Inspection on 27/03/08 for Allied Back-up Project Limited - The Old Bakery

This inspection was carried out on 27th March 2008.

CSCI found this care home to be providing an Adequate service.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

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

Allied Back-up Project Limited -... 13/04/05

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

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

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Allied Back-up Project Limited - The Old Bakery The Old Bakery 54 Park Street Crediton Devon EX17 3HP Lead Inspector Sue Dewis Unannounced Inspection 27th March 2008 10:30 Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.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 Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.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. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Allied Back-up Project Limited - The Old Bakery Address The Old Bakery 54 Park Street Crediton Devon EX17 3HP 01363 777565 01647 24447 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) Allied Backup 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 Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2006 Brief Description of the Service: The Old Bakery is owned by the Allied Backup Project Ltd, and is situated in a residential area of Crediton. The home is close to the centre of the town and from the road has nothing to distinguish it as a residential home. The Old Bakery is a smaller home and is registered to provide personal care for up to four people with learning disabilities. The registered person is also responsible for the day-to-day management of the home. The inspection report for the home is available on request from the office. Fees for people living at the home range from £1000 to £1500 per week. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced visit took place over 6 hours, one day towards the end of March 2008. The home had been notified that an inspection would take place within three months and had returned a completed AQAA (Annual Quality Assurance Assessment) that shows how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. During the inspection all 4 people living at the home were case tracked. This involves looking at peoples’ individual plans of care, and where possible, speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to 4people living at the home and their representatives. At the time of writing the report, responses had been received from 3 representatives. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection 1 person living at the home was spoken with individually, as well as 2 staff. A full tour of the building was made and a sample of records was looked at, including medications, care plans and the fire log book. The owner was not at the home and some records were not available to us, including staff files and some information held on people living at the home. Some people living at the home have limited verbal communication skills, and as we are not skilled in their other methods of communication it was difficult for us to have any meaningful communication with these people. However, the interaction between the people living at the home and those who care for them was closely observed. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 7 Most of the items identified in this section have been highlighted because we were unable to confirm that information was present, due to the records being unavailable while Mr Saunders was on holiday. Arrangements must be made to ensure records are available for inspection at all times even when Mr Saunders is away. A thorough pre-admission assessment must be obtained before anyone moves into the home so that the home can assure the person their needs can be met, this should also be confirmed in writing. Care plans should give staff more detail on how the day to day needs of the individual are to be met so that people can consistently receive the care they need. The plans should also contain a thorough assessment of people’s needs so that any changes to their health or personal care needs can more easily be identified. All recordings, including those relating to health care matters, should be made on the individual’s care plans, so that if they wish to see information held on them they would not have access to information held on other people. All daily recordings should be useful and non-judgemental. For example phrases like ‘had a good day’ are not useful and ‘bit silly again’ are judgemental. A list should be drawn up of sample signatures and initials of all staff who administer medications so that it is easy to identify which staff member administered which medication. The complaints procedure should be amended to show the correct details of the Commission so that people would be able to contact us if they wish to do so. There are areas around the home, particularly individual bedrooms that need redecorating. The staff rota should be looked at to ensure there two members of staff on duty during the evening to enable more social opportunities during this time. Staff should receive more specialist training in caring for people with a learning disability so that they have more knowledge on how best to meet the needs of the people they care for. A formal and recorded supervision system would enable the home to ensure staff are working consistently. A copy of the report on the quality of care at the home must be sent to the Commission. The fire log book should be maintained in line with the recommendations of the fire authority. As there is no fire risk assessment for the home, we have written to the fire authority to ask them to look into this matter. Please contact the provider for advice of actions taken in response to this inspection. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 8 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. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 9 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 Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People thinking of moving into the home cannot be confident that the home’s assessment and admission procedures will ensure that their needs will be met. EVIDENCE: There has been one admission to the home since the last visit. This person was able to tell us that Mr Saunders had visited them before they came to the home. However, there was no pre-admission assessment on their file. Some information was seen that had been supplied by the previous placement, but there was no indication that the home had assessed this information or that they had confirmed they would be able to meet the needs of the individual. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People cannot be assured they will receive sufficient and consistent support to achieve their personal goals. EVIDENCE: The care plans of all four people living at the home were looked at. The plans included a general ‘pen picture’ of each person. However, they do not provide staff with the information they need to meet the needs of individuals on a day to day basis. This means that people are at risk of receiving inconsistent care, as staff may be delivering care and responding to behaviour in different ways. The care plans did not include detailed assessments of the individual’s current abilities. Without these assessments it is difficult to build pictures of the current needs of the person and therefore to plan for increased independence. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 12 Daily recordings for people living at the home are kept in a file separate to the care plans. This means staff do not always refer to the care plans during the day, and while any changes to care needs are related at staff handover and written on daily records, they are not always written on the care plans. This could lead to people not receiving the care they need. Daily recordings were not always useful in so far as they reported ‘good mood’ and did not specify the behaviour associated with this mood. The recordings also had many negative comments relating to behaviour such as ‘bit wound up’ and ‘been silly again’. Not only do these comments show a judgemental attitude of staff, but again are not useful as they do not describe the person’s behaviour. There were also different responses by staff recorded in response to this behaviour. For example, one staff member might send someone to their room, another might take them for a walk. This also relates to the comments above about care plans not containing detailed instructions to staff on how to care each individual. Three of the people living at the home have limited verbal communication and it was not possible for us to ask them direct questions about their lives at the home. However, we did speak to one person who was happy with their life at the home. Staff were heard offering alternatives for meals and drinks and responding appropriately to one person’s requests to go for a walk. Staff and individuals were seen to communicate well and appropriately with each other. Staff told the inspector that individuals make choices about many aspects of their daily lives and are encouraged to do so as much as their abilities allow. We were told how staff now showed examples/pictures to one person to help them make a decision. This person always repeated the last word spoken to them and staff had realised this may not always be because that was the person’s choice. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to encourage more family contact and to provide specialist input to improve communication between people living and working at the home. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst there is evidence that people are supported to live their lives as they choose, the records showing this are not always evident. Meals are nutritious and balanced and offer a healthy and varied diet. EVIDENCE: Each individual now has a notice board that shows them how their day will be organised. For example, they may have breakfast, followed by a bath, followed by an outing in the car. Another notice board shows people which staff will be on duty caring for them. One staff member told us that everyone has an individual routine planned for them and that sometimes this will mean they have a one to one activity/outing and other times the activity/outing will be as a group. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 14 The amount of activities and outings on offer has increased since our last visit and we were told of many new ideas that had been tried with individuals. For example, one person now visited a local hairdresser on a regular basis, when previously this had been thought to be too much of a risk due to concerns over behaviour in the community. A weekly activities/ rota is slowly forming and there are regular visits to a church coffee morning, there is also a weekly lunch outing, playing skittles and shopping. Two people also visit a nearby day centre one day each week. There are daily walks and we were told that a summer holiday is being planned for this year. Comments received from relatives (via survey forms) praised the fact activities had increased and included ‘Confidence and trust has been gained by introducing a more structured but flexible programme, social skills and activities are slowly coming to the fore thanks to the patience and dedication of the staff’. Another commented that they were able to visit at any time. There are also regular trips out and these have included visiting the Cathedral in Exeter, Fingle Bridge and Dawlish. Two people enjoy painting and colouring and materials have been purchased to enable this within the home. Various jigsaw puzzles of differing levels have also been purchased and we were told that someone who has a very short concentration span is now doing very simple puzzles. However, whilst we were told about these activities and outings there is little evidence to support this. A daily activities record is meant to be kept, but this often consisted of ‘dressed themselves’. Another common recording was ‘been to church’, we were told this was the church coffee morning and people did puzzles and danced. The recordings do not reflect the time spent on, or the content of the activity and it appears from these recordings that not all staff are keen to encourage people to participate in activities. Currently there is only one member of staff on duty from 8pm to 8am. This prevents any form of spontaneous social outings during the evening and restricts the types of activities that can take place within the home. Staff shift patterns need to be looked at in order to enable more activities to take place in the evening. People are encouraged to help with chores around the home and to make decisions whenever possible (see also previous section). Menus are drawn up based on what staff know people like to eat. Alternatives are shown to people to help with choices and we were told that shopping takes place more regularly so that more fresh food can be used rather than frozen. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 15 The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to increase the involvement of individuals in daily activities within the home, and to provide a holiday this year. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there was some evidence that people’s health care needs are being met records were not available to confirm this. Medication procedures and practices have improved but more improvement is needed. EVIDENCE: Care plans contained little information relating to health and personal support. Most of this information is contained in the files we were unable to see. We were told that one person visited the practice nurse regularly and visits are recorded in the diary. Personal information should not be recorded in this way as it is in contravention of the Data Protection and means that anyone viewing their own information could see information personal to other people. Several people at the home have serious health concerns including epilepsy and staff have been trained appropriately in the administration of emergency Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 17 medication to this person. Special epilepsy monitors have been purchased to alert staff when the person is in bed. A special diet is required by another person, though we were told not all staff appreciate the need to ensure the diet is adhered to, and that this can result in problems for the individual. Some good and useful information has now been recorded on care plans in relation to the individual’s wishes relating to dying and death. We were told that there are still issues around people being able to receive care from someone of the same sex. There are occasions when the staff member sleeping in is male and we were told that a female staff member has had to be called in to give personal care to a female living at the home. The home uses the Boots MDS (Monitored Dosage System) system including the associated documentation. Medication was stored securely and staff were signing the MAR (Medication Administration Record) when they had given medication to individuals. The home is now recording the quantities of medication being received into the home. The two staff spoken with had received appropriate training. However, there is no list of staff signatures and initials to enable easy identification of the person who administered a particular medication. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to continue to seek help and advice from specialists and to utilize local support. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is good, but individuals may be at risk of abuse as there is no evidence to show that staff have been properly trained to recognise abuse. EVIDENCE: There is a complaints procedure for the home and we were told that this is explained to everyone. However, it is felt that the procedure could be made more ‘user friendly’ and the home is looking to do this. Also, the details of the Commission needs to be changed to show the new address. No complaints have been received by the Commission since the last time we visited. One of the staff members that we spoke with had received training in POVA (Protection of Vulnerable Adult) issues. The other person said that they had not received any POVA training. Although both were able to describe differing types of abuse and explain what they would do if they suspected abuse was occurring. Staff records were not available to look at, so it was not possible to see how many staff had completed POVA training. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 19 Information relating to individual’s finances was not available to us, so it was not possible to ensure they were being appropriately maintained. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to review and update the complaints procedure and to make it more accessible to people living at the home by the use of symbols. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 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 provides a comfortable environment for people to live in. However, there are areas of the home where the standard of décor is not so good. EVIDENCE: The home is generally in a reasonably good decorative order, and provides the residents with a homely environment. The lounge area was comfortable and contained many pictures and ornaments. However, there are areas around the home that still need attention. For example, at the last visit we were told by Mr Saunders that the hall, stairs and landing would be decorated within the next few months and this area has still not been attended to. The bathroom has recently has recently been Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 21 redecorated and was fresh and clean, although there was no shower curtain around the bath which would discourage people from showering. The fourth bedroom is now in use and has been comfortably furnished and nicely decorated. Other bedrooms are small and are looking very shabby, but are due to be refurbished. More attention to detail would provide people with a more comfortable environment and ensure that they feel they are valued as individuals. Although bedrooms are small, they contain many items of a personal nature, and reflected the particular likes of each individual. There is no lift to the first floor and there are no ground floor bedrooms, therefore the home would be unable to offer a placement to anyone with mobility problems. All areas of the home were clean and fresh smelling, and staff reported they had access to disposable gloves and aprons if needed. Paper towels and liquid soap are now available in the bathroom. This has minimised the potential of cross infection as people being are now able to wash their hands effectively. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to continue to decorate throughout the home. