Care Home: Autumn Vale Care Centre

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What the care home does well One person living in the home when asked; `what does the home do well?` answered "all of it". Several people answered `nice food`, `nice care staff` `good activities` and a health and social care professional assessed that the home provided; "lovely accommodation and a calm environment". The following comment from the main carer of a person living in the home perhaps best sums up the overall feedback received; "We judge this home to be outstanding" As a new home the built environment is indeed outstanding and provides pleasant, comfortable and spacious accommodation for the people who live there. The standard of record keeping found was good supported by an effective care planning and quality monitoring systems and procedures. People living in the home were very positive about the standard of care and nursing staff; "The always have a smile when they come in" was one comment. In turn the care staff were very positive about the standard of management in the home and the support and training they receive. "I love working here" and "It is a privilege to work here" were just some of the comments received. What has improved since the last inspection? This is the first inspection of this service since in was registered in July 2009. What the care home could do better: A consistent `complaint` by care staff was the restricted size of the staff room. This could become even more of an issue when the home becomes fully staffed. One service user indicated that they would like more opportunities for walking outside of the home on a one to one basis with a care worker, in general however there were few even remotely negative comments received. One person when asked what the home could do better observed that; " don`t know, the sun doesn`t always shine" One health and social care professional observed; "The unit is not full, it is to be hoped that staff cope as well when numbers increase" and that will be the main challenge to Autumn Vale in the immediate future, to maintain the high standard it has achieved when the home is at full capacity. One significant answer provided to the question; `What could the home do better` was; "The quality of care at the home has well exceeded our hopes and expectations". Key inspection report Care homes for older people Name: Address: Autumn Vale Care Centre Danesbury Park Road Welwyn Herts AL6 9SN     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jeffrey Orange     Date: 1 0 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. Care Homes for Older People Page 2 of 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC 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: Autumn Vale Care Centre Danesbury Park Road Welwyn Herts AL6 9SN Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Debra Kathryn OHare Type of registration: Number of places registered: care home 69 autumnvale@goldcarehome.com www.goldcarehomes.com GCH (Heath Lodge) Limited Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 69 The registered person may provide the following categories of service: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Date of last inspection Brief description of the care home Autumn Vale Care Centre was first registered with the Care Quality Commission (CQC) in July 2009 and is registered as a 69 bed care home for people with nursing needs, ademntia or an early onset dementia. Autumn Vale Care Centre is a newly built care home and comprises two care units Care Homes for Older People Page 4 of 27 Over 65 0 69 69 0 Brief description of the care home linked by a central building. One unit will accommodate 33 people with dementia the other 36 people with nursing and physical needs. The home is situated on the outskirts of Welwyn, Hertfordhsire in a rural but accessible location. The home has a comprehensive brochure, including a statement of purpose and service user guide, along with an informative question and answer document that addresses some frequently asked questions about residential care. Details of individual costs are available from the home as are copies of the latest inspection report by the CQC. 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: This is the first inspection of this service since it was registered in July 2009. Throughout we have taken account of the information provided by the service in the course of their registration. The CQC operates a rules based approach to help ensure transparency and consistency in its regulatory activity. The overall quality rating rules are available to providers of care services through the CQC website @ cqc.org.uk As this is the first key inspection of Autumn Vale following registration, the overall quality rating rules stipulate that it could not be rated as excellent as it lacks a track record of performance over time. This unannounced inspection was carried out by one inspector, where this report refers to we, it recognises that it is written on behalf of the CQC. Care Homes for Older People Page 6 of 27 The inspection visit took place in the morning and went through to the afternoon, which gave opportunity to observe the morning routine of the home as people living there were being helped to get up and ready for the day ahead and also to observe the lunch and early afternoon routines. We were able to speak to some of the people who live in Autumn Vale and to family and other visitors to the home. We spoke to staff working in the home and to the homes manager and the area manager for Goldcare. We also looked at some key records, including those for staff recruitment and training, medication administration and care plans. We have received a large number of surveys returned to us from people living in the home, staff working in the home and from health and social care professionals associated with the home. The home also sent us their annual quality assurance assessment or AQAA. The