Inspection on 09/06/06 for Glebe Villa

This inspection was carried out on 9th June 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe Villa 24/06/08

Glebe Villa 22/06/07

Glebe Villa 27/01/06

Glebe Villa 02/08/05

Glebe Villa 26/01/05

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

CARE HOME ADULTS 18-65 Glebe Villa 26 Glebe Road St George Bristol BS5 8JH Lead Inspector Sandra Jones Key Unannounced Inspection 9 & 16th June 2006 09:30 th Glebe Villa DS0000061212.V299237.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 Glebe Villa DS0000061212.V299237.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. Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe Villa Address 26 Glebe Road St George Bristol BS5 8JH 0117 9541353 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) Aston Care Homes Mrs Etylin Astbury Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons with learning disabilities aged 18 64 27th January 2006 Date of last inspection Brief Description of the Service: Glebe Villa is registered to provide accommodation and personal care to six adults with learning disabilities. It is located in the St George area of Bristol close to shops, amenities and bus routes. The property has the appearance of a domestic dwelling, blending well with its local residential environment. It is arranged over three floors with shared space on the ground floor and bedrooms on the first and second floor. An application to extend the property has been received and it is the provider’s intention to increase the numbers from six to seven people and relocate the dining room and kitchen, thereby being able to offer accommodation on the ground floor. Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted over two days in June 2006 as an unannounced visit. This visit focused on the assessments of key standards through the evaluation of records and discussions with staff and residents. Resident surveys were sent to the home in advance of the inspection and full responses were received. Relative comment cards were also sent and four responses were received. Feedback from the member of staff on duty was sought on the conduct of the home and from six residents on the standards of care. What the service does well: What has improved since the last inspection? Positive comments were received from an outside professional on the standards of care observed at the home. The professional commented that there has been a 100 improvement since the registration of Aston Health Care. The introduction of Essential Life Plans will ensure that a person centred approach to meeting resident needs will be used at the home. The registration of the deputy for vocational qualifications will ensure that the home develops Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 6 further and empowers residents to make decisions about all aspects of their future. 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. Glebe Villa DS0000061212.V299237.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 Glebe Villa DS0000061212.V299237.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The Quality in this Outcome area is good. The policies and procedures in place for admission to the home will ensure that admissions to the home are based on full assessments. EVIDENCE: Within the home’s Statement of Purpose are the arrangements for admission. The process is clearly described and stipulates that assessments must be undertaken before admission to the home. There is a criteria for living at the home, which is listed and includes introductory visits and trial periods. The Service User Guide informs potential residents about living at the home, enabling residents to made decisions about living at the home. One resident confirmed through the survey that introductory visits to the home were arranged. There is a registration application in progress for an increase in the number of people that can be accommodated. It was understood from the staff in charge that there was one person interested in the new room and the person visited the home. Since then there has been no other request for accommodation. The service providers are actively seeking to fill the vacancy. Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 9 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 & 9 The Quality in this Outcome area is adequate. A person centred approach to meeting needs is used to prepare care plans and residents confirmed their participation in the process. The frequency of support must be specified within the care plan. The manager promotes the use of external support for residents to feedback on the care at the home. Risk assessments are completed for activities that may contain an element of risk. Risk assessments must describe the options available to ensure the level of risk reflects the actions. EVIDENCE: A person centred format was recently introduced to prepare individual care plans. Essential Life Plans (ELP) are prepared by the staff at the home. The identified needs are detailed in the plans along with a description of how the Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 10 identified needs are to be met. The name of the person responsible for the task is listed for each need. However, the frequency of support is not detailed in the plans. Copies of the plans are handed to residents’ representatives for their input. A meeting with the resident, their representative and staff at the home is then arranged. At the meetings the individuals strengths, goals and routines are discussed. Following from the review meeting an action plan is developed to ensure the persons goals and aspirations can be put into effect. While there are ELP’s in place for the residents, review meetings have not occurred for all residents. The member of staff in charge reported that review meeting will be convened by for all