CARE HOMES FOR OLDER PEOPLE
Abbey Park 49-51 Park Road Moseley Birmingham B13 8AH Lead Inspector
Jill Brown Announced 6 October 2005
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Abbey Park Address 49-51 Park Road , Moseley ,Birmingham B13 8AH 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) 0121 442 4376 0121 449 1300 Mr M Salim Pat Bannister Care Home 28 Category(ies) of Old Age (28) registration, with number of places Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 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. 3. That the Registered Manager obtains NVQ 4 in Care and Management and the Registered Managers Award or equivalent by September 2006. 4. That the Registered Provider provides consultancy support until January 2006 specifically in setting up quality assurance tools in the home and providing support about staff management.. Date of last inspection 27th April 2005 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. A small amount of car parking is available at the side of the home. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The announced inspection took place over 2 days in October. During the inspection 6 residents, 2 staff, the manager and the owner of the home were spoken to. The inspector received 13 comment cards about the home, 4 from residents, 8 from relatives and 1 from a social care and health professional. The inspector toured the building including the kitchen, laundry and cellar. Five resident case files were looked at and 3 staff files. The inspector looked at the medication records, duty rotas, the home’s pre-inspection questionnaire, maintenance and inspection records for gas, electric fire and so on. The inspector joined the residents for their main meal of the day. What the service does well:
A resident said I always get a cup of tea when I want it, the food is good, they always check me on a night and I can come in here (the smokers dining room) to smoke. Care staff ask residents to make a choice of the meals available that day. Residents can choose what they feel like eating now rather in a days time. It was clear that resident’s, where appropriate, can have breakfast or a drink in their bedroom. Where possible the home consults with residents about their assessment and reassessments are done every six months by the home. Arrangements were made for residents to see the health professionals when needed and residents saw opticians, chiropodists and dentists routinely. Medicine management was good with checks against the Medicine administration Record showing the home had the correct amount of medication. A number of residents that needed to have put on weight on since being admitted to the home. The home had the required maintenance and inspection records for utilities such as gas and electric and for lifting equipment. Fire checks, drills and training were being undertaken routinely. Appropriate insurance was in place and was displayed.
Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 6 Financial records for resident’s personal allowance showed that this money was handled appropriately and could be traced from money coming into the home to being spent on behalf of residents. Food supplies were good and stored in reasonably well. What has improved since the last inspection? What they could do better:
The home’s assessment gives good information but this did not always get put on to a care plan to tell staff how care was to be given to the resident. For example there was no clear detail on residents smoking habits and potential hazards. Personal care to be given and any special nutritional needs were not written down. Although staff interviewed knew what care to give this lack of record could lead to inconsistencies in how a resident is cared for and potentially puts residents at risk. There was a lack of review of the care given and so in continence planning there was no check that the continence plan was working for individual residents or that it took account of the resident’s usual patterns. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 7 The home did not have a controlled drugs cabinet. Further checks such as a photograph of the resident and a copy of the up to date prescription with the medicine administration records would make the administration better. A number of shared rooms have curtaining that only gives full privacy to one occupant. The home had a plan of activities but needed to see if residents had any previous interests that could provide useful activities. The home’s complaint procedure must be updated with the Commissions name and telephone number and it is recommended that a copy of this procedure be given to relatives. A number of health and safety issues needed attention such as care alarms in the bedrooms were not always either in right position or had leads for residents that were able to use them. Two bedrooms had wrinkles in the carpet that could cause a resident to trip. Water from the hot water outlets were not always at the right temperature and this could cause accidental scalding. The kitchen needed fly screening against windows and doors. Fridge and freezer temperatures needed to be recorded. A number of bedrooms needed to be redecorated and details of these need to be sent to the Commission. Recruitment practices had improved but the home was still not getting Criminal Record Bureau checks prior to employing staff. The home was relying on the se checks undertaken under previous employment and this is not acceptable. The Commission may take legal action about as it is deemed a matter of serious concern. The home had not displayed both pages of its registration certificate as required. The home had not undertaken risk assessments for the building and in case of fire. The food safety department visit report was not available for inspection nor was a food risk assessment. These risk assessment and the need to ensure clear audit trails for the service the home provides must be prioritised for action. 