Inspection on 24/09/09 for Belvedere Lodge

This inspection was carried out on 24th September 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Belvedere Lodge 05/10/07

Belvedere Lodge 02/05/07

Belvedere Lodge 27/07/06

Belvedere Lodge 22/11/05

Belvedere Lodge 12/04/05

Belvedere Lodge 08/09/04

Belvedere Lodge 01/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Belvedere Lodge 1 Belvedere Road Westbury Park Bristol BS6 7JG     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Vanessa Carter     Date: 2 4 0 9 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Belvedere Lodge 1 Belvedere Road Westbury Park Bristol BS6 7JG 01179731163 01179691973 sam.hawker@blueyonder.co.uk www.AbleCare-homes.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Willcox Bros Ltd t/a Ablecare Homes care home 20 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: No new residents will be admitted in the OP category The agreed action plan is implemented to agreed timescales Those residents currently acommodated, who do not have a Dementia, may continue to live at the home as long as their needs are met Date of last inspection Brief description of the care home Belvedere Lodge is a care home registered with the Care Quality Commission to provide accommodation and personal care for up to 20 persons aged 65 years and over with a Dementia. Although the registration relates to 20 persons with a Dementia, a condition of the registration permits those persons already accommodated, who may not have a dementia, to remain accommodated in the home, as long as the home can meet their needs. All new admissions will focus on persons who have a Dementia. Care Homes for Older People Page 4 of 27 Over 65 20 0 Brief description of the care home The home is situated in a busy suburb of Bristol convenient to local shops and amenities. It is a period property and adapted to meet the needs of the residents, with provision of a stair lift, ramped access, level rear gardens, and an environment aimed at ensuring those persons with a Dementia feel comfortable. The home is one of six care homes owned and operated by Ablecare Homes. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last inspection of this service was undertaken in October 2007 and our overall judgement about the quality of the service provided for the people who live in Belvedere Lodge was that people received a good service. After that inspection we planned to visit again within two years. In 2008 we completed a service review and were at this time assured that the service was still providing good quality outcomes. Prior to this inspection the registered manager and the director completed the annual quality assurance assessment (AQAA). This is a self assessment document that focuses on how well outcomes are being met. The assessment had been fully completed and told us about those areas where improvements have made over the last 12 months and identified those areas where they felt they could do better. We also sent out survey forms to people who live in the home and to healthcare professionals who are involved in peoples care. Care Homes for Older People Page 6 of 27 During the inspection we looked at records kept by the home, including care records, staff records and those that are kept in respect of the running of the home. We spoke to those staff on duty, the registered home manager and we observed the interactions between the staff and the people who live in the home. We spoke to some of the people who live in Belvedere Lodge and asked them what it was like to live in the there. At the time of this report the fees for placement in the home range between 550 and 600 pounds per week. The fees are dependent upon individuals assessed care needs. Additonal charges may be made for other services and these are detailed in the homes brochure, and can be obtained from the home manager. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 8 of 27 following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 27 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be provided with clear information about the home and the pre-admission assessment process will ensure that any person who chooses to live in Belvedere Lodge will have their needs met. Evidence: The Statement of Purpose and Service Users Guide are both kept under regular review and have been updated as needed. Copies of the documents can be provided by the home manager upon request although a copy of the service users guide is kept in the main foyer. This means that any prospective person who may visit the home or want to live in the home, they will be able to make an informed choice about whether Belvedere Lodge is the right place for them. We received four of our survey forms from people who live in the home - three said they received enough information about the home, the forth was unsure. Before any admission is arranged an assessment will be undertaken, usually by the Care Homes for Older People Page 11 of 27 Evidence: home manager, to ensure that Belevedere Lodge is able to care for the person. We looked at the most recent admission as part of this inspection to check what process was followed. The home uses a good assessment tool that covers all aspects of personal and healthcare support, mobility, mental state, social interests and hobbies, personal safety and risks, religious and cultural needs. The assessment was detailed and informative and included information about the persons family life and social interests. In those circumstances where a person is admitted from further a field, and the home manager is unable to visit, they will gather as much information as possible from family, health and social care colleagues in order to make a judgement. The home provide placement for people who have a dementia on a residential basis. Nursing care is not provided and those who have nursing care needs will be visited by healthcare professionals. Any new person or their relatives are encouraged to visit the home prior to placement being offered. Placements