AQAA is a self-assessment document that focuses on how well care outcomes are being achieved for people living in Autumn Vale. It also includes some useful statistical information, for example about staff training and complaints. Care Homes for Older People Page 7 of 27 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 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Care Homes for Older People Page 8 of 27 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 are only admitted to Autumn Vale after a thorough and detailed assessment process has determined that their individual needs can be fully and appropriately met. As part of the admission process they will be given comprehensive information, in an appropriate format and will be encouraged to visit the home. Evidence: When we asked people living in Autumn Vale if they had received enough information before they moved in to help them decide if it was the right home for them, 65 said that they had, 15 said that they had not and 20 did not know. When we asked if they had a contract covering the terms and conditions of their stay in Autumn Vale, 55 said that they did, 10 that they did not and 35 did not know. When we looked at the information provided for people who may be considering Care Homes for Older People Page 11 of 27 Evidence: Autumn Vale as a home for themselves or someone for whom they are responsible, we found that it was very comprehensive and clear, was presented in a format that is attractive and includes a series of frequently asked questions with clear answers, for example about mealtimes and their ability to bring their own furniture into the home if they want to. The information seen included clear guidance about the costs of accommodation and care and what factors affect charges. The documentation includes a commitment to take full account of the diverse cultural needs of people considering Autumn Vale as their home. This demonstrates an appropriate priority on the part of the home to diversity and equalities issues and responsibilities of care providers. When we looked at pre-admission assessments for some of the people who have recently moved into Autumn Vale we found that they were comprehensive and included the information required to ensure that only those people whose care needs can be met in a way that takes full account of their individual circumstances, preferences and life history are admitted into the home. When we spoke to some of the people visiting their relatives during the inspection they told us that they had been able to visit the home prior to the admission of the person they were responsible for in order to assess its suitability. One person told us; They were very helpful and answered all our questions and put us at ease. In their AQAA the home confirm that their Statement of Purpose is available in large print, braille and different languages on request. 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 who live in Autumn Vale can be confident that they will receive effective health and personal care support, in line with their expressed preferences and that they are protected by effective and accurate systems for the administration of medication. Evidence: When we asked people living in Autumn Vale if they received the care and support that they needed, 79 said that they always did, 16 that they usually did and 5 that they sometimes did. When we asked if care staff listened to them and acted upon what they said, 68 said that they always did, 21 that they usually did, 5.5 that they sometimes did and 5.5 that they never did. When we asked people living in the home if they got the medical care they needed, 80 said that they always did, 15 that they usually did and 5 that they never did. The staff have been outstanding in their personal care and support, The staff Care Homes for Older People Page 13 of 27 Evidence: consistently demonstrate great skill matched by quality care that respects individual choice and dignity were some comments made on behalf of one person living in the home. When we asked health care professionals that visit the home to treat their patients, they told us that the social and health care needs of people living in the home are usually properly monitored, reviewed and met. When we looked at care plans we found that they were especially well constructed, comprehensive and clear. They were being completed appropriately and included details of how people receiving care preferred their care to be given, for example in terms of bathing routines and frequency, gender of care workers and other personal care routines. This together with the personal life history information obtained by the home during the assessment process and thereafter, enables care to be individualised to take account of the individuals background, preferences and culture. The care plans we saw provided evidence of the involvement of a range of health care professionals with people living in the home and also access to community healthier facilities and services such as chiropody, dentistry and opticians. When we observed care throughout the inspection we found that overall the standard seen was high and demonstrated appropriate respect and concern for the dignity of people living in the home by care staff. When we spoke to care staff, we found that they had a good understanding of the person centred philosophy of care and were aware of the need to adjust the routine of the home to suit the individual wherever possible, rather than the other way around. When we checked the medication records and administration records we found that these were basically sound and accurate. Where there were any slight concerns about practice, for example the time lapse between administration and recording of medication or the over-stocking of some creams, we were assured that this would be corrected. 