Inspection on 27/04/05 for Abbey Park

This inspection was carried out on 27th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbey Park 02/04/09

Abbey Park 08/04/08

Abbey Park 27/04/07

Abbey Park 11/05/06

Abbey Park 06/10/05

Abbey Park 27/09/04

Abbey Park 06/04/04

Abbey Park 02/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abbey Park 49/51 Park Road Moseley Birmingham B13 8AH Lead Inspector Jill Brown Unannounced 27 April 2005 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 Older People. 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. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbey Park Address 49/51 Park Road Moseley Birmingham B13 8AH 0121 442 4376 0121 449 1300 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) Mr M Salim Patricia Bannister (not registered) Care Home 28 Category(ies) of Older People registration, with number of places Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate a maximum of 28 people for reasons of old age. 2. Three named people, who were under 65 years of age at the time of admission can be accommodated and cared for in this Home for reason of physical disability or mental disorder, 25 OP, 2 PD and 1 MD. Date of last inspection 27 September 2004 Brief Description of the Service: Abbey Park is a home registered for 28 older people and has both single and shared bedroom accommodation. It is situated in the Moseley area of Birmingham in a residential street within a ten minute walk of Cannon Hill Park. The park houses an art centre as well as formal gardens and walks along the river. Within walking distance there is access to bus services that will take you to the centre of Birmingham or to Acocks Green or, on another route to Birmingham and to Druids Heath. The home is an adapted building over three floors. The third floor is accessed by a stair lift and there is a passenger lift to the second floor. The home has three lounges and two dining areas. One of the dining areas is reserved for service users that smoke. There is an assisted bathing facility on the ground floor and an assisted shower on the first floor. The home has a large accessible enclosed garden to the rear of the property. The home has a ramped access at the front of the house but this is not the main access to the building and there is ramped access at the rear of the building. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place at 7.15 am on a weekday in April. The home had an unannounced visit prior to this inspection in February at 6.40 am following a complaint in part about hours of rising. The inspector viewed records of 4 service users fully and the admission paperwork of two service users. Six service users and 2 staff were spoken to as well as the manager of the home. A meal, staff and medication administration records were sampled and four weeks rotas were taken to check staffing levels. Some maintenance and inspection documents for the building were sampled and a tour of some areas of building was undertaken. What the service does well: What has improved since the last inspection? The home has showed that staff have recorded supervision at appropriate intervals and plan to improve the quality of supervision to improve service users’ lives. The home now has an assisted shower facility on the first floor of the home for service users that need assistance. Medication administration has improved with many previous requirements being met. The home clearly checks that new service users have the right medication and advice is sought on service users conditions. Service users medication is now safely administered. Staff files have been checked and all staff have an application being processed for Criminal Records Bureau (CRB) checks. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 6 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. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3, & 5 The home’s assessment procedure generally meets the requirements but must be followed for service users that are accommodated for respite care to ensure that care is given according service users’ needs. The home could improve on the information they collect about personal care to ensure that service users care is delivered in a personalised way. EVIDENCE: The home has provided the Commission with a Service User Guide and Statement of Purpose prior to this inspection. The inspector noted that the previous two inspection reports were on prominent display. The home has a structured format to their assessment of service users. The format consists of measuring service users dependency levels across the required areas of need such as mobility, mental health, physical assistance needed and so on. The manager tended to complete these on the information given at time of admission but this information needs to be added to as more becomes known about the service user. The scoring system was not always Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 9 completed but this clearly was a useful tool in determining dependency levels in the home and appropriate staffing levels. The assessments had some personal information such as: - ‘meals need to be cut up fine and then service user can manage’ and ‘requires a soft diet and likes orange squash’. This individuality needs to be encouraged in the assessment of personal care to inform the service user’s care plan. The format directs the manager to consider some areas of risk but does not encourage a full assessment and therefore actions to minimise risk were not comprehensive. Assessments are updated on a six monthly basis and this is good practice. Major changes in service users health and well being did not always prompt reassessment. One service user file indicated that the service user was very dependent and a nursing assessment must be undertaken prior to returning to the home. Service users spend the day at the home whilst an assessment takes place before admission. Prior to the inspection the inspector received a compliment about the home’s management of the admission of three service users that needed to be resettled following a home closure. Two service users receiving respite did not have any admission paperwork as to their care needs and this was not acceptable. