Inspection on 14/08/07 for Fullwood House Limited

This inspection was carried out on 14th August 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fullwood House Limited 06/06/06

Fullwood House Limited 31/01/06

Fullwood House Limited 28/07/05

Fullwood House Limited 07/03/05

Fullwood House Limited 19/05/04

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

CARE HOME ADULTS 18-65 Fullwood House Limited 65/67 Lord Haddon Road Illkeston Derbyshire DE7 8AU Lead Inspector Janet Morrow Unannounced Inspection 14th August 2007 11:15 Fullwood House Limited DS0000049691.V340719.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 Fullwood House Limited DS0000049691.V340719.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. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fullwood House Limited Address 65/67 Lord Haddon Road Illkeston Derbyshire DE7 8AU 01159 323469 0115 9179 752 fullwood.house@ntlworld.com 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) Philip Nigel Weston Mary Murray Barrett Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: The home was opened by the current provider in January 2004, following the building being extensively refurbished and modernised. The home is situated close to the centre of Ilkeston and provides accommodation for 10 Adults who have long-term mental health problems, requiring support and rehabilitation. The home’s original aim was to move residents on to more independent housing as part of an extended rehabilitation programme, but lately has received referrals from people needing longer-term stable accommodation. All bedrooms offer single person accommodation, with en-suite facilities. There is also extensive communal space that allows for large or small group interaction and activities. Links have been made with local services and professionals to assist with rehabilitation and therapeutic processes. The current weekly fee for this home is £666. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over one day for 5.25 hours. An ‘expert by experience’ assisted with the inspection process. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The ‘expert by experience’ was present for three hours and spoke with five service users and four members of staff. His findings are incorporated into the report. Care records, maintenance records and staff records were examined. The manager and the provider were not on duty at the time of the inspection visit but were contacted by telephone following the visit. The senior member of staff available assisted in providing relevant information for the inspection visit. A tour of the building was undertaken. Two service users’ surveys were returned to the Commission for Social Care Inspection during the inspection visit. Both service users had received help from a member of staff in completing the survey. Written information in the form of an annual quality assurance assessment was provided by the home prior to the inspection and informed the inspection process. What the service does well: The home has made links with local services and facilities that help people who have poor mental health, and has also helped residents to use local community facilities such as libraries, leisure centres etc. The proprietor ensured that the home was well maintained and comfortable and furnishings and fittings were of good quality. Staff received good levels of support from both their colleagues and the home’s management. They are committed to their work and to the service users at the home and relationships were described as positive. The staff provided care and support in a structured and planned way and the documentation used made sure this was given consistently and safely. Most of the service users spoken with reported that staff had time to talk with them privately and that they also had time with outside professionals. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 6 Health services were called in when required and specialist help and advice was sought as necessary. Care needs were reviewed regularly with a health professional. This ensured that service users’ health needs were met and healthy living was promoted. Meals were well managed and service users enjoyed them. There was choice and variety and an emphasis on healthy eating. What has improved since the last inspection? What they could do better: Quality assurance processes need to be fully implemented to show that the service is continually striving to improve. There must be clear demonstration of how consultation takes place with different groups of people such as relatives, service users and visiting professionals and what action is taken to address any comments received. Complaints must be fully addressed to show what action has been taken and what the outcome is. This will give service users greater confidence that their concerns will be listened to. Two written references must be available on all staff files as part of the recruitment process. Some aspects of medication administration needed refining to ensure the safest method of administration occurs, as recommended by the Royal Pharmaceutical Society Guidelines. The policy on medication administration for homely remedies needs reviewing, as it did not match what was happening in practice. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 7 There must be evidence of consultation with service users about their care; for example, a signature on their care plans. All parts of the care plan must be fully completed to ensure no care needs are missed. Arrangements for privacy in relation to personal relationships and General Practitioner visits should be made explicit in care plans and service user information, such as the service user guide. Service users’ meetings should take place as detailed in the written information supplied by the home to ensure that they have a forum to discuss common issues. Staff training in safeguarding adults should take place and a copy of the Derby and Derbyshire Local Authority Social Services safeguarding adult procedures should be available in the home. More effort should be made to have a wider range of activities or recreational facilities available in the home as an alternative to the television. The identified toilet and the front gate must be repaired. The safety of the front path should be reviewed. Gas safety must be checked on an annual basis. All staff must undertake mandatory health and safety training regularly. The development of a training matrix to identify which staff need to be updated should be put in place. 