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 living in Autumn Vale can be confident that they will be encouraged and enabled to exercise choice in and control over their lives including their activities and daily routines and that they will be able to build and maintain contacts with family, friends and the community. Evidence: When we asked people who live in Autumn Vale if there are activities arranged for them to take part in if they want, 58 said that there always are, 21 that there usually are, 16 that there sometimes are and 5 that there never are. When we asked if they liked the meals at the home, 60 said that they always did, 25 that they usually did and 15 that they sometimes did. People who live in the home told us; We have some nice activities and The hairdresser is good. When we spoke to the activities co-coordinator we were impressed by the range of activities on offer and the enthusiasm of the activities staff. We saw people who live in the home being encouraged to consider going out in the mini-bus that had been Care Homes for Older People Page 15 of 27 Evidence: arranged for that day. In response to some late changes of mind the organiser was trying to adjust the days programme to meet their revised requirements. When we looked at documentation used in determining activities we found a good level of life history and personal information to inform decisions. For example someone living in the home who had an interest in joinery had been asked to help make a bird table for the home. In their AQQA the home identifies as one of the things they could do better; We would like to further improve on our social activities for all residents, especially those with dementia and we need to raise the awareness of all staff to ensure that they know what an activity is. This is a positive approach to the development of activities in the home and is supported by the homes membership of a nationally recognised organisation that promotes best practice in the provision of activities in care settings. When we looked at care plans we found clear and detailed residents choice forms, setting out for example when people prefer to get up and go to bed, what they like to wear in bed, whether they want the door open or closed and the light on or off. We saw copies of minutes of recent residents meetings and also relatives meetings which provide opportunities for passing information and hearing views and suggestions about the daily routines of Autumn Vale. We observed the lunch in one part of the home and saw that it was a sociable occasion, with care staff offering assistance where required in a discrete and sensitive manner. When we spoke to people visiting the home they told us that they were always made to feel welcome and that they did not feel that there were any unreasonable restrictions on their visits. 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 who live in Autumn Vale have the necessary information to enable them to make a formal complaint if they want to, although in most cases they prefer to use informal ways to raise any concerns they may have. They can be assured that care and nursing staff have the training they require to help protect them from abuse and to take appropriate action if abuse was seen or suspected. Evidence: When we looked at the documentation provided to people living in or considering Autumn Vale as their home we found that full details of the complaints policy is included. However when we asked people who live in Autumn Vale if they knew how to make a formal complaint only 55 said that they did, with 45 saying they did not. When we asked if there was someone they could speak to informally if they were not happy 85 said that there was with only 15 saying there was not. This suggests that the formal process is less well understood than the informal one. In their AQAA the home informed us that there have been no complaints received. One complaint raised with the CQC was dealt with at area manager level and did not appear in the complaints statistics of the home at the time the AQAA was completed. That complaint was dealt with satisfactorily and the complainant indicated that their concerns had been addressed and that in their view the homes performance in that respect had improved. When we looked at staff training schedules we saw that the safeguarding of vulnerable Care Homes for Older People Page 17 of 27 Evidence: adults training is undertaken regularly by staff and when we spoke to care staff they were aware of what constitutes abuse and the correct action to take if it were to be seen or suspected. This means that people living in Autumn Vale can be confident that care staff should be alert to any instances of abuse were it to take place and that appropriate action would be taken to protect them if it were seen. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Autumn Vale provides a safe and comfortable environment for the people who live or work there. Evidence: When we asked people living in Autumn Vale if the home was fresh and clean, 89 said that it always was and 11 that it usually was. Throughout the inspection we found that the home was clean and tidy with no obvious problem with odour. One person we talked to with their family told us that they had been able to reconfigure the furniture in their room to accommodate some personal items; It is very comfortable, I have everything just as I want it was the comment as a result. Another person noted; The physical standard of provision is the highest I have seen. it is kept remarkably clean and fresh As a new build, the environment reflects current best practice, for example in the choice of colours and furnishings for people living with dementia. In their AQAA the home informed us that major home audits are to be carried out three times a year, and that any concerns with the environment arising from those will be addressed in action plans. Care Homes for Older People Page 19 of 27 Evidence: The home has a sensory garden and patio area that people living in Autumn Vale can access readily, weather permitting. There is now a shady walk through trees to make a pleasant and safe paved pathway for people who like walking in the open air. The only negative comments received about the home came from staff surveys which suggested the staff room was too small. 