residents by June 2006. It was further stated that the Local Authority will be reviewing all placements at the home. Two residents giving feedback, during the inspection, confirmed that meetings with relatives and the home took place to discuss the care planning approach. One resident uses a combination of Makaton and symbols to communicate and the care plan lists the persons ability to communicate. Two residents will at times exhibit inappropriate behaviours. Care plans include the actions to be taken to diffuse and divert the behaviours. The residents and relative surveys were used in advance of the inspection. The staff ensured that where possible, residents were assisted with survey completion by professionals outside the home - for example, relatives, work colleges and day care staff. Care plans incorporate the person’s abilities to manage their finances, the support provided by the staff and relatives. Running reports are used by the staff to record their observations, decisions made by residents about their daily lives, outcomes of visits and activities. Risk assessments are completed for any activity that may involve an element of risk. Within the care plans, the individuals personal safety, mobility needs are described which relate to road safety, fire evacuation and personal needs. While the actions are clear, the actions to be taken must support the level of risk. Risk assessments must detail the options available to evidence that actions reflect the level of risk. There were no accidents at the home since the last inspection. Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15, 16 & 17 The Quality in this Outcome area is good. Residents participate in a variety of structured daytime activities and learning development logs will ensure activities are meaningful for residents. Residents are part of the local community. The staff support residents to strengthen relationships and links with family and friends. Residents are valued as individuals by the staff. Meals provided at the home are varied and meals served are sufficient. Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 12 EVIDENCE: The residents at the home undertake a variety of activities during the week. Two residents are employed, one is paid part time employment and the other is full time voluntary. Two attend structured day care services each day and one attends twice weekly with one person undertaking daily activities. One person is currently at home twice weekly. Essential Life Plans (ELP) meetings are convened to discuss residents goals and aspirations. An action plans is then developed and incorporated into the care plan. For the person at home twice weekly, there is an activity programme of independence living skills, shopping, visiting parks, shopping and restaurants. It is the intention of the deputy to introduce a learning development logbook to monitor the progress and value of the activity. The deputy reported that the staff at the home are invited to IPP meetings. Where the responsibility to meet the need is designated to the home staff, the need is described within the care plan. For residents that are employed, home staff maintain contact with employers. At weekends three residents are accompanied by a member of staff to visit the local library, shopping and lunch out. The other two residents go food shopping and have a meal out together. The residents consulted during the inspection, confirmed the arrangements in place for daytime activities. Through questionnaires residents indicated that “they can do what they want at all times”. A further comment was included that staff usually organise shopping trips and other outings at weekends. Visitors to the home record the date, time and nature of their visits. Relative’s surveys were sent in advance of the inspection and they indicated that they are made welcome by the staff, whenever they visit the home. Relatives confirmed that visits can take place in private and residents reinforced their comments, that bedrooms can be used for more privacy. The deputy of the home at the time of the inspection reported that the staff ensure that residents participate in local events and festivals. In terms of valuing the person, it was stated that mail is handed to the residents unopened, designated household chores are included in their care plans and there is open access to all parts of the home. Bedrooms are lockable and residents are provided with room keys and house keys. Within the Service User Guide the home’s approach to residents’ rights to dignity and Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 13 privacy are included. The rules and expectations of both parties are detailed in the Service User Guide including the expectation that residents participate in household chores. Rules for the home are based on smoking alcohol, drugs and taking strangers into the home. The residents consulted during the inspection endorsed the comments made by the person in charge additional comments were made about the staff respecting their rights. Residents reported that staff knock and wait for an invitation before entering bedrooms and staff ensure that personal care is provided in private. Menus are prepared with residents and where necessary alternatives are provided. There is a record of alternatives prepared kept at the home. Residents stated that they prepared their own packed lunch, refreshments and there was plenty to eat at the home. There is a wide variety of fresh, frozen and canned provisions, with fruit in the dining room for residents to have. Glebe Villa DS0000061212.V299237.