are arranged on a months trial basis with a review of how things have gone, taking place at the end of this period. This will involve all the necessary parties. Care Homes for Older People Page 12 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured that their individual care needs will be met and that they will be treated respectfully and with dignity. Evidence: Three care plans were looked at, including that of one person who had only recently come to live at Belvedere Lodge. The plans record the overall objective of the care plan and specific guidance for the staff on how the persons identified care needs should be met. It was evident that the person is involved, where possible in the drawing up of the plans as they are encouraged to sign their agreement to the plans. The plans contained enough detail to provide a clear picture of the persons needs. The care plans had each been reviewed on a monthly basis although this process had been missed for the last month. The plans are based upon the comprehensive assessment of need that included all those areas as listed in the assessment documents. The plans were well written and gave a clear insight into the persons needs. Care plans are supported by a number of risk assessments, for example in respects of Care Homes for Older People Page 13 of 27 Evidence: the likelihood of falls and nutrition. Staff have attended training sessions and will now ensure that the resident remains at the heart of the risk assessment process. Where staff need to assist with moving and handling tasks, a manual handling risk assessments will result in a safe plan of work being devised. A written record is maintained of any contact with GPs, community district nurses, psychiatric nurses, chiropody, opticians and dentists. The home monitors the body weight of each person on a monthly basis to ensure that nutritional needs are met. Although the monitoring sheets for the three people we looked at showed that these measurements had not been filled in for three months, these records were located and added in. We did not look at the medication systems as part of this inspection but were told that no changes have been made to the procedures followed. We have had no concerns raised by health care professionals about medication procedures. We did look at the medication administration charts and we noted that some drugs had been handwritten on the forms rather than being printed by the pharmacist. This is because it is either a new prescription during the charted period or the dosage has been amended. Handwritten entries must be checked by another member of staff and countersigned to eliminate the chances of any errors being made. During the course of the inspection the staff were heard conversing respectfully with the people who live in the home. Staff were present in the communal areas and there was a great deal of interaction and stimulation. One person became a bit distressed and this was handled appropriately and effectively. The home will continue to look after people who develop end of life care needs and are dying, where this is possible, so ensuring that the person is cared for by staff who are familiar with them. They would need to be supported by the GP, district nursing services and the family, as necessary. The home does not admit people in to the home who are already already at end of life stage. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to participate in a range of different activities both inside and outside of the home and will be provided with well balanced and nutritious meals. Evidence: During the course of the inspection people were involved in a range of different activities that took place- there was a lot more meaningful activity noted than on previous inspections of this home. One person was making use of the garden and said I like to get out in the fresh air every day. Others were watching day time television, listening to music or chatting with the staff or other people who live in the home. One person who was quite unsettled was taken for a walk and returned to the home later in a calmer frame of mind. A record is kept for each person of the activities that they have participated in and they are able to choose what they would like to do. A variety of external entertainers visit the home on a monthly planned basis and other activities are arranged as and when, and maybe on a one to one basis. We were shown photographs of some of the activities that have taken place this year - for examples trips out to the seaside, the Downs and to a local pub. There were also photos of several of the people and staff members planting up the tubs for the back garden. All four people who completed our survey forms said that there was always or usually activities arranged that they could take part in. A number of people prefer to spend Care Homes for Older People Page 15 of 27 Evidence: their time in their room and do not use the communal areas at all. As part of the assessment process each person, or their family, is asked about social interests, hobbies and past times. This information however does not appear to be used to formulate any activity plan and could be a missed opportunity in satisfying peoples social needs. The home produces a regular newsletter and one will be displayed on the noticeboard in the hallway. The letter refers to events that have taken place and those that are planned. The director visited with their dog during the inspection, and this created a great deal of interest for many of the people who liked to stroke the dog and fuss over it. People who are able to, wander around the house and the garden as they wish. Some people were still finishing their breakfast at the start of the inspection. People are able to choose where they spend their day time. People are able to make choices about what time they eat and where they spend their time. Care planning documentation makes note of the preferred time of getting up and going to bed for each person (usual preferred routine). The home has an open visiting policy and visitors can come and go at any reasonable time. There were no visitors to the home on the day of the inspection. The home has a four week planned menu and people are provided with a varied and balanced diet. We did not look at the menus during this inspection and were told that seasonal changes are made. People are asked what meals they would like to have served. Following this suggestions are trialed - some are successful, others are not. The four people who returned our survey forms said the meals were always or usually liked. Specific dietary needs will be catered for as necessary and the home manager explained how they were meeting the needs of one specific person. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured that any complaints they have will be listened to and acted upon and that they will be safeguarded from harm. Evidence: The homes complaints procedure is included in the homes statement of purpose and a copy is displayed in the hallway on the notice-board. Those people we spoke with during the course of the inspection said they were happy and contented - everyone is so kind here - and that they would talk to the staff if they were unhappy. The four people who completed our survey forms and said that they knew how to make a formal complaint. We have received one complaint about this service. In this instance we asked the home manager to deal with the complaint following their complaints procedure. We were advised that this was dealt with appropriately. The home maintains a log of all complaints and compliments received. We noted that there was a number of compliments on file. The home manager has dealt with two complaints since June 2008. The records evidenced the actions that had been taken in dealing with the issues raised. The home has policies and procedures in place to ensure that people are safeguarded from any form of abuse. The staff team have attended safeguarding of vulnerable adults (SOVA) training and Bristol City Council No Secrets guidance is available for staff to refer to. Two staff members were spoken with during the course of the Care Homes for Older People Page 17 of 27 Evidence: inspection and demonstrated a clear understanding of safeguarding matters and of their responsibilities. The home manager has previously demonstrated a full understanding of her responsibilities in safeguarding those people who live in the home. Care Homes for Older People Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Belvedere Lodge is a comfortable, safe and well maintained home. Evidence: Belvedere Lodge is a three storey end-of-terrace Victorian property. It has been operating as a care home since 1983 when the Willcox family set it up. There is a small garden area to the front of the property, laid to well established shrubbery. The gardens to the rear of the home have been re-designed and a pathways now enables people to wander in the garden, there is lighting and a water feature and a summer house. I love going out in the garden and we helped plant those flowers were comments made. The communal rooms are all on the ground floor. There are two lounges, one large and one small, and a separate dining room. All rooms are well decorated and furnished appropriately - the home benefits from regular upgrading as a smart, comfortable and clean environment is important to the service providers. The large lounge is set up mainly for the use of the TV and music, whereas the smaller lounge is a much quieter room. Stairs lead down to the basement area where the kitchen is located and where three of the bedrooms are located. People who are accommodated in these rooms will need to be fully mobile as they must be able to use the stairs. There are two toilet rooms located near the communal areas, for one there is a small Care Homes for Older People Page 19 of 27 Evidence: step to negotiate. There are also two shower rooms, one assisted bathroom and two other ordinary bathrooms located throughout the home. One of the shower rooms has been converted in to a wet room since the last inspection. Stairs from the main hallway lead up to the remainder of the home - they are wide and a stair lift is installed that provides access to the top of the house. Some people are able to walk up and down the stairs and are not impeded by the stair-lift, as the staircase is wide and handrails are fitted both sides. The majority of bedrooms are located on the first and second floors, but two are accessed from the half-landings. The home has a variety of equipment installed in the home to aid the people who live there. There are grab rails at various locations throughout the home, a swivel bath seat is installed in one bathroom, and raised toilet seats fitted to a number of the facilities. A number of people need to use walking frames to get around. The owners are fully aware of the need to purchase additional equipment, as and when necesary to meet the needs of older and frailer people. Some of the bedrooms have en-suite facilities - either a toilet, or a toilet and wash hand basin. There are two shared bedrooms. A number of the bedrooms are smaller than the national minimum standards, but are exempt from these minimum spatial requirements as the homes was registered before these were set. Some rooms have door guards fitted so that doors can be left open, and some have door alarms fitted so that night staff will be alerted to any person who may wander at night. People are encouraged to personalise their rooms as they wish and can bring in mementos and small items of furniture. The home employs a cleaner who works each weekday, but there are plans to recruit additional staff to raise standards. We were told that several relatives have expressed concern about the cleanliness of the home at times and that the cleaner needs to be carefully monitored to ensure the job is carried out effectively. One person wrote on our survey form I am not always very happy with the way the cleaning and the laundry is attended to. On the