Care Home: Fullwood House Limited

What the care home does well People found the home a relaxing, warm and friendly place to be and saw Fullwood house as their home. People said they could come and go as they pleased and got support when they needed it. Care records were well maintained and enabled staff to see at a glance what peoples` care needs were. People were able to live a varied lifestyle of their choosing. Comments included `can go out when I want` and `can get up when want to even if it`s the afternoon`. People said they were happy with the care they received. One relative said `I am very happy with the way (X) is being looked after and he likes living there`. People told us that staff looked after them well and had the right skills to care for their needs. What has improved since the last inspection? Better documentation to record care needs had been introduced so staff could gather more detailed information about peoples` individual social circumstances and needs. Documentation was also more able to support that people were involved in the planning of their care. The manager had obtained some new forms to ensure that any complaints received were more fully documented. CARE HOME ADULTS 18-65 Fullwood House Limited 65/67 Lord Haddon Road Illkeston Derbyshire DE7 8AU Lead Inspector Helen Macukiewicz Unannounced Inspection 11th June 2008 09:30 Fullwood House Limited DS0000049691.V366259.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.V366259.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.V366259.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.V366259.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th August 2007 Brief Description of the Service: The current provider opened the home 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 owner said that the current weekly fee for this home is £682.90 to £787.90. A copy of the latest Inspection report is kept in the foyer. You can also obtain a copy by visiting www.csci.org Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This Inspection was unannounced. Pre-inspection questionnaires were received from every person living in the home, staff, some relatives and a social worker. Findings from these questionnaires are included in this report. The Manager had completed a self-assessment of the home and information from this was used in the planning of this inspection. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were also referred to in the planning of this visit. During this Inspection discussion with people who use the service and their relatives took place. Time was spent in discussion with the Manager and some staff. Two peoples’ care files were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including one bedroom. 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 two and a half hours and spoke with people living in the home. Her findings are incorporated into the report. What the service does well: People found the home a relaxing, warm and friendly place to be and saw Fullwood house as their home. People said they could come and go as they pleased and got support when they needed it. Care records were well maintained and enabled staff to see at a glance what peoples’ care needs were. People were able to live a varied lifestyle of their choosing. Comments included ‘can go out when I want’ and ‘can get up when want to even if it’s the afternoon’. People said they were happy with the care they received. One relative said ‘I am very happy with the way (X) is being looked after and he likes living there’. Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 6 People told us that staff looked after them well and had the right skills to care for their needs. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fullwood House Limited DS0000049691.V366259.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.V366259.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2 and 4. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Pre-admission information and assessment ensures that peoples’ needs are met by the home. EVIDENCE: In her completed pre-inspection self-assessment, the manager stated that she intended to ‘revise service user guide, to include contract, terms & conditions, complaints procedure and statement of rights and responsibilities’. Some updated information about the home contained within the Service Users Guide was seen. This gave an accurate description of the home and included information about the costs and any extras people would need to pay for. This meant that people had the information they needed to make a choice about whether to move in. The building only has steps to the first floor bedrooms; there is no passenger lift. This means that if peoples’ mobility deteriorates they may not be able to access some parts of the building. This had meant that one person had to leave the home. This was not clearly explained in the Statement of Purpose and would be a useful addition. Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 9 In their pre-inspection surveys people told us they had a choice to move into the home and had enough information beforehand. During the Inspection people confirmed this. They also said they had been to visit the home several times before they moved in permanently. One person said they had stayed for meals. The care records for recently admitted people were seen. Since the last Inspection a new pre-admission assessment form has been developed. A completed one was seen in the latest care file. An assessment by the mental health services was also in the file. Both provided enough detail to allow the staff to make an assessment as to whether they could meet the persons’ needs. One person told us that it ‘feels like home’, another that it ‘feels welcoming’ and ‘the staff are very friendly and normal’. Fullwood House Limited DS0000049691.V366259.