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. Fullwood House Limited DS0000049691.V340719.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 Fullwood House Limited DS0000049691.V340719.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): 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient admission information is available to ensure that the home is suitable and can meet service users’ needs. EVIDENCE: Two service users’ care files were examined and both had an assessment in place. Information from external professionals was available. The information covered all the essential areas such as health care needs, risk assessments in relation to mental health needs and daily living skills. Two service users spoken with described how they had been able to visit the home and to meet other residents and staff, before deciding to move in. Most service users felt their needs were met and that they had made a positive choice in coming to the home. Fullwood House Limited DS0000049691.V340719.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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are generally good and ensure that consistent patterns of support are given and that independence is maintained but more attention to social needs would enhance the care offered. EVIDENCE: Two service users’ care files were examined and they each had an individual ‘rehabilitation’ plan, put together from the assessments that had taken place. These covered areas such as personal hygiene, mental and physical health needs, medication and daily living skills. These plans indicated that they had been looked at regularly and revised where necessary, which made sure that support was being given in ways that were based on up-to-date information. However, on one of the two files examined, there was limited social information and the care plan did not address any social needs or hobbies and Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 11 interests and there was no guidance on activities or daily structure. The member of staff in charge stated that this was because the service user concerned had had a period of mental ill-health and social and leisure opportunities would be addressed when they were well. Neither of the files seen had a service users’ signature as a means of indicating that consultation about care had taken place. This was raised as an issue at the last inspection in June 2006. There was evidence from general observation and discussion with service users and staff that they were involved in decisions about their life and able to make decisions, with assistance, as required. Those service users spoken with were able to pursue their own interests. In discussion, however, service users indicated that there had not been any service users’ meetings recently to discuss common issues regarding the home, although the written information supplied by the home stated that these occurred. Staff and service users spoken with stated that the meetings should occur every month. However, it was not clear whether these all take place as the most recent ones recorded were in June and April 2007 and November 2006.It was also unclear that they were providing a means for service users to have a say in how Fullwood House was run and developed, as the only examples of issues service users gave that had been discussed recently seemed to be about destinations for holidays. One service user was unhappy that staff members ‘hold’ cigarettes on their behalf and only hand them out ‘on request’. However, discussion with the manager on the telephone after the inspection visit stated that this was due to health reasons and was documented in their care plan. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Community access, meals and choice in daily routines are well managed, which enhances service users quality of life. EVIDENCE: Service users spoken with stated that they could take breakfast at different times and choose different items. There were always at least two menu options for lunch and evening meals. They had access to tea, coffee and squash around the clock. Occasionally service users prepared food with the cook and a member of staff. Specialist diets were catered for and one service user was pleased with the options provided for their diet. Staff spoken with stated that fresh fruit was available and service users confirmed this. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 13 All service users have been encouraged to participate fully with activities inside and outside the home, with varied success depending on individual inclination and motivation. Services that the home had made contact with ranged from ‘drop-in’ and structured day centres, the local college to a local church. However, staff spoken with stated that in-house activities were run on an ‘ad hoc’ basis and these appeared to be more limited with a focus on TV, bingo and card games. General observation during the visit showed that service users were able to go out as they wished and that use was made of local facilities such as shops and libraries. Staff stated that that service users participated in a swimming group and badminton group at the local leisure centre. Service users stated that they were able to maintain relationships with friends and family but one reported a difficulty in a personal relationship due to a lack of privacy. This had taken some time to resolve. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Access to health care professionals ensures that service users’ health needs are met. EVIDENCE: Two service users’ care records were examined and showed that access to health professionals such as optician and General Practitioner (GP) were recorded. Service users spoken with stated that if they had any health problems they could quickly get appointments to see a local GP and that staff members usually accompanied them to visit the GP. It was unclear whether or not service users had the option of seeing their GP in private as those spoken with thought it appropriate that the staff member sat through the appointment with them. Because of the nature of the needs of the service user group, all have required emotional support from staff regularly and care records indicated that help was Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 15 offered in both informal and structured ways. Generally self-care skills were high. The records showed that a range of health needs were covered including medication and mobility. However, the physical health needs on one care plan were not fully completed although monitoring of a specific condition was being recorded. One record also mentioned continence issues but there was no action recorded to deal with this. Weight was being monitored on one service user’s record. Two service users’ medication administration record (MAR) charts were examined and found to correspond accurately with the dispensing system, with the exception of two missing signatures on one chart for the administration ear drops. However, one ‘as required’ medicine did not have a code used to indicate why it was not given. A general check of all MAR charts and three from the previous month showed that they were signed accurately. However, two people were not signing handwritten charts. This is recommended as good practice to minimise the risk of errors. The staff member spoken with stated that there were no controlled drugs on the premises but suitable storage was available for them if necessary. There was also a medication refrigerator and temperatures were being recorded on a daily basis and showed that these were within safe limits. A copy of the Royal Pharmaceutical Society Guidelines was not available. The medication policy stated that homely remedies such as cough and cold medicines were administered from a General Practitioner prescription but the staff member spoken with stated that this was not actually what happened. Usually, medicines of this nature were purchased directly from a pharmacy. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lack of response to service users’ concerns had the potential for service users to lack confidence that complaints were addressed objectively. Safeguarding issues were not fully addressed through staff training and knowledge of Local Authority procedures. EVIDENCE: The written information supplied by the home stated that there had been ‘no complaints received since opening’ but examination of the complaint record showed that two complaints had been received in 2007. There was no recording of any action taken in response to the complaints. The manager was spoken with by telephone following the inspection visit and said that one complaint had been withdrawn and notes had been taken in response to the other. However, no written confirmation of this was seen during the visit. The member of staff spoken with stated that the home complaints policy and procedure was included in the Service Users Guide, which was given to service users and their representatives. The procedure was on display in the home and stated that complaints would receive a written response within twenty-eight days. The home had a detailed policy and procedure in relation to the safeguarding of vulnerable adults and a copy of the Department of Health guidance ‘No Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 17 Secrets’. However, a copy of the Derby and Derbyshire Local Authority Social Services safeguarding adult procedures was not available and the member of staff spoken with was not sure if the home had a copy. Although safeguarding adults training was advertised on a notice on the wall, it was unclear at the time of the visit whether or not this was taking place and there were no certificates in staff training records that indicated that any safeguarding training had taken place. Fullwood House Limited DS0000049691.V340719.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, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is furnished and maintained to a high standard, which ensures homely and spacious facilities for service users to safely enjoy. EVIDENCE: The fittings and furnishings of the home were in good condition and it was well equipped and furnished in a modern style. Maintenance records were available and a repair book showed that repairs were responded to promptly. The written information supplied by the home stated that communal areas had been redecorated, two new central heating boilers had been installed, a new freezer had been purchased for the kitchen, two bedrooms had been completely refurbished, the office refurbished and the smoking area had been relocated to the small lounge. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 19 The service users spoken with stated that they enjoyed their own rooms and that they were large enough and furnished to their liking; they were ‘spacious, comfortable and well equipped.’ The laundry was neat and tidy and had three washing machines and one drier. Staff spoken with stated that there was plentiful supply of gloved and aprons. Service users were able to do their own laundry with assistance if required and the housekeeper supported them in this. The home was clean, tidy and odour free. However, one service user spoken with said that the toilet downstairs was always smelly and sometimes not clean. One toilet was leaking at the time of the visit and a member of staff spoken with stated that this had been reported and was due to be repaired. One service user’s bedroom was viewed and showed that it was personalised and there was safe secure for personal belongings and the door was lockable. The outside gate was in need of repair and on the day of the visit and wet weather had made the front path slippery. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient, well trained and qualified staff to ensure that service users’ needs were met. Recruitment procedures were robust and ensured service users were fully protected. EVIDENCE: The staff rota for the 13th – 19th August 2007 was examined and showed that there was one member of staff on the early shift plus one during the day (9am – 4.30pm) and two members of staff on the late shift. There was one waking night staff plus an on call person. Staff spoken with stated that this was sufficient to be able to undertake the necessary tasks. The written information supplied by the home stated that all staff had achieved a National Vocational Qualification at level 2 and were working towards a level 3. The home is therefore commended for its commitment to qualification training for staff. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 21 Examination of staff training certificates showed that a wide range of courses had been undertaken since September 2006. These included dealing with challenging behaviour, medication, dealing with conflict, mental health, anxiety and depression, record keeping and moving and handling. Staff spoken with also stated that they had recently undertaken person centred training, which they had found beneficial, and training on the new Mental Capacity Act was also booked. Two staff files were examined and showed that most of the information required by Schedule 2 of the Care Homes Regulations 2001 was in place, including identity information, Criminal Record Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) checks. However, only one, instead of two, written references was available on both files. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality assurance procedures were not robust enough to ensure that the home was run in service users’ best interests. EVIDENCE: The manager was a nurse with a mental health qualification and had extensive experience of working in mental health services. She had registered as manager with the Commission for Social Care Inspection in 2004 and had managed the home since then. The home had a Quality Assurance Audit file that had been professionally produced and this included a number of different questionnaires about the Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 23 home for completion by service users, family members and professional visitors to the home. However, none of these had been completed since 2005 and there was no evidence of other activity taking place as part of quality assurance processes. For example, there was no annual plan for 2007. Service users and staff spoken with indicated that service users’ meetings should take place on a monthly basis but the last recorded ones were dated November 2006, April 2007 and June 2007. Service users spoken with could only give examples of holiday destinations as issues recently discussed, as opposed to having a say about how the home was developed and run. The last staff meeting recorded was in 2006. Health and safety issues were generally addressed with a risk assessment of all rooms in the building being undertaken on an annual basis and maintenance checks being carried out. The fire risk assessment was dated June 2007. Maintenance checks were mostly up to date. Records showed that the fire alarms were checked in June 2007 and fire equipment in November 2006. The written information supplied by the home stated that portable electrical appliances had been tested in August 2006 so this was now due, and emergency call systems in May 2007. However, records showed gas safety had not been checked since March 2006. Certificates in staff files showed that some mandatory health and safety training had occurred; for example, food safety in May 2007, infection control in March 2006 and moving and handling in February 2006. However, although staff reported that fire training had occurred in March 2007 and this was recorded, there was no easy reference to find out whether or not all staff had attended this and who required updates. This was raised as an issue at the last inspection visit in June 2006. There was also no quick reference available to find out which staff needed updating in other health and safety areas and there were no records to show what health and safety training had occurred since the last inspection visit inspection in June 2006, with the exception of fire training and food safety. The last visit from the Environmental Health Department was recorded as July 2006. Fullwood House Limited DS0000049691.V340719.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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 25 YES 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 14 (1,2) 15 (2) Requirement All care plans must contain the signature of the service user, indicating their involvement in the development of their care plan. (Previous timescale of 31/07/06 extended to 30/09/07) The registered person must develop a protocol for the administration of occasional (PRN) medicines and include them in the MAR folder for staff to follow. (Previous timescales of 31/03/06 and 31/07/06 not met). Timescale extended to 30/09/07) Complaints must be fully investigated and outcomes recorded to ensure service users’ concerns are dealt with objectively. Staff must receive training in safeguarding adults and a copy of Derby and Derbyshire Local Authority Social Services DS0000049691.V340719.R01.S.doc Timescale for action 30/09/07 2. YA20 13(2) 30/09/07 3. YA22 22 (3) 30/09/07 4. YA23 13 (6) 31/12/07 Fullwood House Limited Version 5.2 Page 26 safeguarding adults procedures must be obtained. 5. 6. YA24 YA34 23 (2) (b) 19 (1) (b) & Schedule 2 The identified toilet and front gate must be repaired. Two written references must be obtained for all staff to comply with the Care Homes Regulations 2001 and to safeguard service users. Quality assurance processes must be fully implemented to include obtaining the views of service users, relatives and visiting professionals. All staff must undertake mandatory health and safety training on a regular basis to ensure they are up to date with current practice. 31/10/07 30/09/07 7. YA39 24 (1) 31/10/07 8. YA42 18 (1) (c) (i) 31/12/07 9. YA42 23 (2) (c) Gas safety must be checked on 30/09/07 an annual basis. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA8 YA14 Good Practice Recommendations All key health and social care areas should be fully completed in care plans. Service users meetings should be held as stated, on a monthly basis. More effort should be made to have a wider range of activities or recreational facilities available in the home as an alternative to the television. Arrangements for privacy in relation to personal DS0000049691.V340719.R01.S.doc Version 5.2 Page 27 4. YA18 Fullwood House Limited relationships and GP visits should be made explicit in care plans and service user information such as the service user guide. 5. 6. 7. 8. 9. YA20 YA20 YA20 YA24 YA35 Two people should sign and date handwritten medication administration record (MAR) charts. A copy of the Royal Pharmaceutical Society Guidelines should be available. The homely remedy policy should be reviewed to ensure practice follows the procedure. The safety of the front path in wet weather should be reviewed. A training matrix should be established for health and safety courses to easily establish which staff need updates. Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Fullwood House Limited DS0000049691.V340719.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!