day of inspection the home was clean, tidy and there were no unpleasant odours. The laundry facilities are sited in an attached building to the rear of the house - all care staff undertake laundry duties. Care Homes for Older People Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be looked after by staff who have worked in the home for a long time. They are well trained and competent. Evidence: There has been little change in the staff team at Belvedere Lodge since the last inspection meaning that the team is well established. This means that people will be looked after for by staff that are familiar with their needs. There is no use of agency staff and any vacant shifts are covered by the existing staff team. The team is made up of the home manager, senior care assistants, care assistants, one cook and a domestic. An apprenticeship scheme is provided that enables young people under the age of 18 to be employed and to gain caring experience whilst completing their National Vocational Qualifications (NVQ). We were told that the staffing numbers are arranged to take account of the collective dependency levels of the people living in the home. The home has 11 permanent care workers and four have achieved a NVQ level 2. The home manager is in the process of completing the Leadership and Management course whilst two staff members are enrolled on the NVQ level 3 in health and social care. One member of staff spoken with during the inspection said they had worked at the home for a number of years but have as yet not considered doing NVQ training. The home continues to show real commitment to having a trained workforce and needs to Care Homes for Older People Page 21 of 27 Evidence: work towards having a 50 ratio of the workforce with an NVQ at Level 2 or equivalent. People are cared for by competent, skilled staff who are able to meet their needs. There has been only two new members of staff recruited since the last inspection. Their recruitment files were examined in order to determine the processes the home use in employing suitable staff. The home follows safe vetting and recruitment procedures, by asking for a written application form to be completed, two satisfactory written references and CRB and POVAfirst checks prior to employment starting. The home has a training plan for all six Abelcare Homes that includes mandatory training such as manual handling, food hygiene, first aid, safeguarding adults and fire awareness plus other relevant training such as dementia awareness, activities for the elderly, risk assessment, mental capacity act (MCA) and deprivation of liberty safeguards (DOLS), and managing medications. The induction-training programme for new recruits meets Skills for Care Common Induction Standards. The sample of staff training files that were looked at were all in order and evidenced that the staff team have attended a range of different training courses. Managers from other Ablecare Homes will provide some of the training, for example safeguarding adults and manual handling. Care Homes for Older People Page 22 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Belvedere Lodge is well managed and has clear leadership. The home is run in the best interests of the people who live there and their safety can be assured. Evidence: The registered manager is Mrs Vanessa Kilfoil. She has worked at the home for many years, previously being the deputy manager. She has completed part of the Leadership and Management award and expects to finish this in 2010. She is responsible for the day to day management of the home and is supported by the care team, a Director of Ablecare Homes and the other home managers in the Ablecare Homes group. Regular Home Manager meetings are held. The home undertakes an annual service satisfaction survey. The results of the last survey completed in 2009 were included in a report along with an action plan to address those issues raised. We saw that people are asked about meals and meal time arrangements, activities, the surroundings, aids and adaptations, and complaints or comments. Relatives are also included in this survey. We were told that menu Care Homes for Older People Page 23 of 27 Evidence: suggestions had been implemented, that suggestions for outings had been actioned and that a new TV was to be purchased. The Director makes regular unannounced visits to the home. This evidences how the home monitors the quality of the service and ensures that people are satisfied with the service they are receiving. The home has procedures in place to look after monies for a number of people but the records were not checked on this occasion. The home have previously demonstrated that they have good accounting systems in place. All staff receive formal supervision. The records were seen and evidenced that this is done on a regular basis - work performance and any training and development needs are discussed. A look at the fire safety records evidenced that the staff team has attended fire drills and training at regular intervals. The checks on the equipment and alarm system have all been completed at the appropriate intervals. The manager has retained responsibility for fire safety in the home and has attended fire warden training. No health and safety concerns were raised as a result of this inspection. Although the homes maintenance records were not checked on this visit, these have previously always been in order. Care Homes for Older People Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 Hand written enteries on MAR sheets must be double signed, to check the details and to eliminate the chance of an error being made. Peoples personal preferences are interests should be incorporated in to a plan of activities either on an individual or group basis. Continue working towards achieving a 50 ratio of staff who have at least an National Vocational Qualification in health and social care at Level 2. 2 12 3 28 Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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