Inspection on 31/01/06 for Fullwood House Limited

This inspection was carried out on 31st January 2006.

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

The inspector found 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 14/08/07

Fullwood House Limited 06/06/06

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 Brian Marks Unannounced Inspection 31st January 2006 09:30 Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 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.V279791.R01.S.doc Version 5.1 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.V279791.R01.S.doc Version 5.1 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 Not given 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.V279791.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2005 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 town centre. It provides accommodation for 10 adults who have long-term mental health problems, requiring support and rehabilitation, and the home aims to move residents on to more independent housing in the long term. All bedrooms offer single person accommodation, with ensuite facilities and 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 the rehabilitation and therapeutic process. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over two mornings. Additionally, time was spent in preparation for the visit, looking at previous reports and other documents. At the home, apart from examining documents, care files and records, time was spent looking around the building and speaking to some of the residents who were at home, and to the manager and staff. An important activity of inspection is the careful examination of residents’ individual care records, and 2 were selected for this purpose. The aim of inspection activity during the current inspection year is to assess a service against the ‘key’ National Minimum Standards and these are identified at the beginning of each section of the report. The majority of these keys standards were examined at the last inspection so, for a more complete picture of this service, this report should be read in conjunction with the report dated 28th July 2005. What the service does well: Fullwood House offers its residents domestic style living in a community setting and aims to help people overcome previous difficulties by giving them encouragement to look at their lives positively and to make progress to a more independent life. 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 ‘ordinary’ facilities in the same way as everyone else. The staff group work flexibly to help the people who live at the home and activities take place both inside and outside the home with each individual’s needs in mind. Following a detailed assessment of the type of problems people have had, the staff provide care and support in a structured and planned way and the documentation they use makes sure this is given consistently and safely. The residents spoken to reported that staff had time to talk with them privately and that they also had time with outside professionals, who worked alongside the staff group. The home had been converted to make a comfortable environment and is modern looking and suits the choice of the residents; furniture, fittings and decoration are to a high standard. Staffing levels are set above the minimum standard and they receive good levels of support from both their colleagues and the home’s managers. They are committed to the work and residents at the home and relationships were described as positive, there has been no turnover of staff since the last inspection and this stability assists with the provision of a consistent pattern of care. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 6 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. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not specifically looked at this inspection, other than as part of a general examination of individual care records. It was noted that the manager had started a programme of replacing the existing care planning and assessment documents but this had not been completed. For the full assessment of the key standard see the inspection report dated 28 July 2005. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 EVIDENCE: These standards were not specifically looked at this inspection, other than as part of a general examination of individual care records. As noted in the previous section the manager had started a programme of replacing the existing care planning and assessment documents but this had not been completed. All of the care plans looked at had been recently evaluated and updated by the care team, as required at the last inspection, but some items required by law were still not included. For the full assessment of the other key standards see the inspection report dated 28 July 2005. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Residents are assisted to enjoy a varied and healthy diet that is based on their preferences and individual needs. EVIDENCE: At the time of the inspection the planning of menus was being changed to reflect the new range of foods being available for a new supplier. Menus have been planned on a weekly basis and those on display in the dining room showed that a choice is available for residents. Other recording of meals had not been carried out on a routine basis, as is required by law. As the main meal is in the evening, residents were seen having a variety of cooked and uncooked snack meals during the visit. All the residents have their meals together in the dining room and none require help with this activity. The cook, who works shifts in the afternoon, takes seeks out the individuals’ choices for the main meal of the day and some of the residents routinely get drinks and arrange their own breakfasts and suppers. One resident has a diabetic condition that is managed through mealtime monitoring. For the full assessment of the other key standards see the inspection report dated 28 July 2005 Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The administration of medicines by staff is well organised and staff receive appropriate training to ensure safety in this area. EVIDENCE: There is one resident who manages his own medicines and each care file contains a form for residents to sign and indicate their wishes on this subject; this had not been signed in his case and areas of responsibility were therefore unclear. The home operates the Monitored Dosage System for the management of medicines on behalf of residents, and storage, records of administration and stock control systems were generally satisfactory. However, the written record and instructions for administration which were handwritten and also and the arrangements for medicines to be used occasionally (PRN), does not contain sufficient detail for complete safety and consistency. Examination of staff training records indicated that all staff administering training had received appropriate training. For the full assessment of the other key standards see the inspection report dated 28 July 2005. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has comprehensive policies and procedures in relation to making complaints and the protection of vulnerable people, and staff are made aware of their responsibilities in these areas. Most of the residents have their interests supported by outside professionals and family members, but a local advocacy service is available to help if they do not. EVIDENCE: The home has a comprehensive complaints policy and procedure, a copy of which is included in the Service Users Guide, which is given to residents and their representatives, and a summary is also on display at the home. The manager reported that there had been no formal complaints made by anyone within the past 12 months. The manager reported that the local advocacy project had been in contact with the home and a number of information leaflets are available on the notice board for individuals to use. Nobody is making use of this service at the present time. The home has a detailed policy and procedure in relation to the protection of vulnerable adults, but the description of the statutory procedure to be followed was not included with this. Staff are given instruction on the latter at the time they join the home and the manager has plans for all to receive training via the Social Services Department, which will substantially increase staff knowledge on the subject. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not specifically looked at this inspection, other than to note that the high standards of the home’s environment had been maintained. For the full assessment of the key standards see the inspection report dated 28 July 2005. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 The home is well staffed with experienced, skilled and knowledgeable people who are supported to work effectively by management and the staff peer group. Systems at the home ensure that only the right people for the job are employed at the home. EVIDENCE: Records on staff files showed that 9 care staff had completed or were completing an NVQ qualification at a minimum of level 2, and the required target of 50 of staff should be achieved within the next few months. The manager stated that it is her aim to qualify all staff to level 3 and this has already started. The membership of the staff group has stabilised and no new staff have commenced during the past 6 months. Staff were observed with the residents during the inspection and interactions were seen to be warm and professional. Residents have described how the staff support them and how they have improved their lives through the carried out at the home. Records on file indicate that staff have enjoyed regular access to training and development opportunities, although those that were newly appointed had missed some key health and safety subjects. The home’s main diary indicated that updates on safe moving and handling and food hygiene were planned for later in the month. New staff receive adequate preparation through induction training, and a number of additional subjects are regularly covered through links with the Social Services Department and Skills for Care – a national training organisation. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 15 Examination of staff files indicated that a satisfactory recruitment process is followed at the home and that only the right people for the job are employed. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The manager, a qualified nurse, has begun a system of assessing the overall service of the home through the use of surveys and formal feedback. Regular servicing of equipment, management audit and staff training make the home a safe place for people to live in. EVIDENCE: The manager is a nurse with a mental health qualification and has extensive experience of working with people with this type of difficulty. She is in the process of completing a Registered Manager’s course (NVQ4) with a local training outlet. The manager maintains a Quality Assurance Audit file that has been professionally produced and this includes a number of different questionnaires about the home that had been completed by residents, family members and professional visitors to the home. An annual plan had not been developed for the home, as required at the last inspection, although the proprietor ahs produced a business plan for the home that covers the first years of the home’s operation. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 17 Staff records indicated that training in relation to fire safety for staff had been carried out in 2005 but not all staff, particularly those recently appointed, had received training in all of the important aspects of health and safety practices. As indicated refresher courses were planned for later in the month. A full examination of records indicated a good standard of health and safety activity at the home and this protects the residents; the proprietor carries out an extensive annual audit of his own the last inspections of the Environmental Health and Fire Officers were satisfactory. One item of annual servicing had not been completed. Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 18 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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 X 3 X X 2 X Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 YA2YA6 Regulation 14(1,2) 15(2) Requirement Timescale for action 31/05/06 2. YA17 17(2) Sch 4 3. YA20 13(2) 4. YA20 13(2) The manager must complete the programme of updating residents’ care records and ensure that the following are included: Broad assessments of need carried out as part of the admission process, A comprehensive care plan that describes how those assessed needs will be met, An indication that the above are kept under regualr review, at least six monthly, A recent photograph and signature of the resident, indicating their involvement in the development of their care plan. The manager must keep records 28/02/06 of the food served to residents at the home, particularly if a fixed menu system is not to be followed. Residents must indicate in 28/02/06 writing that they are taking responsibility for the management of their own medicines and their safekeeping. Any handwritten instructions on 31/03/06 DS0000049691.V279791.R01.S.doc Version 5.1 Fullwood House Limited Page 20 5. YA20 13(2) 6. YA39 24 7. 8. YA42 YA42 13(3), 18(1) 13(4), 23(2) the Medicines Administration Records (MAR) must clearly indicate the name, dose and times of medicines and be signed and dated by the responsible person. The registered person must develop protocols for the administration of occasional (PRN) medicines and included them in the MAR folder for staff to follow. The Registered Provider must develop an annual plan for the home indicating aims and objectives for 2006. (Previous timescale of 31/08/05 not met). All staff at the home must receive training or instruction in emergency first aid. The registered person must ensure that all gas equipment is serviced and a copy of the safety certificate forwarded to CSCI for examination. 31/03/06 31/05/06 31/05/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations The registered person should amend the home’s procedures in relation to the protection of vulnerable adults to include reference to the local statutory procedures for identifying and reporting potentially abusive situations. The risk assessments of the home’s environment should be regularly reviewed, including the one that examines fire safety. 2. YA42 Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fullwood House Limited DS0000049691.V279791.R01.S.doc Version 5.1 Page 22 - 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. 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