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 The Quality in this Outcome area is good. Residents were positive about the support provided by the staff with their personal and health care needs. To maintain safe handling of medications, a running balance of paracetamol administered to residents, when required, must be maintained. EVIDENCE: Care plans detail the individuals personal care needs and the action plans which ensure that staff consistently meet residents assessed needs. Two residents have some mobility impairments and mainly require assistance with using the stairs. For this reason banisters on both sides were installed to provide adequate support to these residents. The deputy stated that two residents have support with personal care from staff. Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 15 It was confirmed that a keyworker system is in operation including the service provider who participates in keyworking. Residents giving feedback during the inspection described the health care support provided by the staff. Two residents visit their GP and other NHS facilities without staff support. Other residents stated that the deputy accompanies them on all health care appointments. Residents’ health care needs are recorded in the individuals care plan. With one exception, female residents attend routine screening checks. Members of staff monitor residents’ health care and would request referrals from their GP for specialist support. Residents access local NHS facilities, regular visits are arranged to the dentist, optician and dentist. Two residents are on regular prescribed medication, which are administered by the staff from standard packaging. The records of medication indicate that staff sign the records immediately after administering medications. There is a record of medications received at the home. Paracetamols are administered from a stock supply when required. The record of administration for paracetamol must include a running balance. Glebe Villa DS0000061212.V299237.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The Quality in this Outcome area is good. Residents feel confident to raise concerns with members of staff at the home. Members of staff are aware of their responsibilities towards reporting poor practice. EVIDENCE: Relatives that responded through questionnaires indicated that they were aware of the complaints procedure but had not made a complaint. Residents confirmed through questionnaires, their awareness of the complaints procedure and to whom they are to be directed. Their comments during the inspection were again verified. There were no complaints received at the home from residents or their relatives since the last inspection. Residents meetings taken place monthly and it is usual for all the residents to attend the meeting. The agenda is generally set from discussion following the staff meeting and includes complaints. Residents were consulted about the steps that they would take to report any incidents of mistreatment from staff. From their responses, the residents found it incomprehensible that they would be subject to any form of abuse by the current staff. Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 17 Two members of staff have attended external POVA training. POVA training was discussed with one member of staff. The member of staff was clear on the applying the knowledge to the work practices at the home. Glebe Villa DS0000061212.V299237.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30 The Quality in this Outcome area is adequate. The recent upgrade of the premises has provided residents with a more homely and comfortable environment: however, evidence of the safety of the work being done to increase the number of people that can be accommodated is still outstanding. There are sufficient bathrooms and toilets to meet residents needs. The shared space is comfortable for residents to sit together as a group. The home is kept clean and free from unpleasant smells. EVIDENCE: Glebe Villa is a care home in St George it is located in a residential environment close to shops, bus routes and other amenities. It has the appearance of a residential dwelling arranged over three floors. Shared space is on the ground floor and bedrooms will be on all floors. Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 19 There is an outstanding registration application to increase the registered number that can be accommodated. Within the application there is also a proposal to extend the premises and re-site the kitchen, laundry and dining room. An immediate requirement was issued at the inspection for the service providers to provide in writing an account of the outstanding work. Documentation and certificates to demonstrate that the environment is safe for residents and staff was provided. Prior to the publication of this report the required documentation was provided. The kitchen is in part of the new extension and what was the laundry, the laundry is now adjacent to the kitchen and dining room was re-sited to where the kitchen was previously. The dining room has been divided into an en-suite and a shared toilet. This bedroom and toilet are not usable at present. Extensive refurbishments have occurred since Ashton Care Homes have registered as service providers for Glebe Villa. It was understood from the person in charge that corridors will be redecorated and carpets replaced. It is the intention to undertake the redecoration during residents holidays. One relative through questionnaires reported that the recent alterations are for “the better of the residents.” Additional comments were made that the home is comfortable and clean. Residents’ surveys specify that the home is always clean and fresh. With the exception of one double room, all bedrooms are single occupancy. In bedrooms there is a combination of the home’s furniture and residents’ personal belongings. Each bedroom is decorated to the individuals taste and reflects their individuality. The bedroom to be registered will be en-suite. The double room and the room on the top floor are full en-suite with shower, toilet and wash hand basins. There is on full bathroom on the first floor and a separate toilet. Three residents currently share the bathroom and once the toilet downstairs is in use there will be a 1:1 ratio. Shared space consists of the lounge and dining room. In the lounge there is seating for nine people and in the dining room there is sufficient seating for the residents to sit together. The laundry is adjacent to the kitchen. The flooring is laminate and the walls are painted for easy cleaning. The washing machine is domestic in scale and can reach 95 temperatures. Glebe Villa DS0000061212.V299237.