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 &10 Limited progress had been made to improve arrangements to ensure the care needs of service users were identified and met especially in regard to known risks. These shortfalls have the potential to place service users at risk. EVIDENCE: A complaint was received in February about the routines for service users rising in the morning and an inequality of treatment of service users. It was found in February that half of the service users of the home were up and their personal care attended to by 7am. There were no clear ways to ensure that service users choices, within a risk assessment framework, were respected in regard to this; this part of the complaint was upheld. At this inspection six service users were dressed and awake. Those service users able to express an opinion stated that this was their choice. The complainant said some service users received preferential treatment but no evidence was found and this was not upheld. The care planning element of the home’s documents did not adequately show how identified care needs were to be met. Some instructions to staff were Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 11 contained in the daily records but not enough to deliver the care in the way service users wished. Actions to minimise risks to service users were limited. The limited actions on risk and care management recorded were reviewed monthly. Staff spoken to were able to describe the care given to individual service users and this was appropriate to the needs described in their assessment. Service users were weighed on admission but not all service users were weighed monthly or other measurement taken if this was not possible. Service users saw health professionals if required. Service users did not have an undue number of falls and there was evidence that these were responded to individually. Daily records did not always follow through when concerns were raised especially about difficult or challenging behaviours. A service user record showed ‘aggressive’ and ‘abusive’ incidents had taken place but these incidents were not described so a consistent approach could not be taken. The medication appeared adequately administered. Checks were in place for new service users medication and for service users going out for the day. Handwritten MAR did not have two signatures of staff clerking in medication. The procedure to be followed after a drug error was missing and the home had not shown that medication had been sent to the hospital with service users in all cases. One service user spoken to was not keen to share the double room and this must be resolved. There was no adequate privacy curtain and the needs of the two service users were incompatible. One service user said that the staff were kind and particularly mentioned one staff member who she said she looked forward to her being on duty. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 Social activities in the home were not well planned or creative and service users had little to interest or divert them. The meals were generally liked by service users but there were occasions when the home fails to meet the dietary cultural needs of all service users. EVIDENCE: During the inspection it was clear that the home was now giving service users the choice of rising time. Some service users staying in bed beyond 11am. There was a formal choice of main meal. Service users were seen exercising a choice of breakfast some opting for bacon sandwiches. One service user said they can always have bacon or sausage sandwiches if they want. One service user was observed having an Asian food option for their main meal. Another service user said that the food was not good and that he was not having enough African Caribbean food. The home must maintain offers of appropriate food and record when this is done. The storage of food and kitchen were not inspected on this occasion. The home records service users religious beliefs and there was evidence of Christian services were being held in the home. A musician attends the home on a monthly basis, but an activities programme was not found. Individual activity records indicated that most service users had Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 13 a conversation or individual time with a member of staff several times a week. Specific activities to enhance the lives of service user with dementia were not available. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed at this time. EVIDENCE: An anonymous complaint was made about the home in respect of the rising routines, inequality of treatment for service users and the management of staff. These issues are reported in Health and Personal Care, and Management and Administration sections of the report. These complaints were partly upheld. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21 The home has made limited improvements to the décor and has created an assisted bathing facility on the first floor since the last inspection. But the outstanding matters do not provide the people living in the home with safe, comfortable surroundings. EVIDENCE: The staff at the home were aware of odours arising and immediately took remedial action. The grounds were tidy and seating had not yet been re-sited for the summer. The home was excessively warm in the dining area on arrival. The home must ensure that windows can be opened with an appropriate restraint to minimise risks. Bedrooms have been redecorated and others must be programmed for refurbishment. Some room’s chairs needed replacing. Bedrooms were individualised but required a lockable pieces of furniture in each room. All bedroom doors were unlocked and on the files there was no information to say that service users were unsafe to have a key to their bedrooms. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 16 The home has provided another assisted bathing facility and this must have the finishing touches and be brought into daily use as soon as possible. The home must re-site the radiator in the assisted bathing facility on the ground floor to ensure appropriate legroom is available to use the bath hoist and replace the moulding on the bath that could cause an injury. The home needs to ensure that as it becomes more occupied that the assisted bathing facilities meet the needs of the service users. One service user’s shower was not working and this must be repaired and water temperatures appropriately restricted. Laundry was kept airing on the corridor radiator and cupboard door; this poses risks in transferring infections and fire and must cease. Laundry must be separated for washes individual to the service user. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 The homes recruitment procedures and training have not been robust and although there had been some remedial improvement since February this does not provide adequate safeguards for service users. Staffing in the morning is not adequate and safe to meet the increased number and needs of the service users resident. EVIDENCE: At the time of the inspection one staff member had telephoned to say they were unable to work and this put the home’s staffing arrangements under significant pressure. Service user records showed that service users’ needs were increasing and therefore becoming more dependent. The home was also reaching full occupation. It is clear, that as a minimum, 4 care staff must be available on the morning shift in addition to management and ancillary hours. The home must review its staffing arrangements through out the 24-hour period. A complaint was received in respect of the management of the home. Staff holding temporary posts did not have contracts, job descriptions were not on staff files and some staff worked long hours without a written agreement being maintained. The home has put the contracts and job descriptions in place since February. In the interim period the home has ensured all staff have an enhanced police check or one has been applied for. However until the home has met these standards in full these requirements will remain. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 18 The home did not keep a matrix on staff attendance on training so auditing was not possible. Staff files showed a mixture of training, all had a first aid certificate, and most had health and safety and infection control certificates. There were staff that had training in dementia care and challenging behaviour and this was appropriate to the current service users of the home. However, training was inconsistent and future training needs to be planned to fill in the gaps. Fire training was outstanding for all staff. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35, 37 & 38 The management of the home had recently changed and this had been a source of some staff conflict. This appears to be resolving. Limited improvements have been made in staff management and this has benefited service users. Health and safety matters did not consistently show good management and this could put service users at risk. EVIDENCE: Staff and manager relationships had been difficult but issues had not been raised appropriately or conflicts resolved. The manager had appropriate contacts with health and social care and health professionals. The above matter was part of the complaint mentioned earlier in this report and was partly upheld. Staff spoken to felt that relationships within the home had improved and that there was more clarity in expectations. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 20 The homes arrangements for assisting service users personal monies was found to be adequate ad appropriate. The home has records with individual receipts and the balances of the three sampled were correct. There was evidence that new service users balance of personal allowance had grown since admission. The money held by the owner on behalf of service users was not inspected. Staff files showed that recorded supervision was taking place routinely. The registered manager discussed ways of making this more relevant for the staff and the service. The home had undertaken to record when personal care was given as required at the last inspection but this was being kept on a communal record. This fails to respect and protect service users privacy and dignity. The home had evidence of maintenance of hoists and passenger lift. Maintenance of the stair lift and the insurers inspection of the passenger lift were outstanding. