Inspection on 01/05/07 for Wilton Villas

This inspection was carried out on 1st May 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wilton Villas 09/10/09

Wilton Villas 25/07/06

Wilton Villas 20/12/05

Wilton Villas 15/03/05

Wilton Villas 01/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Wilton Villas Wilton Villas Islington London N1 3DN Lead Inspector Edi O`Farrell Unannounced Inspection 1st May 2007 09:55 Wilton Villas DS0000020974.V331957.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 Wilton Villas DS0000020974.V331957.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. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilton Villas Address Wilton Villas Islington London N1 3DN 020 7359 9990 020 7226 2714 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) St Martin of Tours Housing Locum in post Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/07/06 Brief Description of the Service: Wilton Villas is a registered care home for men with a forensic psychiatric history. People living in the home are supported within the multi-agency framework of the Care Programme Approach, which is the national framework for supporting people with mental health problems. There are 26 single bedrooms spread across three floors, which are accessed via a lift and stairs. Each floor has a small kitchen, bathrooms and toilets. There is a large lounge and recreational area on the ground floor. The, walled, garden is shared with a sister home, New North Road. Staff offices are on the ground floor. The focus of the service is on rehabilitation and partnership working with the forensic services and Community Mental Health Teams. There is an emphasis on risk assessment, care planning and structured individual sessions with key workers. Project and support workers run a range of group activities. Relevant professionals are available to support therapeutic groups. Service users are self-catering, and, as the home is mental health aftercare service, they do not have to contribute to the cost of the placement. Placing authorities pay the £970 per week charge. The home is situated in Islington in North London, in a residential area. It is within walking distance of Essex Road, and bus routes to Dalston, Highbury & Islington Tube Station and Angel Tube station. Parking is not available. The home is managed by St Martin of Tours Housing, which is a local, not for profit, organisation. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this, unannounced, key inspection took place on a weekday through the morning to mid afternoon. It lasted approximately five hours and was carried out by one inspector. Prior to the site visit all information held at our office had been reviewed. This included quality review reports that have to be sent to us on a monthly basis, and reports on any serious incidents, which had occurred since the last inspection. The chief executive of St Martins had requested a meeting with CSCI to discuss proposed changes, and current management arrangements. This took place at our Camden office the week prior to our visit. We checked two staff recruitment files at the end of that meeting. During the visit we talked to two people living in the home, the locum manager, deputy manager, acting deputy manager, a project worker and a support worker. We checked the arrangements for medication administration, including looking in the medicine cabinet. We toured the building, including some empty bedrooms, with the maintenance manager. We looked at assessment and introduction for two people who were being considered to move in. We also looked at risk assessments, care plans, daily records, and keywork records for two people currently living in the home. We crossreferenced this information with other records such as accident and incident reports, staff and house meeting records, and health and safety records. All the above information has been used to form the judgements contained in this report. At the end of the visit we left a form for the locum manager to let us know how he felt we conducted the inspection. What the service does well: The home provides a community placement for people leaving secure hospital settings. This allows a period of readjustment and rehabilitation prior to people moving onto more independent living. They are supported and assisted in learning or reacquiring daily living skills, which may have been lost whilst in hospital. Their stays also allow the psychiatric teams, who are responsible for them, to assess their adjustment to living in the community. Staff at the home work closely with the psychiatric teams in continually assessing any risks, both to the person themselves, and to others. Risk assessment, and risk management, is central, as is key working and care planning. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 6 The organisation sends CSCI monthly reports following a visit by an external manager. These are informative, and identify shortfalls and actions to address these. The actions are then checked up on at the next visit. This is very positive as it means that the organisation seeks to improve the service, rather than waiting for CSCI to inspect. Whilst the home has not had a registered manager for some considerable time standards have not slipped. The deputy manager, and the staff team, are to be congratulated on maintaining the service during a difficult period. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Wilton Villas DS0000020974.V331957.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 Wilton Villas DS0000020974.V331957.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&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have comprehensive information about the service, including via visits and overnight stays, prior to them moving in. They are fully assessed prior to them moving into the home. EVIDENCE: In response to a Requirement set at the last inspection the Statement of Purpose had been changed, so that it reflected who the home could, and could not, admit. The referral procedure remained good, and included accompanied visits, overnight stays, and trial periods. Evidence was seen in the files of the process being adapted to meet individual needs. This included extending the trial period where necessary. Two files of prospective residents were examined, along with those of the two most recent admissions. In all four cases pre-admission information gathering and record keeping was excellent. There were full forensic histories, including known risk and potential triggers. In one case the keyworker had prepared the detailed care plan prior to admission. A very positive point was that the home’s assessment started with a selfassessment by the person who was considering moving in. This was then followed up by an interview, of which written records were kept. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ needs were identified within a risk management framework. Whilst frequency of keywork sessions and review, set by the provider, had not always been met action plans had been put in place to address this, and there had been improvements in recent months. EVIDENCE: Two case files were looked at in depth, and the needs of another person discussed with staff and managers. There was very good follow through from pre-admission information to risk assessment and management and care plans. Care plans were reviewed on a regular basis. The care plans seen were comprehensive, and included any restrictions set as a condition of hospital discharge. Since the last inspection the monthly manager reports had highlighted that some reviews were not taking place with the correct frequency. This was based on the frequency set by the provider. They had also identified that Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 11 keyworker sessions were sometimes being missed. In both cases action had been identified and checked at the next month’s visit. Improvements had been noted over recent months, and regular audit of case files was continuing. This was excellent as it demonstrated the high level of importance that the organisation gives to assessment, including risk assessment, and care planning. As at previous inspections it was possible to see that changing needs, both positive and negative, had been responded to promptly. The two people spoken to who lived in the home said they felt their needs were understood by staff, and were being met. They felt that staff supported them to achieve their personal goals and objectives. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have opportunities for personal development, within a risk management framework. EVIDENCE: The home continued to provide a range of in-house activities, which had a focus on the development of new skills, and self-awareness. This had included percussion workshops, a men’s therapy group, a cooking group, and ‘art for life’ workshops. Together with the adjacent home the men had recently produced a newsletter, which built on their creative skills. There was evidence in keywork session notes of staff encouraging people to attend both specialist and community services, such as colleges, day centres, drug and alcohol services, leisure centres and cinemas. One of the men spoken to reported that staff had been encouraging him to access such services, including proving him with information. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 13 Rights and responsibilities were included in the care plans, with any restrictions, such as prohibited locations, clearly identified. Such restrictions were usually conditions of hospital discharge. The home did not provide meals, as people self-cater. Staff encouraged healthy eating via keywork sessions and the cookery group. One person spoken to said they particularly enjoyed the latter, and the communal cooked breakfast at weekends. The activity records showed that people had particularly enjoyed a recent Caribbean meal, cooked by a staff member. In a recent house meeting, which was chaired by one of the men, they had said that they wanted to cook a communal meal and invite all the staff. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ health needs are met and changes responded to. Improvements in medication administration and audit procedures are needed so as to safeguard the people living in the home. EVIDENCE: As at previous inspections there was evidence to show that physical and psychological needs were met by joint working with CMHTs and forensic services. The case files showed that people were supported to access local community health services, such as GP practices. The two men spoken to confirmed this. The medication administration charts were checked and discussed with the acting deputy manager and the locum manager. A new audit system had recently been introduced, which if used correctly would have made audit relatively easy. However, not all staff were using the system correctly so accounting for medication received, given, and remaining was not possible. The locum manager, who had only been in post for two weeks, had already identified this as an area for action. He provided evidence, that he had alerted his manager to this, and had proposals for change. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 15 There were some gaps on medication administration charts, where staff had not signed that the medication had been given, or a reason why it had not. The system required staff to sign both the chart and a prompt sheet. The latter was being used as an aide memoir to ensure that no one missed medication. However, as it resulted in gaps on the chart the usefulness of the system has to be questioned. There were no pictures of the men at the front of the charts, or notes of any known allergies or cultural and dietary needs in relation to medication. The acting deputy manager reported that a new medication policy and procedure had recently been agreed and was to be shortly implemented. She thought that these issues were addressed by the new system. We discussed the possibility of a CSCI pharmacy inspector carrying out a site visit in relation to the above points. As the locum manager had already taken action, and a new policy and procedure was going to be introduced, we agreed to leave this for the time being. We will review the situation over the coming months based on the monthly management reports. This is Requirement 1. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected by the home’s response to complaints and allegations, but there must be more consistency in reporting significant events to CSCI and placing authorities. EVIDENCE: The information supplied by the home prior to the site visit stated that there had been no complaints during the previous 12 months. This would be very unusual, and was shown not to be the case when house-meeting records were examined. People had raised concerns and complaints, but as part of these regular meetings. In some cases staff had resolved the issues, either immediately in the meeting, or via keywork sessions. In other cases the monthly manager’s report had highlighted that action was outstanding. Some of the issues had been about equipment not working, whilst others had been about how the behaviour of one person had affected others who lived in the home. The home needed to consider how concerns and complaints were recorded so that there was an audit trail of action taken and outcome. In practice staff were responsive, and had worked with the men to resolve dayto-day issues. No Requirement has been set, as the monthly manager’s reports were already identifying these issues. The two men spoken to felt able to raise any concerns with staff, and keyworker records supported their views. There had been two admissions to accident and emergency, and one death in hospital, since the last inspection. None of these events had been notified to Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 17 CSCI as is required under Regulation 37. In addition a care manager told us via a postal survey that they had not been informed by the home their client was staying with a relative during March 2007. Informing placing authorities and CSCI of significant events is important as it alerts both parties to potential problems, and demonstrates transparency and a commitment to protection. This is Requirement 2. There had been no allegations of potential abuse since the last inspection. During this visit staff demonstrated knowledge of what constituted abuse, and how to respond to it. Wilton Villas DS0000020974.V331957.