Inspection on 13/04/05 for Allied Back-up Project Limited - The Old Bakery

This inspection was carried out on 13th April 2005.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Allied Back-up Project Limited -... 27/03/08

Allied Back-up Project Limited -... 20/06/06

Allied Back-up Project Limited -... 07/11/05

Allied Back-up Project Limited -... 17/11/04

Allied Back-up Project Limited -... 30/06/04

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St George`s

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Credence House

Radfords

Honeybourne House

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

CARE HOME ADULTS 18-65 Allied Back-up Project The Old Bakery 54 Park Street Crediton EX17 3HP Lead Inspector Susan Lyons Announced 13 April 2005 th 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 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 Stationary 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. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Allied Back-up Project Limited The Old Bakery 54 Park Street Crediton EX17 3HP Address Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01363 777565 01647 24447 Allied Back-up Project Limited Mr Frederick James Saunders Mr Frederick James Saunders Care Home 4 Category(ies) of Learning Disability [4] registration, with number of places Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17th November 2004 Brief Description of the Service: The Old Bakery is a home belonging to the Allied Backup Project Ltd. and is situated in a residential area of Crediton. It is close to the centre of the town and from the road has nothing to distinguish it as a residential home. It is a small home catering for four service users with learning disabilities. The home provides personal care for the service users and ensures that they are able to use community facilities. The registered person is also responsible for the dayto-day management of the home Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place during the day and lasted for 3 hours. The inspector was able to meet with one of the service users. There are currently three service users accommodated at the home. It was difficult for the inspector to obtain opinions and views from the service users due to their disabilities. However the one service user appeared relaxed and comfortable within the home. The inspector looked around the home. A number of records were also seen. What the service does well: 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. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 7 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 standard(s) 1-2 Service users are provided with information to enable them to make an informed decision about living at the home. The home ensures that they are able to meet the needs of new service users. EVIDENCE: The home has completed a Statement of Purpose and Service Users’ Guide, copies of which have been sent to the Commission. The Service Users’ Guide has been produced with photographs to help service users’ understanding. There have been no new admissions to the home but Mr Saunders is aware that he must obtain a copy of the shared assessment when he receives a new referral. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 8 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 standard(s) 6, 7 and 9 Some progress has been made in making sure that staff receive clear information on how to meet service users’ individual needs. Service users are assisted to make as many decisions as possible about their lives. Good progress has been made in identifying risks. EVIDENCE: Care plans were seen for all three service users. They contain details of how service users’ needs are to be met and guidance in relation to meeting difficult or unusual behavioural issues. Reference was made to bathing guidelines in one care plan but the guidelines were not actually available. Restrictions are in place in relation to one service user and her clothing. This needs to be recorded in the care plan. Service users are supported to take as active a part as possible in making decisions about their lives. Risk assessments are available in relation to individual service users and in relation to the building. Mr Saunders, himself, recognised that there needs to be written guidelines and a risk assessment for staff in relation to the garden gate being left open when they drive out Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 9 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 standard(s) 12-17 Service users are supported to use the local community and encouraged to maintain links with families and friends. Staff provide limited in-house activities for one of the service users. Nutritious meals are provided. Information concerning a specialist diet is not readily available. EVIDENCE: Currently none of the service users are attending further education classes or are in employment. Two service users attend day care for two days a week from 9.30 – 2pm. Staff should investigate the possibility of further education classes for one service user to provide new experiences and activities. Service users make use of as many community facilities as possible such as shops restaurants etc and evidence of this was seen in the daily recording. Puzzles and games are available within the home and staff said that one of the service users particularly enjoys being read to. Evidence was seen in the daily recording that one service user enjoys cutting things out and also colouring. It is difficult to motivate some of the service users and their concentration span is short. This is an ongoing challenge for staff. There are no restrictions on visiting times within the home. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 10 Service users are able to lock their bedroom door. Post is given unopened to service users. There is unrestricted use of the house and garden. Food eaten is recorded on an individual basis in service users’ diaries. Currently the only specialist menu provided is for medical purposes. Mr Saunders said that there is a list in relation to this diet but was not sure where it was at the time of the inspection. This needs to be readily available for staff to follow. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 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 standard(s) 18, 19, 20 and 21 Same gender care is provided except in emergencies. Service users’ physical and emotional health needs are met. Prescribed medication is appropriately stored and administered. Progress is being made in establishing service users’ wishes in relation to terminal illness and death. EVIDENCE: On past inspections staff have confirmed that they do not provide cross gender care unless in an emergency. Care plans show how personal care is to be given. Service users are supported to choose their own clothes both to wear each day and when buying new ones. Additional support is provided on a regular basis from a local psychiatrist. Service users are registered with a GP and receive regular optical and dental treatment. The home uses a monitored dosage system from a local pharmacy and staff have received training in the administration of medication. There was no record available to confirm that the GP had agreed for service users to take ‘homely remedies’ The home is in the process of checking service users or their representative’s wishes in relation to terminal illness and death. They are doing this through the review procedure and have addressed this with one set of relatives so far. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 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 standard(s) 22 and 23 Complaints are well documented and staff are made aware of Adult Protection procedures. EVIDENCE: The home has received two complaints since the last inspection in relation to noise. These are documented and the action taken. Mr Saunders was unable to find the complaints procedure to be given to service users/ their representatives. A recommendation was made following the last inspection that additional information was required to be included. There is a policy for staff to follow. Mr Saunders said that staff have seen the ‘No Secrets’ video and staff that are undertaking NVQ receive information in relation to Adult Protection. An Adult Protection Policy is available within the home. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 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 standard(s) 24 and 30 The home is well maintained, furnished and clean. EVIDENCE: The home has recently had the hall and bedrooms redecorated and currently the lounge is being completed. Mr Saunders said that they now intend to redecorate the landing, bathroom and stairs. The laundry is situated next door to the main building and the walls have recently been redecorated to ensure that they are washable. A notice is displayed to show at what temperature foul laundry should be washed. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 Service users are being put at risk by the lack of checking of new staff. Staff have received some training but this could be improved EVIDENCE: It was noted that the CRB and POVA check had not been received for the most recently recruited member of staff. This member of staff was undertaking night duty, which means that he would be working unsupervised. For another member of staff the CRB check was not available although Mr Saunders had noted that it had been received and was certain that he had seen it. References were seen for recently recruited members of staff. Currently two members of staff are undertaking NVQ 3 and two are undertaking NVQ 2. Other mandatory training is also undertaken. Currently the home is not undertaking LDAFF accredited induction and foundation training. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41 and 42 The home has failed to complete their own self-monitoring and some records required to be in the home are still missing. Health and safety within the home is being maintained. EVIDENCE: As yet the home has not completed a Quality Assurance Audit, although Mr Saunders says he has sent out some questionnaires. A requirement was made following the last inspection that a copy of each member’s passport be available within the home, if they have one. This was not available. Records indicate that fire safety checks and training are being completed. Information supplied by the home indicates that electrical wiring has been checked and the boiler and gas service is not due until May 2005. Window restrictors are fitted to bedroom windows but they could not be seen on the new bedroom window. Mr Saunders agreed to check this. Radiators, apart from in the lounge and bathroom, are covered and risk assessments are in place for these. Mr Saunders confirmed that a thermostatic mixer valve is fitted to the bath. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 1 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 2 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Allied Back-up Project Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score x x 1 x 1 3 x D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 17 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 YA22 Regulation 22 Requirement You must ensure that a complaints procedure, which meets the needs of the service users is available within the home. You must ensure that staff do not work at the home unsupervised until all the required checks have been completed. You must ensure that a system is in place to monitor the quality of care provided. (Timescale of 30-11-04 not met) You must ensure that a copy of each member of staffs passport is available within the home (Timescale of 28-2-05 not met) Timescale for action 14/5/2005 2. YA34 19(1) 14/4/2005 3. YA39 24 14/6/2005 4. YA41 17 14/5/05 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 YA6 Good Practice Recommendations Any restrictions agreed with service users must be included in the care plan. D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 18 Allied Back-up Project 2. 3. 4. 5. 6. YA9 YA12 YA20 YA21 YA35 A risk assessment must be in place in relation to the gate being left open It is recommended that college courses are investigated for one service user You should obtain the GPs consent in relation to the individual use of homely remedies Continue to obtain service users wishes in relation to terminal illness and death, where possible. Look at using LADAF accredited induction and foundation training. Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Suite 1, Renslade House Bonhay Road Exeter EX4 3AY 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 Allied Back-up Project D54 D06 S21873 Old Bakery V212837 130405 stage 4.doc Version 1.30 Page 20 - 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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