilities and has attained several additional qualifications each villa has a team leader and designated staff team. One of the three villa managers will deputise in her absence and this makes sure that the management is consistent. There is a survey format for people who use the service and relatives continue to be sent out periodically. Each Villa manager either delegates or takes responsibility for health and safety issues. There is a checklist to assess environmental health and safety and the accident and incident reports were properly completed. Any use of positive intervention is fully documented. There have been no incidents where PRT has been used recently. Staff training continues in this technique. Staff accident and incident forms are all held in the office. Resident accident/incident forms are kept on the villas. The manager is aware of the provisions of regulation 37 which have been submitted when required. There is fire risk assessment available on the villas and individual risk assessments in relation to each resident and fire safety. There were up to date records of hot water checks and bath temperatures. The load test on the hoist is up to date. Liability insurance certificates were on display and in date. There is no insurance in place for residents property unless privately arranged. Both an internal and independent external audits of financial records and proceedures take and no irregularities have been identified. Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 X 3 3 X 3 X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13.2 Requirement Timescale for action 01/04/07 2 YA24 23 2 d The registered person must make sure that when medications are administered the Administration sheets are signed each time. Replace the carpets in lounge 31/07/07 areas that are marked RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Elysian Villas DS0000020356.V331240.R01.S.doc Version 5.2 Page 27 - 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. 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