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The continued programme of upgrading and redecoration has greatly improved the environment that people live, and work, in. EVIDENCE: The building was toured with the maintenance manager. This included looking at some of the upgraded bedrooms, and the three bed roomed flat next door. The continuing refurbishments had greatly improved the home, which was much more inviting than previously. The upgraded bedrooms had vanity suites and were furnished and decorated to a good standard. Colour schemes were tasteful and calming. Curtains had been put up in the communal lounge, and an extractor fan was going to be fitted. Bathrooms have also been refurbished using more sealed units, and walk in showers. All parts of the building were clean. Wilton Villas DS0000020974.V331957.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. 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. A competent staff team supports the people living in the home. EVIDENCE: From written records, indirect observation of staff during the visit, and discussions with two members of the staff team, it was apparent that staff had a sound knowledge of the needs of the people living in the home. This included some excellent examples of keywork records, where it was possible to see how the worker was supporting the person to address their problems and meet their personal objectives. Members of the staff team had either already gained NVQ level 2 or above, or were registered. The annual training plan was seen, as were the last year’s training records. Training was job related. The day following the site visit all staff and the people living in the home were attending training in the mental health ‘recovery’ model of working. This is the model that the home is to be using in the future, and is considered good practice in working with people with enduring mental health problems. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 20 At the last inspection staff had raised concerns regarding the clinical supervision sessions. A Requirement had been set that the functioning and purpose of these be reviewed, taking in to account the views of staff. This was discussed with the locum manager during this visit. As he had already identified it as an on-going issue the Requirement has not been taken forward. This will be checked on at the next inspection. Recruitment files had been checked the week preceding the site visit, during a meeting with the Chief Executive (CE) of St Martin of Tours, held at the CSCI Camden office. All required checks were in place. The check demonstrated that the organisation continues to have an excellent and robust recruitment procedure. This now includes psychometric testing, as well as continuing to recognise the importance of equality and diversity in the recruitment process. During the meeting with the CE we were informed that a staff regarding exercise had been carried out since the last inspection. We were told that this had followed full legal procedure, and was based on a baseline comparison with similar services. We saw letters in the staff files confirming this. On the site visit we discussed the changes with the locum manager and two members of staff. We were particularly concerned to find out how the changes had affected staff morale, and, potentially, the quality of the service. Whilst there was no doubt that staff morale had been affected by the changes, we found no evidence that this had adversely affected the people living in the home. Staff were to be commended for dealing with a very sensitive issue with a high level of professionalism. Wilton Villas DS0000020974.V331957.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst the home has not had a registered manager for some considerable time, this has not adversely affected the quality of the service. EVIDENCE: The home has not had a registered manager for some considerable time. The lack of a permanent manager, to provide strong leadership and boundaries, is a recognised factor in declining quality of services. At the last inspection a locum manager had been appointed but was off sick on the day of the visit. He was subsequently appointed to the permanent position, and applied to our regional registration team for registration. However, he then went off on longterm sickness in December 2006, and the application was withdrawn. Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 22 The deputy manager covered the post until another locum manager was appointed two weeks prior to this site visit. Both senior management and staff praised the job that the deputy manager had done during that period. On this visit there were no indications that standards had slipped since the last inspection. As one member of staff put it ‘She gave us real leadership’. A new locum manager had taken up post two weeks prior to our visit. He had correctly identified the key issues facing the service. He provided evidence of having taken steps to raise these with his manager. He was knowledgeable about the needs of the people being referred to the service, and the support that staff needed. He was also knowledgeable about the care standards legislation, regulations and standards. As commented on earlier in this report the monthly management reports supplied to us since the last inspection had identified areas for improvement. They had set actions plans, which had been checked on at the next visit. People living in the home were asked for their views in several ways. This included regular house meetings, keywork sessions, and yearly satisfaction surveys. A Requirement set at the last inspection had focused on the need for a clear strategy for filling the empty places. This had been in order to be sure of the future viability of the home, and the safety of peoples’ placements. The CE forwarded a report prior to our visit regarding this. This report had been agreed by the board, and concerned the adaptation of the recovery model. It also included structural changes to more fully utilise semi-independent living space within and adjacent to the home. At the meeting the week prior to the site visit the CE had informed us that a new partnership arrangement was in place with a neighbouring local forensic service. This had increased the number of referrals. Health and safety arrangements had been covered in depth since the last inspection by the monthly management reports. As with other issues required action had been identified, and followed up on at the next visit. The small sample of records we looked at on this visit were up-to-date, and in order. Wilton Villas DS0000020974.V331957.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 4 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 X X 3 X Wilton Villas DS0000020974.V331957.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 YA20 Regulation 13 (2) & 26 Requirement The registered person must ensure that staff at the home follow correct procedure in relation to medication administration and audit. They must assure themselves that the systems being used comply with CSCI guidance and national best practice. They must provide evidence of this via the Regulation 26 monthly reports. The registered person must ensure that all significant events are reported to the commission, in a timely fashion. Timescale for action 30/06/07 2 YA23 37 30/06/07 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 Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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 Wilton Villas DS0000020974.V331957.R01.S.doc Version 5.2 Page 26 - 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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