Inspection on 06/06/06 for Fullwood House Limited

This inspection was carried out on 6th June 2006.

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 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 5 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 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 Brian Marks Key Unannounced Inspection 6th June 2006 09:00 Fullwood House Limited DS0000049691.V296476.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.V296476.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.V296476.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 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.V296476.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 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 ensuite 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.V296476.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place at the home over a period of 7 hours in one day. Additionally, time was spent in preparation for the visit, looking at previous reports and other relevant documents and preparing a structured plan for the inspection. At the home, apart from examining documents, care files and records, time was spent speaking to the proprietor, manager and 3 of the staff working at the home during the visit. The care records of 5 people who live at the home were examined and 3 were spoken to at length whilst 2 others were spoken to briefly. Written survey forms were sent out to the home and 4 were received back from residents before the inspection; their comments are incorporated into the general text of this report. 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 has been converted to make a comfortable environment and is modern looking and suits the choice of the residents; good quality furniture, fittings and decoration have been provided. Staffing levels are set above the minimum standard and they receive good levels of support from both their colleagues and the home’s management. They are committed to their work and to the residents at the home and relationships were described as positive; no staff have left the home in the past year, and this stability assists with the provision of a consistent pattern of care. The overall size of the home’s operation continues to achieve success with people; as 1 resident remarked – ‘Small is a nice size’. Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 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.V296476.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Resident care is planned consistently, usually following a period of trying out the home and information about individual residents is supplied by people who know them well. EVIDENCE: The care records of the most recently admitted resident was examined in detail and these contained a number of documents that looked at his care needs, social interests and ways that the home might be able to help him and had been prepared before he had come to the home. These were made to assist with his admission and matching activity, and were provided by all the people involved with the person; a member of staff at the home had completed additional documents. Where the person is part of the statutory mental health system, an additional assessment document is provided to meet the requirements of the law. The residents spoken to described how they had been able to visit the home and to meet other residents and staff, before deciding to move in. In addition, the new resident mentioned above had been able to have a few days living at the home and had been able to experience the standards of care at the home directly. Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Detailed individual care plans have been developed at the home so that support can be given consistently, and the welfare and safety of residents maintained. Residents are actively encouraged to make decisions about their lives and are supported to develop opportunities that may help them move on to more independent ways of living. EVIDENCE: Three sets of care records were examined in detail at this visit, but it was noted that the newly admitted resident was having a plan of care prepared and the other 2 were reported to have recently had their care plans reviewed and revised and they were due to be printed off the home’s computer. Two other care files were examined in addition and they each had an individual ‘rehabilitation’ plan, put together from the assessments that had taken place. These included aspects of personal and health care activity, and indicated that support is offered safely and consistently. These plans indicated that they had been looked at regularly and revised where necessary which makes sure that support is being given in ways that are based on up-to-date information. For Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 10 those residents subject to the statutory system, a legally required review takes place outside the home, usually with a psychiatrist. The residents themselves were involved in preparing their care plans but not all had indicated this with their signature. The residents spoken to felt that the style of the home is flexible and relaxed, and that they had all chosen the home for themselves. The ability to decide on their own lifestyle was also confirmed, although they all said that staff were around to help when they were needed – ‘They encourage me to do things for myself but help out if you need them’ ‘I like my keyworker but they’re all OK’. One made favourable comparisons with life at other establishments and previous experiences of independent living – ‘I didn’t like the community place. This is the best place I’ve been in’. ‘I go out to the pub and this is a nice area’ ‘The kitchen isn’t locked and I can make a drink when I want one’. Detailed assessments of the areas of concern and particular risks in resident lives are the basis of the care being given, and these are clear, comprehensive and, as staff reported, easy to follow. They allow support and supervision to be given in consistent and safe ways. Because of past problems they have experienced, some residents allow staff to place limits on some of the things they do. This is agreed for reasons of long-term safety and welfare and is planned for before they come to the home and written into their care plan. Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents are encouraged to take part in a number of activities, both inside and outside the home, and have an extensive social network. This allows them to become more independent and to lead more satisfying lives. They are assisted to enjoy a varied and healthy diet that is based on their preferences and individual requirements. EVIDENCE: All residents 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 has made contact with range from ‘drop-in’ and structured day centres, the local college to a local church. Within the home, staff arrange more informal activities such as yoga, craft activities, bingo and one-to-one time involving both formal and informal discussions. There is a computer available for resident use and 1 has done so irregularly. Residents also make use of the facilities within the town centre, in small groups or on their own. A new resident reported that he visited the local pub Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 12 by himself, as he had done so when he lived in Derby. Another regularly goes for a walk in the local park and made a visit to the library during the inspection, whilst others visited local shops. Within the home most had their own televisions to watch in their bedrooms. All residents spoken to, during this and past inspections, gave a clear impression that they themselves decide how to spend their time and are given help by staff if they need it. Those with family contacts had been encouraged to keep them and 2 residents described how they had regularly visited family members in Derby since they came to the home. The routines they followed were their own and they all felt that their privacy as individuals was respected and that they also had to respect the requirements of the other residents. ‘I can stop people coming into my room if I want to’. At the time of the inspection a small group of residents were planning a short holiday together, to be accompanied by staff. A 4-week menu has been introduced since the last inspection and this, along with the daily records indicated a choice being available to residents at main meals. 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 no one requires staff help with this activity. The cook, who works shifts in the afternoon, seeks out the individuals’ choices for the main meal of the day and some of the residents routinely make drinks and arrange their own breakfasts and suppers, maintaining their independence skills. One resident has a diabetic condition that is managed by a proper diet. A new supplier has been contracted and food comes into the home on a regular basis or is bought from local shops; good stocks were in the storage areas during the inspection. Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The people living at the home have low physical care needs and they are encouraged to care for themselves as much as possible. They have all had regular access to health care specialists who help them with maintaining a stable level of mental health; the administration of medicines is well organised and operated by appropriately trained staff. EVIDENCE: None of the residents have high physical care needs but the care records indicated that some needed occasional prompts to maintain standards. Because of the nature of the resident group, all have required emotional support from staff regularly and care records indicate that help is to be offered in both informal and structured ways. Generally self-care skills are high. Records examined indicated that the residents receive good support from local health services, both for physical needs and specifically for people who have mental health problems. Most see a psychiatrist at the local clinic and community nurses are regular visitors; other health care professionals, such as a Speech and Language Therapist had been involved for specific assessments and treatments. As noted above staff help people with emotional and mental health problems in a variety of ways and they are actively supported by the Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 14 outside professionals. Staff help people to achieve progress by physical interventions with medication, systems of managing poor behaviour and by helping them experience a positive lifestyle within a setting that is noninstitutional and ‘ordinary’. 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 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 involved with medicines had received appropriate training. There is one resident who manages his own medicines and he had signed a declaration within his care plan to indicate this, others had signed to indicate that they wished the staff to manage this for them. For some, selfmedication is a particular long-term aim as part of progress to more independence. Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. 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, and 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, which has been updated to link with the statutory procedures to be followed. At the time of the inspection there was a situation under investigation involving a current resident and an ex-resident. Appropriate actions had been taken regarding this. Staff are given basic training in the subject of protecting vulnerable people in their care 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 of the subject. Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is equipped, furnished and maintained to a good standard and offers homely and spacious facilities for residents to enjoy. This is both a valued and valuing environment in which to live and work. EVIDENCE: The home is 2 converted buildings with gardens to the front and rear, situated on a residential side road, adjacent to the town centre of Ilkeston. As the home opened in early 2004, after a complete refurbishment, it remains in good condition, well equipped and furnished in a modern style; things were in hand to redecorate the communal areas soon after the inspection. The overall impression of the building is of one that gives good levels of space and comfort to the residents and receives regular attention to maintenance. The residents spoken to stated that they enjoyed their own rooms and that they were large enough and furnished to their liking; it was noted that the curtain rail in one of the bedrooms visited was not in place, apparently pulled down by the resident. His facilities and privacy are accordingly reduced. Standards of cleanliness and hygiene are high and the residents were all well dressed in clean and appropriate clothing, which can be laundered by them, Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 17 accompanied by staff. The housekeeper was spoken to during the inspection and she described satisfactory arrangements for maintaining standards. Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. 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 that ensure that only the right people for the job are employed have not been followed properly with the result that resident safety is challenged. EVIDENCE: Records indicated that 8 (80 ) care staff had completed an NVQ qualification at level 2, and the required target of 50 of staff has been exceeded, which is to be commended. The manager had previously stated her intention for all staff to qualify to level 3 and she has been successful in arranging with the local college these qualifications be adapted to reflect the type of work that the staff carry out. The membership of the staff group has stabilised and only 1 additional care staff and 1 additional housekeeping 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 work 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 Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 19 missed fire safety instruction. 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, although training in the management of difficult behaviours, particularly relevant to this staff group, had not been covered yet. Examination of staff files indicated that a generally satisfactory recruitment process is followed at the home but it was noted that, for the 2 most recent staff employed at the home, the required checks through the Criminal Records Bureau had not been carried out and details of past employment had not been thoroughly covered on the application forms. This could result in people who are wrong for the home being employed and a notice for urgent action was left at the end of the inspection. Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. 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 now been developed for Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 21 the home, as required at the last inspection, and the proprietor has produced a business plan for the home that covers the first years of the home’s operation. Staff records indicated that training in relation to fire safety for staff had been recently carried out but not for all staff, particularly those recently appointed. Refresher courses in the other important aspects of health and safety practices have been carried out in the past year. 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 and the last inspections of the Environmental Health and Fire Officers were satisfactory, although the former had not been to the home recently. Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 22 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 4 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation Requirement Timescale for action 31/07/06 2. YA20 3. 4. YA24 YA34 14(1,2)15(2) All care plans must contain a recent photograph and signature of the resident, indicating their involvement in the development of their care plan. 13(2) The registered person must develop a protocol for the administration of occasional (PRN) medicines and included them in the MAR folder for staff to follow. (Previous timescale of 31/03/06 not met). 23(2) The curtain rail in Room 1 must be properly fixed to the wall. 19(1) Checks from the Criminal Schedule 2 Records Bureau and the POVA 1st system must be urgently obtained in respect of the 2 most recently employed staff and evidence of this occurring must be forwarded to CSCI for examination. (An immediate requirement notice was left at the home in relation to this requirement). 31/07/06 31/07/06 30/06/06 Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 24 5. YA42 23(4) All staff must receive training in fire safety practices relevant to the home every 12 months. 31/08/06 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. 2. 3. Refer to Standard YA6 YA35 YA36 Good Practice Recommendations Copies of care plans should be held in written form within the resident’s care file after being updated. Staff should be provided with training in methods of managing difficult behaviours. The application form for employment at the home should be amended so that details of the applicant’s previous employment are obtained in full, to include reasons for leaving previous jobs and explanations of any gaps in their employment record. The Environmental Health Officer should be consulted about the regularity and need for an inspection at the home. 4. YA42 Fullwood House Limited DS0000049691.V296476.R01.S.doc Version 5.2 Page 25 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.V296476.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. 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!