Inspection on 21/11/06 for Florence Villa and Independent Unit

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Florence Villa and Independent... 20/11/08

Florence Villa and Independent... 31/01/06

Florence Villa and Independent... 13/07/05

Florence Villa and Independent... 07/12/04

Florence Villa and Independent... 27/07/04

Florence Villa and Independent... 02/03/04

Florence Villa and Independent... 03/11/03

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

CARE HOME ADULTS 18-65 Florence Villa & Independent Unit 107 Trentham Road Dresden Stoke-on-Trent Staffordshire ST3 4EG Lead Inspector Mrs Susan Mullin Key Announced Inspection 21 November 2006 10:00 Florence Villa & Independent Unit DS0000008229.V310713.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 Florence Villa & Independent Unit DS0000008229.V310713.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. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Florence Villa & Independent Unit Address 107 Trentham Road Dresden Stoke-on-Trent Staffordshire ST3 4EG 01782 596850 01782 596850 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) www.craegmoor.co.uk Strathmore College Group Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 4 of whom may be LD, minimum age 16 years. Staffing levels will be reviewed to represent the increase in numbers Date of last inspection 31st January 2006 Brief Description of the Service: Florence Villa is part of a specialist residential College registered to care for 18 people with a learning difficulty/disability aged 16 to 25 years, of both genders. The home is a detached, domestic-style property with 4 double bedrooms and 4 single bedrooms. There are two other small buildings in the grounds; the Independent unit that has 1 double and 2 single bedrooms and the Annexe that has two single bedrooms. Only the Annexe has ensuite facilities, the remaining 16 bedrooms all have washbasins. From the home it is a short walk to Longton town centre and a bus ride from other city amenities. The purpose of the home is to provide support to enable Learners to develop independence skills, to enable them to progress into a supported living environment. Learners who are already placed at the College are offered an opportunity to live in a home, where it is felt appropriate and in line with achieving their long-term goals. The Learners have a full programme of activity, which takes into account personal choice. The activities are meaningful and are delivered in the community, making full use of local facilities. Young people stay at the college for a maximum of three years and attend for between 38 and 52 weeks per year, depending on their contract. The Learners are able to access other college facilitates, which include Jasmine a retail outlet in Wostanton and two other residential premises in the local area. All three homes are part of the Strathmore College Group, operated by Craegmoor Health Services. All three homes are also registered with the DfES. Weekly fees are from £801 up to £1491.84 Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced Key Inspection was undertaken by one inspector who used the National Minimum Standards for Younger People as the basis for the inspection. The inspection included a tour of the building, inspection of records, observation, and discussions with service users and staff. 18 Comment cards/service user surveys were completed and returned to the CSCI from service users/relatives/social workers and the GP. There were no negative comments made by health care professionals. Service users had completed 9 cards but only 4 comments were made; ‘staff are always helpful’. ‘I would like to keep Karen Mcmillan as our manager’. ‘I did not get enough information about the home before I moved in but I know it is a good place’. ‘When someone bullies you, you go into the office and you make a complaint’. Relative’s comments included; ‘I am generally satisfied with the care but there is always room for improvement’. ‘There are not always sufficient staff on duty’. ‘My sons progress is fantastic now, he is extremely happy with his education side but we have constant on going problems with his personal care and communication with the home’. ‘My son always looks scruffy and his clothes are never ironed. I am forever finding clothes in his room that are not his. His room never looks clean although the staff says he cleans it to a high standard. I do not think he is eating healthy enough’. ‘Communication is not always regular’. These anonymous comment cards were discussed with the principal, acting manager and deputy manager and it was noted that two parents had raised issues with themselves and these issues were currently being addressed. Several other comment cards were completed and all indicate by ticks that they are happy with the care and facilities provided at the home. No other comments had been made. What the service does well: The acting care manager has been in post for approximately the past 11 months, she has a clear vision for where she wants to take the home, and is very positive in her approach, in order to achieve this. To this end she has been pro-active in making plans, which are in progress. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 6 The home was clean, tidy, comfortable and with adequate heating and ventilation. The general atmosphere was very homely and relaxed and all service users seen on the inspection appeared happy. There was much laughter and banter evident. It was pleasing to observe affectionate and friendly relationships between service users and staff when interacting. The care planning records were well documented and ensured that staff had clear information about the needs of the service users and how to meet those needs. What has improved since the last inspection? What they could do better: It was determined that the fire alarm system and emergency lighting had only received sporadic testing. A requirement was made to ensure that these tests are resumed immediately in line with Fire regulations. The registered person must ensure that night staff have four fire drills per year in line with Fire Regulations. The Fire Safety office visited early in the year and left some requirements, these are currently being actioned by the home and will be checked on the next inspection. The registered person is recommended to inform residents and/or their relatives of the availability of the Commission for Social Care Inspection reports. The service has a complaints procedure that was available in the home. However this needs to be updated to include CSCI details as discussed during the inspection. Both pages of the registration certificate must be on display in the service. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 7 There were lengthy discussions about the content of the staffing rotas. These must be individualised for each service and be easy to cross-reference. New rotas were shown to the inspector, which clearly identified staff deployment, and the principal/acting manager confirmed that these would be put into practice. These will be checked on the next inspection. Training records need to be documented in a more robust fashion as discussed during the inspection. Plans are in place to remedy this situation and these too will be checked on the next inspection. 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. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 8 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 Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes Statement of Purpose and Service User Guide were good, providing service users and prospective service users with details of the services the home provides, enabling an informed decision about admission to be made. The statement of Purpose is currently under review to make it more service specific as discussed during the inspection. A service user guide was included in each service user file. The format was very user friendly in pictorial, symbol and simple language for ease of use. There was evidence in a sample of records seen that service users had the contents of the guide explained to them at the point of admission. The terms and conditions of residence were incorporated into the service user guide as well as in the contract between the service and the placing authority. The College also provide everyone with a CD, which visually explains the services offered at the home. Prospective service users can expect to spend up to a week at the College as part of their pre admission assessment. Florence Villa & Independent Unit DS0000008229.V310713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The needs of the residents were outlined in individual learning plans. These covered a resident’s educational, health and personal care needs, their occupational needs and their social needs. The plans clearly showed the actions required to meet the needs. Records relating to the different elements of the care plans were kept by staff in inanimate files for future/cross reference. The key worker and the resident on a regular basis were internally reviewing individual learning plans. There was also evidence of multi agency reviews within the 6 monthly reassessments. Discussions with a number of staff identified that the residents participated in a range of domestic tasks. These included working with staff to keep their bedrooms clean, doing household shopping, assisting with meal preparation, laying and clearing the table, making drinks and washing up. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 11 The home sought the views of residents over issues relating to the running of the home. Their views were sought over prospective residents, activities they wanted to participate in and over where they wanted to go on holiday. Staff stated that they had regular residents meetings and records confirmed this to be the case. The home also undertook surveys of residents to ascertain their views. The records showed that the home had developed a range of individual risk assessments. These included accessing the community, the management of hot water and hot surfaces and any risks associated with residents’ ability to manage their finances. Risk assessments were always under review. An allocated member of staff audited all individual learning plans every four months. This was particularly useful to ensure that all areas of assessment remained ongoing. Florence Villa & Independent Unit DS0000008229.V310713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home operates a programme of routine and opportunities for young people to develop self-confidence and form meaningful relationships with others. Everyone’s opinions are sought and these make up the structure of the learning experience within the home environment. Externally, the service users have great opportunities to follow preferred pastimes and hobbies. Service users happily contribute to the daily living and learning experience by helping staff to devise menu plans and rotas for domestic chores. They are encouraged to participate in the maintenance of communal areas and through regular meetings to agree actions and remedy issues. Those spoken to has a keen interest in the ‘running’ of the home. Individual religious and cultural needs are identified by key workers and with consultation with families agree how those needs are best met. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 13 The College strive to provide a living and learning environment free from prejudice and abuse. All the service users have their own individual timetable of activities, which is designed to enable them to achieve their objectives as set out in their Individual learning Plans. These are divided into four strands• • • • Daily Living Practical and vocational Personal skills Other support Formal reviews are held six monthly where the service user and all relevant parties input their evaluations and changes (if required) are then made to the plan and agreed with all parties for the following six months. Following discussion with service users, and from observation, it was confirmed that in house activity is organised based upon the individual needs of service users. During their final year at College, service users are supported to access appropriate services that will enable them to achieve their destination goals. Transition meetings are planned to ensure that appropriate resources are made available. During this difficult time and as required the College acts in an advisory role to the service users and the services involved, to create a seamless transition stage. Florence Villa & Independent Unit DS0000008229.V310713.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had identified the health care needs of the residents. Records showed that residents received eye checks, dental checks and accessed the chiropodist. Residents weight was being checked on a monthly basis. Residents received regular health care monitoring. All residents had a GP and the staff would support them to go to the doctor. The staff were alert to changes in residents conditions and had received basic first aid training. The home had procedures in place for the storage and administration of medication. Medication was stored securely. Records were kept of medication received and of medication returned to the pharmacy. Staff had received training in administering medication. A check was made on the administration of medication. The records were fully completed with no gaps in the records. The sample checked showed that the medication in the home corresponded with that prescribed by the pharmacist. The home had procedures in place for the administration of PRN medication. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pre inspection fieldwork identified that two complaints had been received by the home since the last inspection. These involved issues between two students and another when students stated that they could not hear the television over staff talking too loudly. Both these issues were satisfactorily resolved. Records were seen for both complaints. The service has a complaints procedure that was available in the home. However this needs to be updated to include CSCI details as discussed during the inspection. It has been reproduced in a more user-friendly format using symbols, pictures and simple language for the benefit of service users. Pre inspection feedback from service users and relatives was positive, indicating that they knew how to complain and to whom. This was confirmed from discussion during the inspection visit. Relatives meeting were recommended to ensure all interested parties had their views taken into account and acted upon. Training of staff in the area of adult protection had been undertaken and new staff had training organised for late December. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 16 One VA issue had occurred since the last inspection following allegations that residents were at risk on a holiday earlier in the year. The Local Authority and CSCI investigated this and several elements were upheld. The company now ensure future holidays do not carry the same risks and have introduced new policies and procedures. All holidays will have to be sanctioned by the Responsible individual in the future. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was suitable to meet the needs of the residents. It was located within walking distance of local shops and close to the centre of Longton. The home was being maintained satisfactorily. The home was generally well decorated and furnished throughout. The lounge was decorated and furnished in a domestic manner. The kitchen was a good size and was of a domestic type. Its size enabled residents to work alongside staff to undertake domestic tasks. There was also a small training kitchen. The home sufficient toilets and bathing facilities and one shower room is due to be refurbished. The home was a no smoking home but residents that smoked did so in an area of the rear yard. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 18 The home was clean and tidy. The home had cleaning schedules in place and practices in place to control the risk of the spread of infection. The home had adequate provision for hand washing and downstairs in the cellar was a laundry that was positioned so that dirty laundry did not need to pass through eating or cooking areas. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager and her deputy are supernumerary where possible. Both managers are to undertake their Registered Managers Award early next year. There is a robust on call system for all three homes. Agency staff is used where permanent staff cannot cover. The home had suitable staffing levels. The roster showed that the home had adequate care staff on duty during the morning and in the afternoon/ evening. At night there was on sleep in staff on duty. There were lengthy discussions about the content of the staffing rotas. These must be individualised for each service and be easy to cross-reference. New rotas were shown to the inspector, which clearly identified staff deployment, and the principal confirmed that these would be put into practice. These will be checked on the next inspection. It was determined that staff were available to provide them with support to go shopping, to go college, out for trips and during the evening to take part in Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 20 activities if they wanted. The staffing levels allowed for some 1:1 work and activities in small groups. The home provided new staff with induction training and with additional training related to the residents group. The company provided a range of training and accessed training from other providers. Training included adult protection, medication as well as the training relating to safe working practices including fire, food hygiene and first aid. All staff were required to undertake a range of training as part of their employment. Discussions were held with several members of staff who confirmed having attended numerous training courses and these were eventually confirmed in training records, albeit with some difficulty. The inspector and the deputy manager spent some time in discussion over the recording of training sessions. The home is to develop a simple staff-training matrix and was advised to include a due date for each course. The trainee and the trainer must sign all training sessions. Training courses have been organised for late December 2006 and include infection control, fire safety, first aid, POVA, Health and Safety COSHH and Basic food hygiene. The home had only 4 of their care staff who have achieved NVQ 2 or above. 3 have applied and are waiting for funding. All new staff will be encouraged to take up this training. 17 staff have first aid certificates. A sample of personnel files was examined. There was confirmation of CRB checks and the presence of two references on file. Application forms were completed. Confirmation of identity and medical clearance was also on file. Staff were provided with a job description and this was seen in the files. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was an open and friendly atmosphere in the home and the service users and staff benefited from an inclusive and approachable management style in the home. Records showed that service users and relatives were involved in the care planning processes and signed the relevant care plans as evidence of this. Since the acting manager started in January 2006, there have been no relatives meetings. It was recommended to facilitate a relatives meeting whereby they can have their views listened to. Records for the protection of service users, individual records and home records were seen to be secure, up to date and in good order. Policy and Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 22 procedural documentation was inspected and found to be extensive and informative. The inspector examined a range of records and documentation, which evidenced that the health, safety and welfare of service users and staff were not fully protected. It was noted that the fire alarm system and emergency lighting had only received sporadic testing. A requirement was made to ensure that these tests are resumed immediately in line with Fire regulations. The registered person must ensure that night staff have four fire drills per year in line with Fire Regulations. The Fire Safety office visited early in the year and left some requirements, these are currently being actioned by the home and will be checked on the next inspection. The gas and central heating appliances had been serviced. The electrical wiring of the building had recently been undertaken. The home does not have any passenger lifts/hoists or wheelchairs. Accidents and incidents are recorded. Hot water temperatures are also recorded within safe limits. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 23 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 3 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 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 X X X 1 X Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 24 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 YA42 Regulation Requirement Timescale for action 21/11/06 2 YA42 23(4)(c)(iv) The registered person must ensure that the fire alarm system and emergency lighting tests are resumed immediately in line with Fire regulations. 23(4)(e) The registered person must ensure that night staff have four fire drills per year in line with Fire Regulations. 21/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA1 YA22 YA1 Good Practice Recommendations The registered person is recommended to inform residents and/or their relatives of the availability of the Commission for Social Care Inspection reports. The service has a complaints procedure that was available in the home. However this needs to be updated to include CSCI details as discussed during the inspection. Both pages of the registration certificate must be on display in the service. Florence Villa & Independent Unit DS0000008229.V310713.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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