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x 2 x x 2 x 1 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 x x 3 3 2 2 Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 22 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 op3 Regulation 14 (1) Requirement The home must not offer accommodation to any service user unless they have an assessment from a suitably qualified person. The home must determine that they can meet the service users needs within their catgory of registration and appropriately manage any risks identified. Assessments must be reviewed at the point of significant change in a service users condition. All risks identified must have a thorough risk assessment. Care plans must show how care needs are to be met. Care plans must as far as practible include service users wishes. (outstanding 30/06/04) All risks identified must have actions in the care plan to minimise risk. Care plans for service users Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 23 Timescale for action 31/05/05 2. op7 15(1) 12(1)(a) 12(3) & 13(6) 31/05/05 must be easily available for staff delivering the care. 3. op8 12(1)(a) & 16 (i) Service users must be weighed 31/05/05 routinely or have another measurement and unplanned weight loss or gain must result in appropriate action. Aggressive incidents must be recorded in enough detail to enable appropriate risk management to take place. All hand writen Medication Administration Records (MAR) must have 2 signatures. The medication policy and procedure must include procedures in respect of a drug error occuring. (outstanding since 30/10/04) The home must keep a clear record of medication leaving the building for any reason. 5. op10 & op23 12(3) & 12(4)(a) The home must ensure that service users do not share rooms unless this is a positive choice. All shared rooms must have apropriate levels of screening. The home must ensure that they have a weekly rota of activities for service users available for inspection. (outstanding since 31/12/04) Activities must be provided that are suitable to the service users needs. 7. 8. op15 op19 16(2)(i) 23(2)(d) Culturally appropriate food must be available for those service users that wish it. The registered provider must produce a timed refurbishment 31/05/05 31/05/05 Page 24 4. op9 13(2) 31/05/05 31/05/05 6. op12 16(2)(n) 31/05/05 Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 plan for the remaining bedrooms and this must be sent to the Commission. (outstanding since 09/08/03) 31/05/05 Meanwhile all bedrooms furniture must be audited for cleanliness and safety. The results of the audit must be sent to the Commission. 9. op20 23 (2)(p) The dining area must have the facility for windows to be opened but adequately restrained to minimise risks. The ground floor bathroom must be adapted to give adequate leg room for service users that need to use the bath hoist. The ground floor bathroom must have the moulding on the edge of the bath replace to eliminate the possibility of injury. The identified service users ensuite shower must be repaired and appropriately restricted. A lockable provision must be available for each service user. (outstanding since 31/12/04) Service users must have access to keys for their bedrooms unless a risk assessment suggests this is not safe. Temperatures of hot water outlets on communal baths and showers must be taken on a weekly basis. These must be recorded and any deviation from 43 degrees centigrade rectified. (this standard was not assessed on this occasion.) The home must revise its control of infection policies and procedures. 31/05/05 10. op21 23(2)(n) 31/05/05 28/04/05 30/04/05 31/05/05 11. op24 23(2)(m) & 12(4)(a) 12. op25 13(6) 31/05/05 13. op26 13(3) 30/06/05 Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 25 (This part of the standard was not inspected andwas brought forward.) Laundry must not be aired on radiators or hang from doorways in the corridors as this is an infection control hazard and a fire risk. Laundry must be separated by service user for washing. The home must have, as a minimum, four care staff in addition to ancillary and manager hours in the morning. The home must audit the staffing requirements at other times in the day and night and ensure the home is adequately staffed. The home must ensure there is a written agreement that staff are willing to work over 48 hours. Staff that take this option must have a risk assessment to state they are competent over these hours. Staff must not be employed without a CRB police check and POVA check being obtained. Any difficulties obtaining these must be discussed with the Commission on an individual case basis. (outstanding since 13/04/04) Remedial action on existing staff records must continue until these are satisfactory. (outstanding since 11/02/03) 16. op30 18(1)(c ) The home must keep a matrix of staff training performance to enable the required training to take place. A copy of this matrix must be sent to the Commission. 15/06/05 30/04/05 30/04/05 31/05/05 14. op27 18(1)(a) 15. op29 19 schedule 2 28/04/05 31/05/05 Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 26 17. op37 Data Protection Act. 23(2)(c ) 18. op38 All staff must have the required fire training. The home must ensure that records of care given to service users is held on individual records. The home must send to the Commission evidence of the maintenance of the stair lift and the insurers inspection of the passenger lift. 31/05/05 31/05/05 30/06/05 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. 2. Refer to Standard op3 Good Practice Recommendations It is recommended that the home keeps the outcomes of its assessment scores to assist with monitoring dependency levels and required staffing. Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Abbey Park E54 S17004 Abbey Park V195053 270405 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!