Care Home: Henrietta House

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What the care home does well Residents expressed a high level of satisfaction regarding the quality of care and support they receive. Their views including staff and visitors have been reflected in the report. The assessment and admission process is very good and this ensures that the resident`s needs are fully met on admission to the home. The care plan is of a good standard and reflect how identified needs are being addressed. The implementation of health and personal care needs are being monitored internally through a monthly review system, which involves the resident and their representative. Activities offered are wide ranging and this ensures a high level of stimulation for residents, which promotes their development and welfare. Quality and diversity issues are being well promoted and residents are treated with respect. `I have lived at two other homes previously but the staff here are courteous and the best`, reflected a resident in their survey. The staff members on duty were very positive about different aspects of their work and they are well supported. All staff members complete in depth training when they first start working at the home. This gives them information and knowledge about safe working practises, about older people in particular. Staff receive regular supervision. Care and staff management systems including health and safety are being implemented effectively. The service is being managed very well. What has improved since the last inspection? There was one requirement and one recommendation arising from the last inspection report dated 31 May 2007. These have been implemented. Evidence demonstrates that the overall standard of care and support for the residents has continued to improve, a view echoed by the manager, staff, residents and all visitors spoken to. The service clearly meets the residents` needs and requirements, and respect their wishes. In the main, there is clear evidence to indicate that the quality of service provision for residents has been maintained to an excellent standard. What the care home could do better: There is one requirement and one recommendation arising from this inspection report, which need addressing. Requirement: The manager must ensure that all staff receive training in the Mental Capacity Act and how it affects their work. This is so that they comply with it and ensure the protection of residents. Recommendation: The monthly review notes should include the full name and signature of the staff member undertaking the monthly reviews. Key inspection report Care homes for older people Name: Address: Henrietta House 3 Dynevor Road Bedford Bedfordshire MK40 2DB     The quality rating for this care home is:   three star excellent 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: Neil Fernando     Date: 2 5 0 3 2 0 1 0 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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: Henrietta House 3 Dynevor Road Bedford Bedfordshire MK40 2DB 01234359194 F/P01234359194 lansgladehomes@btconnect.com www.lansgladehomes.co.uk Lansglade Homes Limited care home 25 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home The home is registered to provide care for up to twenty-five older people who may also have dementia and/or physical disabilities. Langsglade Care Homes Ltd is the registered provider. Henrietta House is a large double fronted Victorian building located in a pleasant residential area of Bedford. The property is within walking distance of the town centre and local amenities, including the train station and various bus routes. The home has a large and attractive garden at the rear. Parking spaces for a few vehicles is available at the front of the house. The accommodation has been suitably adapted to meet the needs of frail people and is arranged over three floors. The home has twenty-three single rooms, two with en-suite facilities, and one room for shared Care Homes for Older People Page 4 of 27 0 0 0 Over 65 25 25 25 Brief description of the care home occupancy. A large lounge and a large dining room are situated on the ground floor of the property, as is a smaller lounge/diner. Toilet and bathing facilities are located for convenient access through out the building. The building is attractively decorated and well maintained. The home has a very welcoming atmosphere, with a strong emphasis on Henrietta House being a home and on respecting individuals rights. The fees for this service vary between £500 and £520 per resident, per week. 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: three star excellent 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 quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. We, the Care Quality Commission, undertook this unannounced key inspection on 25 March 2010. We spoke with the manager, 8 residents, 4 care staff and the head cook, and 6 visitors including a GP. We had a look round the home and viewed a range of records the home must keep. At the time of the visit, there were 25 residents accommodated with no vacancy. We have received a completed AQAA (Annual Quality Assurance Assessment) a document, which gives the manager the opportunity to tell us how the home is meeting the standards and regulations. We have also received surveys from 10 residents and 7 staff. Care Homes for Older People Page 6 of 27 The last key inspection was carried out on 31 May 2007 and the last annual service review was undertaken on 21 April 2009. The manager was present throughout the inspection. One of the directors was present during feedback at the end of the inspection 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: There is one requirement and one recommendation arising from this inspection report, which need addressing. Requirement: The manager must ensure that all staff receive training in the Mental Capacity Act and how it affects their work. This is so that they comply with it and ensure the protection of residents. Recommendation: The monthly review notes should include the full name and signature of the staff member undertaking the monthly reviews. Care Homes for Older People Page 8 of 27 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. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The comprehensive assessment of needs for the prospective resident ensures that the home only admits people whose identified needs are achievable. Evidence: The home has an up-to-date statement of purpose and a service users guide to the home. A copy of the guide is made available to the prospective resident, their representative and professionals, as appropriate. This is displayed in the hallway and a copy was seen in all the eight bedrooms viewed. Case files for three residents, including one person who was recently admitted to the home were examined. They all contained comprehensive pre-admission assessments completed by the manager and dated and signed, prior to an offer of a placement being made. Each file provides detailed information of the residents identified needs and the level of support required. This includes pressure care, mobility, history of falls, continence, medication usage, mental health, personal safety and risk, personal care Care Homes for Older People Page 11 of 27 Evidence: and well being, recreation, culture and religion and personal preferences. Information about the prospective resident is also sought from their representative, health and social care professionals. Three staff said that prospective residents and their representatives are actively encouraged to visit the home before reaching a decision that the facilities offered are suitable for them. Two residents and two relatives confirmed that they and their family had had the opportunity to visit the home to assess the facilities offered, prior to moving in. Staff and the manager were so helpful when we first visited the home said a resident. However, the Manager makes the final decision, based on the identified needs of the prospective resident, whether a suitable placement could be offered. There is documentary evidence to show that the resident and their representative is given a copy of the placement agreement, at the time of the admission or soon after. 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. The health and personal care needs of residents are being identified and addressed, and they were being treated with dignity and respect. Their involvement in the care planning and review process ensures they are at the centre of attention. Evidence: The manager reported that all residents have a current care plan. Four staff members interviewed confirmed that care plans are drawn up by the home management team in consultation with the resident, their representative and other professionals, as appropriate. Evidence shows that the needs of residents are being identified and addressed well. The care plan indicates how the identified needs are to be met. Staff members record the care given, progress made and interactions with other people. Identified health care needs are being addressed and observations are maintained, in order to respond to any changes, as noted from the records viewed. Residents are encouraged to sign their care plans where this is appropriate. Residents spoken to provided some good examples of how staff help them daily. They are very helpful, my key worker in Care Homes for Older People Page 13 of 27 Evidence: particular, said a resident. Care plans are being reviewed monthly to reflect the changing needs and objectives for health and personal care. Review notes are maintained and reflect the initial of the staff undertaking the review. It has been recommended that the notes should include the full name and signature of the staff member undertaking the monthly reviews. The procedure on medication is comprehensive; only seniors including designated night staff who are authorised to administer medication. They have all received training in the administration of medicines. Currently, no resident administers their own medicines although this could be arranged following an assessment of any risk involved. Medication administration records for eight residents were checked and found to be in order. I receive my tablets regularly, said a resident. Residents have access to District Nurses as and when needed and those who are incontinent have appropriate incontinence aids available. They are registered with a GP from various group practises. Other professionals, residents have access to include Dentist, Optician, Podiatrist, physiotherapist and Dietician. Preferred terms of address are recorded on the care plans. The privacy and dignity of individuals is considered to be of paramount importance and staff are instructed to treat residents with respect from their first induction onwards. Any medical examinations are conducted in the privacy of the residents own bedroom. I always see the resident in their own room, reported a visiting GP. There is only one shared bedroom and Screen is provided. The home operates a knock and wait policy on entering residents bedrooms and sanitary areas. Residents spoken to confirmed that staff members treat them with dignity and respect at all times. All, simply courteous, said a resident and Staff are always polite and welcoming, reflected a visiting relative. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have the opportunity to participate in a range of activities that develop and enrich their social and personal lives. Evidence: The care plans for three residents were examined; they show that residents are being assisted to follow the lifestyle of their choice as discussed and agreed at the time of their assessment. Six residents spoken with said they are very satisfied with their lifestyle at Henrietta House. The AQAA tells us Our philosophy is that every resident is a unique individual with individual views, wishes and needs. Therefore, the daily lifestyle in the home is arranged to support individuals needs and to meet their preferred lifestyle where this can be met within their capabilities. Daily routines are flexible to reflect these needs and wishes with the most organised events of the day being around mealtimes and opportunities to participate in-group activities. The routines of daily living are made as flexible as possible to suit the needs and choice of individuals. Representatives of different faiths visit the home regularly so that residents can attend services and speak with the representative of their choosing about their spiritual needs. There is a number of experienced staff from different cultural backgrounds and they bring a wealth of knowledge, and promote the equality Care Homes for Older People Page 15 of 27 Evidence: and cultural diversity of the people who use the service. There is an activities programme in place. There is good evidence to show that residents are being encouraged to continue to participate in various activities of interests or hobbies they may have had before. Staff are also clear that they would certainly respect the residents right to decline to participate in any activities offered. Residents are encouraged to be proactive in their views about the services offered and make suggestions about improvements or new initiatives. Residents and their representatives are encouraged to complete an annual customer satisfaction questionnaire. Social and recreational activities are arranged either individually or in small groups taking into account the weather for example, or the expressed wishes of the residents. Outside entertainment is planned at regular intervals and residents are informed well in advance. Social events and trips out are offered to residents at various times of the year. Excellent level of activities offered here and I thoroughly enjoy myself, There is always some form of events taking place and Good amount of activities all the times, are examples of comments from residents. Surveys received from ten residents also indicate a high level of satisfaction with respect to activities offered to them. Visitors are welcomed into the home. Residents spoken with said that their visitors could come into the home at anytime. Five visiting relatives and one professional remarked on the welcome they receive and confirmed that there are no restrictions on visiting. Staff are courteous and always welcoming, said a visiting relative. Evidence shows that as well as being information obtained as part of the admission process, residents culinary likes and dislikes are taken into account in the preparation of menu. The cook consults residents daily, in order to ensure that their preference is catered for. Hot and cold drinks are served throughout the day and mealtimes are seen as a social occasion. Lunch was observed and food served was well presented and of good nutritional value. Staff members were observed to be sat next to residents and assisting them in an unhurried manner. We spoke with the cook and she is very knowledgeable about the dietary needs of the residents, which appeared to be well met. Residents were consistent in their views that the variety and quality of food offered to them is of a high standard. I have eaten here as a guest and the food is very good, said a visiting relative. 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. Information on how to make a complaint is available and residents felt empowered to raise any concerns to staff. The protection systems in place are robust to ensure the safety of residents. Evidence: The procedures on complaints are available and accessible to all staff members. Staff members interviewed reported that they have received training on this subject; they also demonstrated a good understanding of the procedures and their responsibilities towards ensuring that any complaint is dealt with quickly and satisfactorily. Residents spoken with reported that they are regularly encouraged to raise any concerns or complaints they may have about the services they receive. Many residents spoken with echoed confidence, in that they would not hesitate to speak with a member of staff or the manager, if they were dissatisfied with any aspect of the service provision. The complaints record indicates that there has been only one complaint made to the home since the last inspection in May 2007. The complaint was resolved speedily and satisfactorily. The home has comprehensive procedures on the protection of vulnerable adults, which were reviewed in January 2010. The Whistle Blowing policy is also available to the staff team. Staff spoken to demonstrated an understanding of the above procedures. The manager reported and staff members confirmed that they have received training on the protection of vulnerable adults, a subject also covered by those members who Care Homes for Older People Page 17 of 27 Evidence: have completed their NVQ assessment. Record viewed indicates that there has been one safeguarding matter referred to the local safeguarding team since the last key inspection of this service. There are good systems in operation, which should adequately protect residents. 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. A rolling programme of maintenance ensures that the physical environment remains comfortable, homely and safe. The standard of house keeping was high and residents appear to appreciate and enjoy the physical environment. Evidence: We undertook a brief tour of the premises. The communal areas and bedrooms are decorated and furnished in a style to reflect the period features of the building. Bedrooms are personalised to suit the taste and preference of the occupants. There is adequate space for residents to sit quietly and or meet with their visitors. The bathroom and toilet facilities have been adapted to meet the needs of people with a physical disability. Suitable specialist equipment is available and serviced regularly. Health and safety Policies and procedures are in place and records seen provide evidence that residents and staff are offered the protection of good safety measures. A high standard of cleanliness was evident throughout those areas viewed. There were no mal-odours present. There are infection control policies and procedures in place, which are known to staff members. Suitable arrangements are in place for the storage and collection of domestic and clinical waste. Risk assessment of the physical environment is carried out as appropriate. There were no health and safety hazards noted. Care Homes for Older People Page 19 of 27 Evidence: The front yard and garden are appropriately maintained. Residents spoken with expressed a good deal of satisfaction with their physical environment. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Adequate numbers of staff, with the appropriate skills are available to meet the needs of residents. The robustness of the recruitment process means that residents are appropriately protected. Evidence: The AQAA tells us Henrietta House has a long-standing group of care staff that have been employed with the company ranging from five to ten years. The manager has worked in the home for 23 years. She has significant experience in the management of a residential care services for older people. She holds the City and Guilds certificate in Advanced Management in Care and has undertaken training in assessing and meeting the needs of older people, the management and development of staff, health and safety systems. There were sufficient members of care staff on duty on the day of the inspection to meet residents needs. Staff duty roster for a period of one month was scrutinised and discussion with the manager and staff members indicates that there are 4 care staff including 1 senior, available at all times during the day shifts and 2 waking members, on each night. The manager works full time and her time is not included in the calculation of staffing levels. The day and night staffing levels are adequate to meet the assess needs of the residents accommodated. Care Homes for Older People Page 21 of 27 Evidence: Staff receive induction that covers mandatory health and safety training. My induction helped me understand better the policies and procedures and practises of the home including health and safety matters, and this surely assisted me to ease myself in my job, said a new member of staff. Training profiles examined, evidence that staff have received specific training on topics such as Dementia, Medication, Care Planning, Management of Pressure Sores, Palliative Care and Safeguarding of Vulnerable Adults. 9 of the 18 care staff also hold an NVQ level 2 or equivalent qualification. Having said this all staff must receive training in the Mental Capacity Act and how it affects their work; this is so that they are able to comply with it. Members of staff on duty, care and ancillary, were seen to treat residents with kindness and good skill. They showed empathy and commitment towards those people they looked after. The best and kindest staff team I have come across, said a resident. The staff files for three members of staff were scrutinised and they all contained the necessary recruitment checks, including CRB checks (Criminal Records Bureau) and other information required by regulations. Feedback from residents indicates a high level of satisfaction regarding the care and support they receive from staff. Examples of comments include They are excellent and very committed to their work, The home provides an excellent standard of care, Staff are sweet and wonderful and This is a real home. All 5 visiting relatives spoken with echoed a high level of satisfaction regarding the quality of care offered at Henrietta House. Nothing short of excellence, reported one visitor. 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. The home is well-managed and robust policies and procedures ensure that residents receive an excellent standard of care. Evidence: The manager has been working for this organisation for over 23 years; she has been the registered manager at Henrietta House for over 11 years. She holds an NVQ 4 in Care and Management and has completed her mandatory training. She clearly has the knowledge, experience and skills to run this service efficiently. Staff, residents and visiting relatives told us that the manager is approachable, always helpful and extremely helpful. The manager is simply excellent, said a staff member. There is very good evidence to demonstrate that quality assurance systems are in place to seek the views of residents, their representatives and significant others in respect of the quality of service offered to residents. The operations manager also visits monthly to ensure appropriate standards are maintained. Reports on these visits are available at the home. A random sample of reports on these visits were viewed Care Homes for Older People Page 23 of 27 Evidence: and noted to be comprehensive. Staff are not involved or keep money on behalf of residents but the home provides lockable facilities in each room. Residents have their relatives to help them manage their financial affairs. There is a plan for regular 1 to 1 staff supervision in operation. Staff interviewed told us they are very happy with the support and supervision they receive. Records viewed were found to be in good order. Health and safety are being attended to. Fire drills are carried out regularly and was last undertaken on 26 February 2010. All members of staff have completed their mandatory training and refresher training is also made accessible, as and when required. 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 1 30 18 The manager must ensure that all staff receive training in the Mental Capacity Act and how it affects their work. This is so that they comply with it and ensure the protection of residents. 15/06/2010 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 7 The monthly review notes should include the full name and signature of the staff member undertaking the monthly reviews. 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). 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