This inspection was carried out on 7th November 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.
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
Susan Lyons Unannounced Inspection 7th November 2005 11:20 Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 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.V264952.R01.S.doc Version 5.0 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.V264952.R01.S.doc Version 5.0 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.V264952.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th April 2005 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 Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. At the inspection which took place on April 13h 2005 the majority of the core standards were assessed therefore only some were looked at on this occasion. This report needs to be looked at in conjunction with that report. The inspector met with all the residents during the inspection, spoke to one member of staff and Mr Saunders the owner and manager of the home. Certain records were also checked. What the service does well: What has improved since the last inspection? What they could do better:
There does need to be a little more detail in care plans about how staff should respond to certain behaviour and there continues to be a need for staff to develop the activities which are offered to residents. The actual amount of medication which comes into the home needs to be recorded on the recording
Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 6 sheets rather than 28 days supply. The home is trying to obtain resident or their representative’s wishes in relation to terminal illness and death but this has been a slow process. The complaints procedure needs to say that anyone wishing to make a complaint is able to speak to the Commission for Social Care Inspection (CSCI) at any time during the process rather than at the end. Whilst refurbishment downstairs has taken place the landing, stairs and bathroom need to be redecorated. There is some specific training required for the most recent member of staff to commence work and some refresher training for the deputy. The home has yet to complete a quality audit on the service provided. 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 Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 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 Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This core standard was assessed on the last inspection, see report for 13th April EVIDENCE: Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Minor adjustments will ensure that staff have the information needed to meet residents needs. EVIDENCE: The care plans for the three residents living at the home were seen. They contain details of how residents needs are to be met they also contain details of certain behaviours and generally how staff should react to this behaviour. It was noted that in a behaviour plan there was insufficient detail of how staff should deal with a specific behaviour. However a recommendation was made following the last inspection that any restrictions agreed with a resident must be included in the care plan. This remains outstanding. Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 There is a lack of variety in activities, resulting in residents social needs being unmet. EVIDENCE: The home is currently investigating one resident attending a Social Skills Course at college. They have also received some initial help from an occupational therapist in looking at activities for residents. Two residents spend two half days at day placement outside of the home. Whilst it is acknowledged that residents do require a lot of motivation to undertake any activities and that they have very limited concentration skills there remains a lack of variety and stimulation in the activities undertaken by residents on a day to day basis. Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 21 Generally residents are protected by medication procedures. Residents and their representatives can not be assured that their wishes in relation to terminal illness and death will be met. EVIDENCE: The home users a monitored dosage system of medication from a local pharmacy. The recording was seen to be appropriate although it was noted that where medication is recorded as coming into the home it does not indicate the number of tablets just 28days supply. A recommendation was made following the last inspection that residents or their representative’s wishes be sought in relation to terminal illness and death. Mr Saunders says that he has started to do this but has not completed the task yet. Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 With minor adjustments resident’s residents needs will be protected by the complaints procedure. EVIDENCE: A requirement was made following the last inspection that a complaints procedure which meets the needs of the residents needed to be in place within the home. A complaints procedure has been produced. It indicates that anyone wishing to complain would not approach the CSCI until after they had spoken to the manager. Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The standard of décor within the home has benefited from recent work continuation of this will ensure that residents have an attractive and homely place in which to live. EVIDENCE: The kitchen and lounge of the home have not long been redecorated and a new conservatory attached to the rear of the property. Mr Saunders said that he intends to redecorate the landing and stairs are now that the downstairs redecoration has been completed. The bathroom also needs to be redecorated. Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Staff are undertaking NVQ training which will enable them to better meet the needs of residents. Improvements in recruitment practice offer protection to residents. The provision of some additional specific training for individual staff will equip them to satisfactorily meet needs of residents. EVIDENCE: Currently one member of staff has completed NVQ level 2 and two other members of staff are just completing NVQ level 3. This will mean that 50 of the staff will be trained to NVQ level 2 or above. The returned Criminal Records Bureau (CRB) with Protection of Vulnerable Adults (POVA) and two references were seen for the last member of staff to be recruited. A recommendation was made following the last inspection that they look at using LADAF accredited induction and foundation training for staff. Mr Saunders says that they have sent for the information but it has not been started as yet. The most recent member of staff has not undertaken any training in relation to dealing with difficult behaviour and the deputy manager said that she needs to undertake refresh her training. Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The home appears well managed and generally results in practices that promote and safeguard the health safety and welfare of residents. The home does not regularly review aspects of its performance through a programme of self review and consultation which includes seeking the views of residents staff and relatives. EVIDENCE: Currently Mr Saunders is responsible for the day to day management of the home but he intends to register a manager who is to start NVQ level 4 and the registered managers award. A requirement was made following the last inspection that a system be in place to monitor the quality of care within the home. Mr Saunders said that he has sent out questionnaires but has not had any returned as yet. Therefore this requirement remains outstanding. Locks have recently been taken off the bedroom doors and new handles fitted as a response to a requirement from the fire officer. The officer is to visit again Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 16 to discuss another fire exit and Mr Saunders is to replace a smoke detector with a heat detector in the laundry. It was noted that there were some cleaning materials stored in an unlocked cupboard in the kitchen. Mr Saunders moved these to a locked cupboard before the inspector left the home. The inspector was informed that sufficient number of staff are trained in first aid to ensure one such trained member of staff is on duty at all times including nights. Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 17 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 X X X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 2 Standard No 37 38 39 40 41 42 43 Score 3 X 1 X X 3 X Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 18 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 YA39 Regulation 24 Requirement You must ensure that a system is in place to monitor the quality of care provided. (Timescale of 30-11-04 & 14/06/05 not met) Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 5. 6 7 Refer to Standard YA6 YA12 YA20 YA21 YA22 YA24 Good Practice Recommendations Any restrictions agreed with service users must be included in the care plan. It is recommended that a range of activities are offered to residents. You should record the actual amount of medication coming into the home. Continue to obtain service users wishes in relation to terminal illness and death, where possible. You should ensure that the complaints procedure informs people that they can make a complaint to the CSCI at any time during the procedure. You should have a refurbishment plan which includes the redecoration of the landing and stairs and the bathroom.
DS0000021873.V264952.R01.S.doc Version 5.0 Page 19 Allied Back-up Project Limited - The Old Bakery 8 YA35 Look at using LADAF accredited induction and foundation training. Ensure that all staff receive training in relation to dealing with difficult behaviour. Allied Back-up Project Limited - The Old Bakery DS0000021873.V264952.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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