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): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. So far as possible, people are enabled to take control over their lives, and take risks within a supportive environment. EVIDENCE: In the completed self-assessment about the home the manager recorded that since the last Inspection ‘residents are more involved with their care planning’. The care files for the most recently admitted people both contained a comprehensive plan of care, these had been reviewed and updated as care needs had changed. A personal profile sheet had been introduced and this enabled staff to gather more detailed information about peoples’ individual social circumstances and needs. There was space for people to sign to agree to their care plan and in most case, this section had been completed. This supported that people were involved in the planning of their care. Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 11 People told us they were able to make decisions about their care and daily life in the home. People told us they could do what they wanted. Where people lacked the capacity to make decisions for themselves, this was clearly recorded in their care files including the reasons for this. People also told us they handle their own finances and had safe places to keep their money safe. All but one person told us they knew how to access advocacy services. One person asked us to organise some advocacy and we passed on this request to the manager, who agreed to organise this. Care files contained a comprehensive assessment of risks and identified ways in which staff could minimise risks to people, whilst still ensuring they retained a degree of independence. Fullwood House Limited DS0000049691.V366259.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): Standards 12-16 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 peoples’ quality of life. EVIDENCE: People told us they were able to make and maintain friendships within the community. One person told us that staff regularly took them to hospital to visit a friend who was ill. Another said they visit family regularly. One person said that friends were welcome to visit them at the home. People told us they go to the shops, pubs and clubs in the surrounding neighbourhood. One told us they had been to the cinema recently and another said they regularly go out bowling. People were coming and going throughout the Inspection, independently visiting the shops or attending appointments Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 13 with staff support. Activities were also provided in-house such as Bingo, which most people said they liked. One said ‘I like the bingo as I win prizes’. There was information on display about groups and activities within the local community. However, a couple of people said that they would like more information about what was available locally, and how to access this. People said the home organise day trips out and minutes of residents’ meetings recorded that they had been involved in the decision making about where to go. One person told us that he had attended more trips out whilst living at the home than he would have done if he were living independently. People had a key for their own bedrooms and locked their doors. People had freedom of movement around the home and stated they could participate in laundering, cleaning and cooking if they chose, but were under no obligation to do so. Some people told us they regularly cooked their meals and enjoyed doing this. One person told us that they could stay in their bedroom all day if they didn’t feel like getting up. People were able to make their own decisions about how they spend their day, whether that is spending it in their own room, in the lounges or out and about. ‘I like to go out as much as possible’ ‘I spend a lot of time in bed’ ’I like the smoking room as it has a door to the outside’ Other comments included ‘can go out when I want’ and ‘Can get up when want to even if it’s the afternoon’. People told us that the meals were good, that there was plenty to eat and a good choice. There was plenty of food in the fridge and storage area. Peoples’ meal plans were seen and supported a range of meal options were offered. One person told us the home catered for their vegetarian needs. People told us that meal times were flexible to suit their social engagements and lifestyle choices. People could help themselves to hot and cold drinks whenever they liked and had access to the kitchen when needed. Fullwood House Limited DS0000049691.V366259.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): Standards 18-20. 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 peoples’ health needs are met. EVIDENCE: People told us that in their opinion they were looked after well. In the care files seen, there was evidence to support that people attended out patients appointments, dental, optical and chiropody appointments as needed. They also received health promotion from local health services. One person told us that staff accompanied them to health appointments but that it was their choice and that staff did not accompany them against their wishes. People accessed services within the community and staff supported them as needed and provided transport. In their pre-inspection surveys people told us they were happy with the level of support offered. One said ‘‘the staff do help me if I feel worried about anything’. In their completed surveys, relatives also said they were happy with the care offered. One said Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 15 ‘I am very happy with the way (X) is being looked after and he likes living there’. Staff surveys recorded that ‘up to date information on each service user is given daily through verbal handovers’ and ‘there is a lot of respect between staff and service users’. In the managers completed survey she recorded that ‘all staff have received additional training on specific areas of mental health’. An audit of the medications by a pharmacist from BOOTS had taken place the day before the Inspection, and all matters were found satisfactory. The records of medications given were completed fully and correctly. The storage of medicines was good and staff had received medication training. On one monitored dosage sheet an allergy had not been recorded in the appropriate space, although this was recorded in the healthcare section of their care file. Having the information in both places would reduce the risk of error. Two people were self-medicating, consent and assessments were recorded in their care files and they had somewhere in their bedrooms to store their medications safely. Fullwood House Limited DS0000049691.V366259.