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some people living at the home are at risk of not receiving the support they need, as staff do not have the specialist training they need to care for people with a learning disability. Lack of access to staff records means that people may be at risk of abuse from staff who may be unsuitable to work with vulnerable adults. EVIDENCE: There are two staff on duty from 8am till 8pm and one staff from 8pm till 8am as previously stated (section 3) the fact there is only one staff member of from 8pm restricts the possibility for evening social activity. The two staff spoken with had received a variety of training, including NVQ’s (National Vocational Qualification), fire precautions and medications. However, neither had received training specifically designed for staff working with people with a learning disability, and neither of them had received LDAF (Learning Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 23 Disability Award Framework) accredited induction or foundation training. No infection control training has been provided and staff said they would like training to help them deal with any behaviour that may be challenging to them. We were not able to look at any staff files, therefore we could not verify that all the required checks had been made on staff, to ensure they are suitable to work with vulnerable people. All records that are required to be kept, must be available for inspection by the Commission at any time. There is no formal supervision system at present, although we were told that this is due to start soon so that all staff will be made aware of what is required of them. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to continue with the staff training programme, to improve communication between people living and working at the home, to improve the consistency of approach towards the care of individuals and to increase staff supervision and support. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Poor records management means that many aspects of care, recruitment and health and safety cannot be verified, which means that people living and working at the home may be at risk in these areas. EVIDENCE: Mr Saunders is currently responsible for the day to day management of the home, and has many years experience of working with people who have a learning disability. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 25 Records were not available to verify if there is now formal quality assurance system in place. In the past the home has not been proactive in establishing a system by which the quality of care it provides can be measured. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Allied Backup Project complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. The accident book was not available for inspection. However, the fire log book showed that systems within the home were not being tested as required. We were assured that the fire alarms had been tested the day before the visit, and had just not been recorded. There is no fire risk assessment for the home and we will be writing to Devon and Somerset Fire Service to ask them to look into this matter. So that the risk of burning from hot surfaces is minimised, radiators within the home are covered. All windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows. So that the risk of burning from hot water is minimised temperature controls are fitted to bath taps. Many records were not available to us during the visit, including staff records and some records relating to people living at the home. The home must ensure that these records are available for inspection at all times. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to continue to review all documentation and to monitor and review the use of individual’s photo boards. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 26 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 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X 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 2 2 2 X 2 X 2 X 2 2 2 Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement Timescale for action 28/09/08 2. YA24 3. YA35 4. YA39 5. 6. YA41 YA42 You must not admit anyone to the care home whose needs the home cannot meet, and you must confirm in writing to the individual that their needs can be met. 16 You must ensure that all parts of (23)(2)(d) the home are reasonably decorated, especially people’s bedrooms. 18 (c) You must ensure staff receive training so that they can satisfactorily meet the needs of people with learning disabilities. 24 You must ensure that a system is in place to monitor the quality of care provided and send a copy of the report produced to CSCI (previous timescales 28/02/06 and 28/09/06 not met) 17(3) You must ensure that records are available for inspection by the Commission at all times. 17 (2) You must ensure that the record sch 4 of all tests carried out on fire equipment is kept up to date. 28/09/08 28/09/08 28/09/08 28/05/08 28/05/08 Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 28 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. 4. 5. 6. 7. 8. Refer to Standard YA6 YA6 YA6 YA6 YA19 YA20 YA22 YA32 Good Practice Recommendations You should ensure that care plans give specific details to staff on how to meet the day to day care needs of people living at the home. You should ensure that there is a detailed assessment on the care plan of everyone living at the home. All information personal to the individual should be recorded on their care plan. You should ensure that daily recordings made about individuals are useful and non judgemental. All health care information should be recorded on the individual’s care plan. You should ensure that a list is drawn up showing sample signatures and initials of all staff who administer medication. You should ensure that the complaints procedure for the home is amended to show the correct contact details of the Commission. You should look at ways to ensure there are enough staff on duty during the evenings to allow social activities and outings to take place. Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Contact Team Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Allied Back-up Project Limited - The Old Bakery DS0000021873.V359664.R01.S.doc Version 5.2 Page 30 - 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. 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