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 The Quality in this Outcome area is good. The recruitment procedure in place safeguards residents from abuse. Members of staff must receive copies of the General Social Care Council’s Code of Practice. Members of staff are registered onto appropriate training as soon as they are appointed. EVIDENCE: It was understood from the service provider that the recruitment process was conducted overseas. Two full time staff were appointed in May 2006, there is a deputy and one part time person already employed at the home. The personnel files of the staff working at the home were examined. Completed application forms are in place for all staff, with written references and CRB disclosures for two staff, National Bureau of Investigation (NBI) disclosures for two staff and work permits for overseas staff. The service provider confirmed that members of staff have not received copies of the General Social Care Council (GSC) Codes of Practice. Copies of the GSC Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 21 Code of Practice must be provided to each member of staff and they must sign to indicate receipt and their understanding. The deputy has contacted training organisations to register the most recently employed staff onto the Foundation and Induction training. This training is divided into five sections and follows National Induction Standards, which entails the Principles of care, role of the worker, service user group, Health & Safety and integration. From this training the LDAF will follow for these staff. Glebe Villa DS0000061212.V299237.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41, 42 The Quality in this Outcome area is poor. Although service users are benefiting from the ethos of the home, a manager for day-to-day operations must be appointed to take forward the running of the home. The service providers must provide an action plan on the day-to-day management of the home and the systems in place to monitor consistency. Records are well managed. The health and safety of residents and staff is promoted. EVIDENCE: From the rota in place, it is evident that for the majority of the week the deputy is left in charge of the home. The service provider is rostered between 2-3 days per week and covered 9 shifts between 22/05/06-18/6/06. The Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 23 deputy is left in charge of the home and undertakes the day-to-day running of the home. On the afternoon of the initial inspection, the service provider was present and it is evident that deputy has more day-to-day understanding of the residents needs. The deputy is undertaking management training NVQ level 4 and the Registered Manager’s Award (RMA). A manager must be appointed to provide a presence and to set developmental plans for the home. An outside professional contacted the Commission to give feedback on the standards of care at the home. The comments received were very positive in terms of contact with the home staff, that staff were always available to discuss the needs of the residents. Particular praise was given to the abilities of the deputy. Members of staff attended meetings convened and from their observations there was a 100 improvement on all aspects of the provisions of care. The member of staff on duty reported that the deputy discusses with them their training needs and suggests training to be undertaken to develop competency. The records that relate to fire safety checks and practices were examined during the inspection. From the records kept at the home, the staff conduct check and attend practices at the stipulated frequencies. Accidents sustained by staff and residents are recorded and from the records of accidents there were no incidents or occurrences since the last inspection. The home’s boiler was recently installed and under guarantee. A record of fridge, freezer and cooked meats is maintained by the home staff. Glebe Villa DS0000061212.V299237.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 x 2 3 3 x 4 x 5 x 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 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 1 3 X x x 3 x Glebe Villa DS0000061212.V299237.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 YA6 Regulation 15 Timescale for action The times and frequency for staff 30/07/06 to undertake tasks must be recorded in the individuals action plans. The running balance of medications administered from a stock supply when required must be maintained. Risk assessments must include the options available to minimise the level of risks. The service providers must provide an action plan on the day-to-day management of the home and the systems in place to monitor consistency. (Previously required 27/01/06) 30/06/06 Requirement 2. YA20 13 3. YA9 13(4) 30/07/06 4. YA37 10(1) 30/07/06 Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 26 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 Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. Extracts may not be used or reproduced without the express permission of CSCI Glebe Villa DS0000061212.V299237.R01.S.doc Version 5.2 Page 28 - 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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