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 who live in Autumn Vale can be confident that they will be supported by appropriate numbers of staff who have gone through a rigorous recruitment process and who receive the training and support they need to achieve good care outcomes for them. Evidence: The staff consistently demonstrate great skill matched by quality care that respects individual choice and dignity is the assessment made by the main carer of someone who lives in the home and who is a daily visitor and therefore has the opportunity to observe care at different times of the day with different care staff. That view was supported and confirmed by comments received in our own surveys and by our own observations during the inspection site visit. Staff training schedules seen provide evidence of a good range of both basic training and more specialist training that should ensure that the skills and qualifications of care and nursing staff meet the needs of people living in the home effectively. When we talked to staff or received surveys from them they told us that they are provided with excellent opportunities for training. We did not receive any adverse comments at all about staffing levels and from the Care Homes for Older People Page 21 of 27 Evidence: care outcomes we saw, for example response times to call bells, meal times and activity support by care staff it appears that the current level of staffing is adequate for the current number and dependency of people living in the home. When we looked at staff recruitment records we found that all the checks required to protect people who live in the home were in place and that recruitment policies and procedures were followed robustly. When we asked care staff if the home had carried out criminal records bureau checks and taken up references before they started work, they all replied that they had. When we spoke to care staff and looked at the schedule for completed and planned supervisions we found that care staff are provided with the support they need to provide a consistently high standard of care. The positive nature of comments made by care staff both in face to face interviews during the inspection and also in surveys returned to us were exceptional. It is a lovely place to work, The teamwork is marvellous It is a wonderful place to work, much better than the home I worked in before are only some of the many comments received. All of the information gained during this inspection process suggests that Autumn Vale has a well trained and supported staff team, who feel positive about their work, and the evidence seen supports positive comments received from people living in the home and those responsible for them about the standard of care provided. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live or work in Autumn Vale benefit from it being well and effectively managed. Evidence: The manager listens to staff and always has time to help us, The manager is supportive and responsive, The manager is very professional and ensures Autumn Vale runs well are some of the comments received from staff about the homes manager. The assessment of the CQC of the current manager, reached during their registration application in October 2009 was; She has the necessary knowledge of relevant regulations and national Minimum Standards and demonstrated a sound working knowledge of equality and diversity issues as well as safeguarding adults procedures We found that the management of the home is well-resourced and that the manager is given the support and assistance she requires by the responsible individual and the Care Homes for Older People Page 23 of 27 Evidence: Goldcare board to enable her to direct the activities and development of the home effectively. When we spoke to the administrator responsible for dealing with the financial records of people living in the home we found that they had a good understanding of the safeguarding implications of their role and we found that there is a robust, wellaudited system in place to protect the financial interests of people living in the home. We found that the AQAA was well-completed and represented a realistic self-appraisal of the the homes operation, how well it has achieved outcomes and how these could be improved in the future. Although only operational for a short time, the home has already undertaken some quality assurance work with people living in the home and has undertaken meetings for both relatives and people who live in the home. Care plans contain an extensive range of risk assessments that are being kept under review and revised as necessary. Staff spoken to, staff surveyed and supervision records seen all evidence that staff are being provided with regular supervision and support to help them fulfil their roles effectively. The standard of record keeping is generally good and provides staff and management with accurate information which is subject to evaluation and review to ensure it continues to meet their needs and support them to provide good, safe and effective care and management outcomes for people living in Autumn Vale. 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 16 The manager should consider how informal concerns or complaints can be recorded so as to enable any patterns or trends to be identified and addressed. This is particularly important given that people have indicated they are more likely to raise concerns informally rather than through the formal complaints process. Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 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) Care Quality Commission (CQC). 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. 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