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): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are fully protected through effective complaints procedures and staff training. EVIDENCE: People told us they knew how to complain and most felt empowered to do so. However, one person said they felt hesitant about raising issues but gave no reason. Most people knew how to access advocacy services and said they would use these if they did not wish to raise an issue in the home. People told us that they felt confident the staff in the home would deal with issues. The complaint procedure was on display and contained within the information booklet about the home. There were also leaflets on display, which told people how they could access advocacy services and us. However, our contact details needed amending. In the returned pre-inspection surveys, every person told us that they knew how to raise concerns. Relatives questionnaires also confirmed they were satisfied with this area. The managers’ questionnaire said there had been no complaints received since the last Inspection and this was consistent with what people told us. The manager had obtained some new forms to ensure that any complaints received were more fully documented. In the managers’ completed questionnaitre she also told us she aimed to ‘ensure all staff receive training on the safeguarding of vulnerable adults via Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 17 social services training course’. Staff training files showed that this had happened. The Local Authroity safeguarding procedures had also been obtained and were stored in the main office. Staff had also received training on the Mental Capacity Act and had guidelines about this. There had been no safeguarding concerns at the home. Fullwood House Limited DS0000049691.V366259.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): Standards 24 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 to enhance peoples’ quality of life. EVIDENCE: There were two lounges, one for smoking at the rear of the building with access to an open area and a lounge at the front with four sofas and a television. Both were well used areas and were enjoyed by all people living in the home. People commented that the ‘Smoke room is good’ and they had choice as to whether they used it or the television room if they didn’t want to smoke. The laundry area was accessed through the smoking lounge, which was not ideal, but there where no concerns raised about this from people living there. Staff washed clothes and laundry and people told us they were happy with the quality of this service. Most people liked the television lounge as ‘comfortable and cool in lounge - good’ as ‘shaded by the tree outside makes it Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 19 feel homely and relaxing’. People told us they liked the way the home was decorated, saying ‘nice stuff’ and ‘I like the colours’. A brief tour of the home took place, one of the people living in the home showed us around and in their bedroom. All areas were clean, tidy and well decorated. People told us they were happy with their environment and had a say in the décor. They had access to most parts of the home. The managers’ pre-inspection assessment form recorded that ‘communal areas have been redecorated, 2 new central heating boilers have been installed, a new freezer has been purchased for the kitchen, 2 bedrooms have been completely refurbished, office refurbished, relocated the smoking area to the small lounge to improve the effects of passive smoke effecting non-smoking residents, visitors and staff alike’. People said they were happy with the new smoking room and their bedrooms. There was a telephone they could use to make calls in private. Fullwood House Limited DS0000049691.V366259.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): Standards 32- 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have their needs met by well-trained and suitable staff. Recruitment procedures ensure service users are fully protected. EVIDENCE: People told us that staff looked after them well and had the right skills to care for their needs. In their completed surveys staff told us that ‘opportunities for training are excellent. Management are approachable and welcome ideas for relevant training’. ‘Up to date information on each service user is given daily through verbal handovers’. The manager, in her pre-inspection assessment recorded that ‘we have a very high retention of staff, we do not use any agency staff. We have higher staffing levels than stated in the Residential Forum guidelines. All our support staff are trained to a minimum of NVQ 2 and are working towards NVQ 3 We have achieved 100 staff training to NVQ 2 plus additional training on challenging behaviour. Manager has completed Registered Manager Award,. 1 member of staff has completed NVQ 3’. Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 21 Staffing rotas showed that there were times where there were 2 staff on duty during the day, but occasions where there was only 1. This happened mostly at weekends. There was no extra cover during times that the cook or domestic were absent. Despite this, people were satisfied with all aspects of their care and there was no evidence to suggest this affected the daily operation of the home. On call support was provided from managers and this was recorded on the staffing rotas. However, the designation of workers and actual start and finish times were not recored on the staffing rotas, this would help to identify the type and level of support people were receiving at any given time. Staff did not have access to a lone workers policy, this would keep both people living in the home and staff better protected. Although a member of staff, in their completed pre-inspection survey told us ‘there are always sufficient staff on duty’ and the managers assessment recorded ‘extra cover is available to ensure the service users access social activities with staff support’. There was no staffing policy to explain why some times of the day /week people only needed 1 member of staff and why 2 would be required at other times. Also what measures were in place to ensure peoples’ social care could still be supported effectively at times of reduced staffing. Recruitment files for the newest employed members were seen. These were generally well completed although 1 reference had not been returned. A POVA first check was needed for 1 member of staff although they had a recent CRB check from another employer. The manager agreed to ensure this was done immediately and sent to us. This member of staff did not work alone. In a completed staff survey one person said ‘I was not employed until confirmation of my CRB check was received by my employers’, ‘regular staff appraisals are carried out, management are always accessible to support and/or discuss any issues we may have’ Fullwood House Limited DS0000049691.V366259.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): Standards 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed in the best interests of the people who live there and is safely maintained. 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. She completed the registered managers award last year. In their completed surveys staff told us ‘the management are lovely to work for’. People told us they found the managers accessible and supportive of their needs. One person told us ‘the managers make this a home’. Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 23 Since the last Inspection there has been development of a quality assurance system, there were 2 quality assurance folders that contained audits ranging from medication to complaints and staff recruitment. Surveys had been sent out by the home to relatives, social workers and people living in the home to gain their views about the service. Comments received included ‘home always seem well organised’ ‘service users are very independent and can do exactly what they want’ and ‘this home in my opinion focuses on person centred care 100 ’. One relative wrote ‘all I can say is it’s the best place (x) has been in’. The managers’ pre-inspection assessment recorded that ‘it is Fullwood House Policy to ensure residents have the greatest control over their own lives and have the ability to make choices. We audit this by having regular Residents meetings, Resident questionaires and listen to their views on a daily basis.’ Minutes of meeting held showed there was wide consultation with peple during residents meetings and that information was also shared on these occasions. One person told us they had been given the compliants procedure at a recent meeting. A risk assessment of the environment was seen and showed that risks to the safety of people were being identified and that maintenance was being requested. Some service records for equipment around the home were seen; these also showed that the environment was being safely maintained. Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 x x 3 x Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 25 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19 & Schedule 2 Requirement Staff must not be employed at the home until all satisfactory pre-employment checks are completed, in order to protect people from potentially unsuitable staff. Timescale for action 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations Limits in terms of access within the home should be clearly explained within the statement of purpose, to ensure people have good information about the facilities to enable them to make an informed decision about whether or not to move into the home. People should be fully assisted to access advocacy services within the community to ensure their rights are upheld. There should be more information, in a user friendly format about what services and support is available locally, and how to access this. Staff should record both on care documentation and the MAR folder where a person has an allergy to a medicine, to reduce the risk of error. DS0000049691.V366259.R01.S.doc Version 5.2 Page 26 2. 3. 4. YA7 YA13 YA20 Fullwood House Limited 5. 6. YA22 YA33 The correct contact details for the Commission for Social Care Inspection should be recorded on the complaints procedures. The designation of workers and actual start and finish times should be recored on the staffing rotas, this would help to identify the type and level of support people were receiving at any given time. Staff should have access to a lone workers policy, this would keep both people living in the home and staff better protected. There should be a staffing policy to explain why some times of the day /week people only needed 1 member of staff and why 2 would be required at other times. Also what measures are in place to ensure peoples’ social care can still be supported effectively at times of reduced staffing. Fullwood House Limited DS0000049691.V366259.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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