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 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 8 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 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 9 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) 3, 4 The home collects useful information on residents prior to and during their stay at the home however nutritional screening must be improved to protect residents. EVIDENCE: Residents that were admitted to the home had a preadmission assessment this was not always detailed enough. However the home also completed an assessment after admission and this had useful information and included a scoring system for levels of dependency. The nutritional area of the assessment did not adequately raise concerns for residents that are admitted with nutritional difficulties and this must be rectified. It was clear from a number of the records looked at that the home was trying to involve those residents that can with their assessment and care plan. This had improved since the last inspection. The staff interviewed were able to describe the care given to specific residents and why this was needed. The home had a number of residents from ethnic
Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 10 communities and it was found that efforts were made to ensure these residents had culturally appropriate food and food that they liked. A social care professional stated on a comment card: - I placed a resident at the home. I visited 2 weeks later, he is happy. I was able to look at his room. I was able to discuss his care needs with the manager who was very approachable and helpful. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 11 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 Arrangements for care planning was not detailed enough to make sure that care was delivered in a way to meet individual resident’s needs. This lack can potentially put residents at risk. Medicine management was good with some recommendations where practice could be improved further. EVIDENCE: Care plans did not show how needs identified in the assessment were going to be met. For example issues about residents smoking, constant requests for cigarettes and safety hazards when smoking were not detailed. Discussion with staff showed that staff knew what the plan was to manage this but these steps were not adequately described in the care plan. Personal care was minimally described as help with one or two staff. It did not describe how those residents that may need help were given this. A number of residents required prompting with personal hygiene, dressing and so on. Others needed help with moving, or help with personal hygiene for the lower half of their body or a hoist may need to be used. This can lead to inconsistencies in care provided and could put the resident at risk. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 12 Reviewing of the care plan was not targeted to ensure that the details of care to be given remained appropriate. Residents were referred to health professionals appropriately and received the benefit of dentists, opticians, chiropodists and so on routinely. The home kept appropriate accident records and informed the Commission of falls and incidents whether or not they resulted in injury. The home had no residents with pressure areas or sores at the time of the inspection. It was clear that the home had a continence programme in place for residents, however it was not individualised. There was no evidence of auditing the effectiveness of the programme for individuals and this caused concern for one resident’s family. Two residents’ weights had substantially improved since being admitted despite the nutritional care plan being poor. The homes medication was well ordered and managed. Drugs audited were found to be correct. A number of the signatures of staff resemble the code for refused and it is suggested another coding is given for clarity. The corresponding photocopy of the prescription was not next to the Medicine Administration Record (MAR) but was available. A photograph of the resident was not next to the MAR and these are all best practice issues. The home had no controlled drugs on the premises but a controlled drug cabinet that meets the standard must be purchased. Residents were seen to interact with residents well. Residents comment cards said that staff were kind and caring and always ready to help. Relative comment cards said that the care was generally good. One comment card suggested that a resident was not able to see their relative privately however this was not the experience of other residents and relatives. Shared rooms had curtaining between the beds to maintain privacy however privacy for resident sharing could not be guaranteed on entering the bedroom. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 13 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, 13, 14 &15 Arrangements for activities, visiting, choice and food had improved and this improves the life for residents. Improvement on ensuring some activities are based on previous interests would make activities more relevant for residents. EVIDENCE: The home keeps a record of planned activity on a daily basis and individual record of what residents have done through the day and this is commended. Due to the disabilities of many of the residents activities are often time spent individually with the resident. Planned activities included chair aerobics, manicure and hand massages, ball games and skittles, bingo, sing alongs, drawing and colouring. Once a month an entertainer came in to sing and a guitar player had also been into the home. It is recommended that the home also pursue activities or interests previously enjoyed by individual residents. There seemed to be no undue restriction on visiting and relatives said they were made to feel welcome in the home. Residents were assisted to get up at a set time in the morning if this would assist their physical condition. However the inspector also saw residents getting up later in the morning and at least one resident had breakfast in bed. Residents said that they could go to bed when they wanted. Meal times were fixed but residents could get drinks and food when they wanted. Residents
Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 14 were told the choices of the meal in the morning so they could make a choice of what they fancied to eat that day rather than the next day. Many of the residents receive assistance from the home to manage their finances. Those that do not are given a lockable store to use. Residents have a choice of food at meal times and can join in or not with activities provided. The home has recently employed a new cook that has appropriate qualifications in both cooking and food hygiene. The food was well prepared and cooked. The choice of the day was between mince, vegetables and potatoes or Cornish pasty with vegetables and potatoes. Residents said that the food was very good. Staff commented on how the cook was now making home made cakes and the residents liked these. The cook is currently reviewing the menus to ensure that the food reflects the tastes of the residents. Halal meat was available for a resident for dinner. The home had good stocks of food. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 15 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) 16 & 18 Procedures for complaints and adult protection investigation were available in the home and this protects residents. The home needed to reissue the complaints procedure to relatives to ensure they are still aware of the process. EVIDENCE: The home and the Commission had not received any complaints about care in this home since the last inspection. The home has a complaints procedure, which despite being available in reception area of the home some relatives had not seen. It recommended that a shortened version be given to relatives. Some details of contact with the Commission needed to be updated. The manager was aware of the recent reissuing of the Birmingham Social Care and Health multi agency guidelines for adult protection and was awaiting delivery of her copy. Staff spoken to had received training on adult protection. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 16 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, 22,24,25, 26 The home had good infection control processes and was clean and fresh. A number of issues with carpets, call alarms and hot water temperatures mean that residents are not in a safe environment. EVIDENCE: The home was clean and fresh during the tour of the building. The home managed this despite it being early in the day before beds had been made in some cases and this is commended. Two bedrooms had carpets that had wrinkles and this was a trip hazard. More rooms had been redecorated as they had become vacant but plans for the outstanding ones must be sent to the Commission. The home had an assisted shower facility made available and had moved a radiator to make the assisted bathroom more accessible since the last inspection. It is suggested on a long-term improvement plan that another
Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 17 assisted bathing facility is added to the home with access to both sides of the bath and so a hoist can be used. Call alarms needed reviewing as only one bedroom had a call lead attached to the alarm. Residents at risk of falling on a night or that wander need a pressure pad alarm by the side of the bed. The call alarm was tested during the inspection and found to be working and responded to in 2 minutes. Lockable stores were only given to residents that manage their own money the home needs to consider that relatives may also want to keep some of the residents’ personal items or documents in the bedroom. One shower in an en suite was not adequately restricted to prevent accidental scalding. Water temperatures through the home were variable. One wash hand basin in an en suite did not have a restrictor and the water was running very hot, in another the hot water was cold. The manager has made a role for a member of staff to monitor infection control in the home. Records are kept of the findings and staff told of any shortfalls and this is commended. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 18 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) 27,28 & 29 The homes recruitment procedure was not robust enough to protect residents. Staffing levels were not always adequate for the needs of the residents. EVIDENCE: The home did not always have available four staff in the morning to provide care for the residents as required by the last inspection. Although the numbers of residents in the home has fallen this is still required because of the dependency levels of the residents. The inspector was made aware that recruitment of staff had been undertaken and further recruitment was continuing. The home stated that currently 57 of staff have attained the NVQ2 qualification. Staff files showed that staff had been employed without the adequate Criminal Record Bureau check. Although in two instances a previous check was supplied these are not transferable. This is of serious concern and legal action may be taken. The qualifications of staff team were not assessed at this inspection and a previous requirement was brought forward. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 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) 31, 33, 35, 38 The management of the home had improved since the last inspection. Clear audit trails and risk management strategies are required to protect residents in all circumstances. Management of resident’s personal allowance was clearly recorded and accounted for and this protects residents. EVIDENCE: The manager of the home had recently completed the NVQ4 management in care and is due to start the Registered Managers Award. The manager has become registered with the Commission since the last inspection. The manager had yet to set up complete audit trails of its service as required. The home had employed the services of a consultant to achieve this and this is a condition of the manager’s registration with the Commission and to be achieved by January 2006.
Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 20 Residents’ individual money spending and receipts held by the manager of the home were checked at the last inspection and found to be satisfactory. On this inspection records held by the homeowner about residents personal allowance as it came into the home from Social Care and Health’s accommodation charges. The inspector looked at how these records matched the manager’s record. These were clearly and satisfactorily held and auditable. Fire drills, training, checks and fire equipment maintenance were undertaken. Fire alarm tests need to state the area of the home tested to ensure rotation of alarm points. Maintenance and inspection of gas, electric, water quality, and lifting equipment was as required. The home had not ensured appropriate risk assessments were in place for fire, building, food and staff. The home was inspected by the Food Safety Department earlier in the year the report was not available. The kitchen was well ordered and clean but is required that fly screens are in place for opening windows and doors and actual fridge and freezer temperatures are recorded. Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 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 x x 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 x 3 2 x 2 2 3 STAFFING Standard No Score 27 2 28 3 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 x 1 x 3 x x 2 Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 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 12(1) & 17(1)(a) schedule 3(3)(m) Requirement Timescale for action 30/11/05 2. op7 3. 4. op7 op7 5. 6. op7 op8 7. 8. op9 op10 All residents must on admission have a nutritional screening to ensure that those residents that have special dietary needs have these described in their plan of care. 13(4)(c) All residents that smoke must have a risk assessment and plans in place that determine how their smoking can be managed safely. 12(1)(a) Care plans for residents must be & 13(4)(c) easily available for staff delivering the care. 15(1) Care plans must show how residents needs are to be met and identified risks minimised. (this remains outstanding since 31/05/05) 15(1) Care plans for two named residents must be devised and sent to the Commission by 15(1) Residents continence needs must be assessed and individual plans devised to ensure a routine to suit the resident. 13(2) A controlled drug cabinet must be purchased and rag bolted to a brick wall. 12(4)(a) The screening in shared room must ensure the same level of
E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc 30/11/05 10/11/05 10/11/05 31/10/05 10/11/05 30/11/05 30/11/05
Page 23 Abbey Park Version 1.40 privacy for each resident. 9. op16 22(7) the registered manager must ensure that the complaints procedure is revised to provide the right information about the Commission and be reissued to each relative. Carpets in two bedrooms must have the wrinkles removed to prevent a trip hazard. Rooms that remain undecorated must identified and given a date for redecoration and this must be sent to the Commission by. All call alarms in bedrooms must be reviewed for: placement next to bed, residents need for a call lead or pressure mat buzzer. all bedrooms must have the availability of lockable stores. (this remained outstanding since 31/12/04) All hot water outlets accessible by residents must be restricted to 43 degrees centigrade. All showers used by residents must likewise be restricted to 43 degrees centigrade. The home must have as a minimum four care staff in addition to manager and ancillary staff hours every morning. (this remained outstanding since 31/05/05) Staff must not be employed with out a CRB police check and POVA check. Any difficulties obtaining thtse must be discussed with the Commission on individual case by case basis. (outstanding since 13/04/04) The registered manager must produce a matrix of the staff training and a copy must be sent to the Commission. 31/10/05 10. 11. op19 op19 13(4)(c) 23(2)(d) 30/11/05 30/11/05 12. op22 13(4)(c) 30/11/05 13. op24 23(2)(m) 31/12/05 14. 15. 16. op25 op25 op27 13(4)(c) 13(4)(c) 18(1)(a) 30/11/05 30/11/05 30/11/05 17. op29 19 schedule 2 08/10/05 18. op30 18(1)(c) 30/11/05 Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 24 19. 20. op33 op38 24(1) 13(4)(c) 21. 22. op38 op38 13(3) 13(3) (This remained outstanding since 15/06/05) The registered manager must develop systems for auditing all areas of the homes service The registered manager must ensure there is a risk assessment for the building, fire, individual staff and food. The registered manager must have a recorded system for ensuring that these assessments are monitored. The Food Safety Report of early 2005 must be forwarded to the Commission by Fly screens must be added to opening windows and doors in the kitchen. Fridge and freezer temperatures in the kitchen must be kept. 31/01/06 10/11/05 10/11/05 30/11/05 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. 3. 4. Refer to Standard op9 op9 op9 op12 Good Practice Recommendations It is recommended that the home keep the latest photocopied prescription together with the relevant Medicine administration record(MAR) It is recommended that a photograph of the resident be kept with the MAR It is recommended that the hoe devise another code for refusal that does get confused with staff signatures. It is recommended that the home explore activities and interests of service users prior to admission and develop an activity section on the care plan of each individual resident It is recommended as part of the homes continual improvement plan that another assisted bathing facility be added that has space to use a hoist. 5. op21 Abbey Park E54 S17004 AbbeyPark V248711 061005 AI Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Birmingham & 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
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