Inspection on 21/07/08 for Villosa II

This inspection was carried out on 21st July 2008.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Villosa II 13/07/07

Villosa II 14/07/06

Villosa II 14/11/05

Villosa II 15/06/05

Villosa II 08/02/05

Villosa II 17/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Villosa II 40 Tippendell Lane Chiswell Green St Albans Hertfordshire AL2 3HL Lead Inspector Julia Bradshaw Unannounced Inspection 21st July 2008 10:00 Villosa II DS0000055526.V368187.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 Villosa II DS0000055526.V368187.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. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villosa II Address 40 Tippendell Lane Chiswell Green St Albans Hertfordshire AL2 3HL 01727 874169 01727 874169 shanmugadasa@psycare.co.uk 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) Psycare Hostels Limited Puvanandradasa Shanmugadasa Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2007 Brief Description of the Service: Villosa 11 is a detached chalet bungalow, which has been extended and converted into a Care Home for six people with a learning disability. The premises comprises of six single bedrooms, a combined lounge/dining room, separate kitchen and laundry room. The home also has a large conservatory on the side of the house, which was built in 2001. The home is situated in a residential area of St Albans with a shopping parade, public house, sports centre and grassed activity centre nearby. The home is a short bus journey from the main City centre. The Service User’s Guide and Statement of Purpose provide information about the service to prospective residents. Copies of the latest report from the Commission for Social Care Inspection (CSCI) are available in the home. The fee range is £1050 per week to £1200. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means the people who use this service can expect adequate quality outcomes. This report draws on information obtained from the recent Annual Quality Assurance Assessment (AQAA) completed by the manager. The AQAA is a selfassessment document that focuses on outcomes for service users and also gives us some statistical information. This key inspection visit was carried out by one inspector on the 21st July 2008.The inspection process included speaking to people using the service, staff on duty and a full inspection of records relating to care planning, medication, health and safety, staff records and training and the general management of the service. Surveys from people who use the service and from staff are part of the ongoing inspection of a service and any issues arising from these surveys and other relevant information received by the Commission could then inform further regulatory visits by Commission in respect of Villosa 11. What the service does well: There are various systems in place, which reflect the good working relationships within the staff team. Working practices were observed as both caring and appropriate to the needs of people using the service. The manager and staff continue to work hard to improve and develop the environment and have endeavoured to create a homely and comfortable atmosphere. The environment continues to be developed and improved to provide a homely domestic style setting in which people can live safely and lead lifestyles that suit them. In particular, the bedrooms are well presented and have suitable furnishings and décor that both promote people’s dignity and provide an acceptable level of comfort and individuality. The current assessment system in place has been further developed since the last inspection was carried out in 2007 and now provides a detailed and comprehensive approach to identifying all the needs of new and existing people living within this service. People living at Villosa 11 appear to have some degree of involvement in their care planning. Three service user plans were inspected and found to be detailed and comprehensive. Care plans are reviewed regularly and signed by either the person using the service or their representative in order to confirm Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 6 they have been fully consulted in this planning process. The manager and staff have worked hard to create this documentation in a pictorial format. The registered manager and two staff were on duty during this inspection and everyone living at Villosa 11 arrived home shortly after the inspection process began. The two care pathway facilitators on duty were spoken to during the inspection and appeared to have a clear understanding of their individual roles and responsibilities. What has improved since the last inspection? What they could do better: The current arrangements for the control of cross infection, with particular regard to hand washing are inadequate and could place people at risk from infection. The current controlled medication book is both worn and damaged and there is a risk that some pages could be lost as the binding is ripped and therefore should be replaced. There must be a current fire risk assessment in place in order to protect everyone who lives, works or visits Villosa 11. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 7 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. Villosa II DS0000055526.V368187.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 Villosa II DS0000055526.V368187.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 –4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the service is kept up to date and provided for all prospective users of this service and everyone wishing to enter the home has a full assessment of need completed. This ensures that all parties can be sure the home can meet all individual needs. The terms and conditions of the service are agreed in writing so that people are clear about the roles and responsibilities of all those within the service. EVIDENCE: Information about the service is available in a statement of purpose and service user guide. These are kept up to date and are available to prospective residents. A total of three care plans were reviewed and evidence gained regarding the initial assessments that are carried out to access if the service can meet the needs of the person. Information is held regarding the persons history and current needs. An assessment of each person’s needs and aspiration are made before the person moves into the service. Competent and qualified staff complete the assessments. The service also receives and seeks external specialist support to meet the individual’s needs. Whole life reviews occur to support the service users in achieving and reviewing individual needs, goals Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 10 and aspirations. The assessment process includes the gathering of information from other professionals. Villosa 11 has its own internal assessment forms. A contract is then drawn between the service provider and the person using the service. The contract includes the terms and conditions within the service and the rights of the people who live at Villosa 11. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 11 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 who use the service can be confident that the care plans reflect a detailed and comprehensive record of people’s needs, which ensures that people using the service are assessed, reviewed and safe from risk. EVIDENCE: Three care plans were inspected in detail and were found to provide a detailed insight into each individual’s needs. Individual notes and guidelines for people were observed within the service. The manager and staff have worked hard to produce theses care plans in a pictorial format that can be easily understood by each person living within the service. Everyone living at Villosa 11 is supported within the whole life review framework and reviews occur to ensure changing needs are continuously assessed and reviewed. Ranges of risk assessments are completed within the service and actions points recorded. These risk assessments are detailed and contain all the required information. Activities and outings enjoyed by people living at Villosa 11 determine that Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 12 people are supported to take risks as part of an independent life style. Risk assessments have been reviewed since the last inspection was carried out. Staff work with people to assist them to lead safe and enjoyable lives and regarding decision making and offering support where needed. There was evidence to confirm that people had been involved in their care planning with signatures from either the person using the service or their representative. People spoken to on the day of the inspection were all positive about the way that care is received in terms of preserving rights and dignity. People spoken to state, “ I like the staff here, they are very nice to me” Another person stated that the staff “ take us on holidays”. Another person said that then manager is kind because he takes them to visit their spouse, who lives some distance from them and often does this when he is off duty. The Community Learning Disabilities Team based in St Albans provides health care support. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16 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 use the service can feel assured that they will be offered and receive appropriate opportunities for social/leisure and community involvement, which meets their needs and expectations. EVIDENCE: Detailed activity programmes are in place and presented in an individual pictorial activity planner. Activities are selected to meet people’s interests and where appropriate to enable them to achieve realistic personal development goals. The individual care plans demonstrated how people are supported to enjoy appropriate community resources. Some people maintain close ties with their relatives and friends and make visits/stays on a regular basis. The people living at Villosa 11 have enjoyed a variety of trip out to the theatre, the circus, bowling, the cinema and as part of everyone’s weekly activity programme people go out for lunch on their day off. People also use both the bricket wood day centre and Thirlmere day centre at Cell Barnes. A variety of holidays have Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 14 taken place since the last inspection, which include, taking one person to Spain, another person to France and further trips are planned for later this year. Routines within the service are designed to promote people’s independence skills. However some of the people living at Villosa 11 have limited independence skills due to their advancing years and for some people, a life that has involved extensive years of institutional care. We therefore assessed the quality of life for these people against the need to further develop these daily living/independent skills and the outcome for these service users is therefore considered good. People living at Villosa 11 are unrestricted in their movement around the home. Menus are offered on a flexible basis, with people making informed choices over their meals. Meals observed were unrushed and relaxed. Adequate food stocks were noted in the kitchen cupboards and freezer. Particular food preferences and dietary needs are noted in the care plans. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 15 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. People who use the service can be assured that their health and personal care needs are carried out effectively and respectfully, ensuring that their wishes and choices are promoted. However, the administration of controlled medication may place people at risk due to an unsafe system of recording. EVIDENCE: All care provided is individual and tailored to each person needs with each person choices and preferences being promoted. Assessments are completed ensuring that the approach adopted is person centred and holistic to each person. People are supported with all aspects of their physical and emotional health and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dieticians. Information and advice is provided to everyone living at Villosa 11 regarding general health issues. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 16 A robust policy and procedure is in place to support the safe administration, storage and receipt of medicines. However on the day of the inspection we saw that the book used to record controlled medication was badly torn around the bindings and pages could be lost or mislaid, giving an inaccurate record of people’s medication. This must be addressed immediately. Medication training was evidenced from the training records for all staff who administer medication within this service. Staff spoken to on the day of this inspection confirmed that they had been both inducted and trained in the administration and safe keeping of medication. The community nurse visits daily to administer insulin to one person living within the service. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 17 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. People living in this service can be assured that they will be protected from abuse and that they will be listened to if they raise any concerns or make a complaint about any aspect of their care. EVIDENCE: The service has a detailed complaints procedure in place. A record is maintained in the home of any complaints made detailing actions and outcomes as necessary. People using the service have been informed about the complaints procedure. Three people spoken to stated that they knew who to talk to if they had reason to complain. The recent AQAA stated that no complaints have been received since the last inspection was carried out. A detailed procedure is in place to ensure that people using the service are protected from abuse and harm. Staff receive suitable and adequate safeguarding training. Staff employed within the home are all subject to enhanced Criminal Records Bureau disclosure. Villosa II DS0000055526.V368187.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, 25,26,27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service provides a well-maintained environment for those who live and work there but the lack of adequate hand washing facilities places everyone at risk from cross infection. EVIDENCE: The environment continues to be further developed and improved with various areas of the service being re-decorated since the last inspection. These include the hallway and corridors, door guards have been fitted to ensure fire safety is not compromised and people are kept safe, one bathroom has been converted into a walk-in shower facility, external lights have been fitted outside the fire exits and there has been a new dishwasher purchased and fitted since the last inspection was carried out. People are encouraged to bring personal items such as furniture and pictures into their room when they move in. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 19 We saw that the home was clean and odour free on the day of the inspection. The cleaning is carried out by the care staff and with service users assisting where possible. The manager monitors this to ensure that standards of cleanliness are maintained. The kitchen and laundry rooms are domestic in style and appear to manage their current workload effectively. However on the day of this inspection there was inadequate hand washing facilities, as there was only one single towel in each of the toilets/bathrooms. This could present an infection control risk to everyone using these facilities. The manager is advised to look at the guidance for care homes from the Health Protection Agency on infection control. Sufficient lighting, heating and ventilation is provided. Each person has a single bedroom. The communal areas of the home are decorated and furnished to an acceptable le standard and there is a selection of home entertainment equipment for service user to access. The water temperatures on the day of the inspection were recorded within safe limits. However the current thermometer in this bathroom was rusty and the face scratched and marked. This should be discarded, as it may not provide an accurate reading and a new one purchased. There were also a variety of bottles of shampoo, bubble bath and unmarked creams in the main bathroom, which appear to be used for general use. Each person living at this service should have his or her own personal toiletries and these should be kept separately. The service still has numbers on each of the bedroom doors, which gives the impression of an ‘institution’. There appears to be no reason for these numbers in relation to each person knowing where their rooms are as this is a small domestic style house and this group of people are very familiar with where all the facilities are. Villosa 11 has a large rear garden and a large conservatory as a secondary communal area. The garden appeared very unkempt and people living at this service would not be able to access the garden in its current state. This should be improved so people can enjoy it, especially during the summer months. Villosa II DS0000055526.V368187.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, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that a loyal, experienced and welltrained staff team, who have been robustly recruited to ensure their continued safety will support them. EVIDENCE: All the staff demonstrated their commitment to their work in caring for the people who use the service. Two members of staff spoken to during this inspection stated that “they found the manager approachable and the training opportunities were good”. There was adequate information provided by the manager to confirm that staff are receiving adequate training and supervision to carry out their roles effectively. There is a minimum of two staff on duty during the mornings and evenings and the manager is supernumery to these staffing levels. There is one waking night care per night. The manager also stated that if there is a particular Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 21 activity/events planned then staffing levels are increased accordingly. This service currently has one full time vacancy for a care pathway facilitator. The recruitment records of 3 staff, including the most recent appointment were viewed; evidence demonstrates that there are good recruitment practices within this service, which means that people living at the Villosa 11 can be reassured they are protected by the effective recruitment systems in place. Villosa II DS0000055526.V368187.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, 40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Villosa 11 can feel confident that they are living within a service that is well managed. However ineffective system of recording relating to controlled medication, infection control and fire prevention currently could place people at risk. EVIDENCE: Generally people living within the service are provided with information that can be understood in relation to the complaints procedure, although the service could further improve this information by creating all documentation in a more user friendly format that can be easily understood by the people using this service. The manager ensures that supervisions and staff training are held regularly and two spoken to on the day of this inspection staff confirmed that they feel supported and respected by the current manager. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 23 People are safeguarded from harm by the homes recruitment procedures, safeguarding training and the complaints procedure. The manager should further implement a more formal quality assurance system in all areas of the service in order to ensure there is regular monitoring and reviewing to improve areas of development, with a particular focus on service user involvement. The manager has agreed to develop a questionnaire, in order to ascertain their views and to ensure that people are consulted and involved in the decisions made at Villosa 11. All records inspected were secure and were up to date and held in accordance with the Data Protection act 1998 ensuring that people’s rights and best interests are safe guarded by the homes polices and procedures. Individual and generic risk assessments were in place. The general standard of fire checks/recording is good and fire records on the day of the inspection were up to date and recorded accurate. However the fire risk assessment on file was out of date and requires updating. As already reported the standard of infection control was found to be inadequate in relation to the hand washing facilities. There needs to a more effective and safe system in place in order to ensure that everyone living, working or visiting this service are protected from cross infection. As reported earlier the controlled rugs record book must be replaced so that it meets the current good practice requirements. Villosa II DS0000055526.V368187.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 3 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 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 x 3 2 x 2 x Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA30 Regulation 13 (3) Requirement To ensure people are kept safe from infection cased by poor hand hygiene there must be an effective and safe system in place for people to wash their hands in a way that does not create a risk of cross infection. To ensure the safety of the service users the current system for the recording of controlled medication is unsafe and must be improved to ensure there is an effective system of recording this medication. To ensure the safety of the people who live and work in the home there must be a current fire risk assessment in place. Timescale for action 28/08/08 2. YA20 13 (2) 28/08/08 3. YA40 23 (4) (a) 28/08/08 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 Villosa II Refer to Standard YA24 Good Practice Recommendations The garden should be cleared up and repairs carried out DS0000055526.V368187.R01.S.doc Version 5.2 Page 26 2 YA39 to make this area more accessible for people living within this service . The quality assurance system should be further developed to incorporate the views of the people using this service and generally documentation produced should be in a format that can be easily understood by the people living at Villosa 11. Villosa II DS0000055526.V368187.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Villosa II DS0000055526.V368187.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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