Inspection on 05/11/09 for Belmont House

This is the latest available inspection report for this service, carried out on 5th November 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

Belmont House 23/10/08

Belmont House 07/05/08

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for older people Name: Address: Belmont House High Street Starbeck Harrogate HG2 7LW     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: Irene Ward     Date: 0 5 1 1 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 37 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 37 Information about the care home Name of care home: Address: Belmont House High Street Starbeck Harrogate HG2 7LW 01423882100 01423882108 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Southern Cross OPCO Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 106 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: The maximum number of service users who can be accommodated is: 106 The registered person may provide the following category of service only: 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 - maximum number of places 73; Dementia - Code DE, maximum number of places 42; Physical Disability, Code PD, maximum number of places 5 Date of last inspection Brief description of the care home Belmont House was built and opened in 2006, and is now owned by Southern Cross OPCO Ltd. It is situated between Knaresborough and Harrogate, near local shops and a Care Homes for Older People Page 4 of 37 Over 65 0 73 0 42 0 5 0 6 0 5 2 0 0 9 Brief description of the care home park. The home is accessible by local transport from both Knaresborough and Harrogate. Belmont House offers residential, nursing and personal care for up to one hundred and six people, some from the age of fifty-five upward, with nursing needs and for people with physical disabilities and dementia. The home has three floors, with three vertical passenger lifts to aid access to the first floor and second floor. There are five separate units. On the ground floor there is the Courtyard Suite for people who need residential help, and the Garden Suite for people with nursing needs. On the first floor there is the Promenade Suite for people with dementia and the Park Suite for people who need temporary care or rehabilitation and on the second floor the Spring Water suite for people with nursing needs. There are a number of bedrooms available for double occupancy and all have an ensuite shower room. There are gardens and internal courtyards for the residents to enjoy, and car parking is available on the site. Details provided on the 6th May 2009 outline the weekly fees between three hundred and seventy five pounds and eight hundred pounds. This does not include hairdressing, chiropody services and individual items like newspapers and branded toiletries. Care Homes for Older People Page 5 of 37 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 quality rating for this service is 2 star Good. This means that people who use the service experience good quality outcomes. The Commission for Quality Care inspects homes at a frequency determined by how the home has been risk assessed.The inspection process has now become a cycle of activity rather than a series of one-off events.Information is gathered from a variety of sources, one being a site visit.More information about the inspection process can be found on our website www.cqc.org.uk This is what we used to write this report: We looked at information we have received about the home since it was registered. We asked for information to be sent to us before the inspection, this is called an Annual Quality Assurance Assessment (AQAA). Care Homes for Older People Page 6 of 37 We sent surveys to people who live at the home and to relatives, staff and Health and Social Care Professionals. Two inspectors visited the home unannounced. This visit lasted eight hours and included talking to the staff and the manager about their work and the training they have completed, and checking some of the records, policies and procedures the home has to keep. We spent time talking with people who live at the home and relatives who were visiting the home. We looked at peoples care records to check that a plan had been formulated which helped staff provide support to people according to their needs and wishes. We focused on the key standards and what the outcomes are for people who use the service. The inspectors were accompanied by an expert by experience for six hours of the visit. An expert by experience is a person who because of their shared experience of using services and /or ways of communicating. Visit a service with the inspector to help them get a picture of what it is like to live in or use the service. During this visit they were asked to look at peoples daily life, social activities, and the environment. Their observations have been used in these outcome areas. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The site visit took place on the 5th November 2009.The new manager and the operations director were both available to assist throughout the visit and available for feedback at the end of the day. Care Homes for Older People Page 7 of 37 What the care home does well: Peoples care needs are properly assessed and they are given the opportunity to stay at the home before they move in permanently. This helps them make an informed decision about whether Belmont House is the right place for them to live. People are given enough information about the home before they move in. The deputy manager and a unit manager from the home visits them and they are offered the opportunity to visit Belmont House if possible for a look around and to ask questions about how the service is delivered.This enables them to make an informed decision as to whether the home is the right place for them to live. People living in the home and their relatives made the following comments: Well looked after. Commend the staff on Springwater for their kindness and a special thank you to the new manager who resolved an issue quickly and professionally on her second day. As far as I am aware Belmont gives the care and attention to my wife which I could no longer give at home. The care and everything. We are absolutely delighted with the care my parents receive. They are so much better cared for and understood than in their previous home. The staff are patient and delightful and my parents really like them. Only that we are thankful my parents can be together despite their problems - and that Belmont House is very good to them and for them. I am entirely satisfied with the care my relative receives who was for the first few months on the nursing corridor and the staff were all extremely caring. Belmont House has always appeared fresh and clean and because of my work I visit at different times. However I have always found the staff to be friendly and welcoming. Health and Social Care Professionals when asked What do you think the service does well? said, I always find Belmont House looks very clean and tidy. The staff are friendly and the unit managers are easy to communicate with. The office staff are extremely helpful. Offers a comprehensive level of residential and nursing care on one site. Service has improved recently, offering more activities. The nurses working directly with their residents make referrals to me directly that are appropriate and if they have concerns on aspects of care they do not hesitate to contact me. Two nurses who work on the nursing side are keen to attend the clinical updates that I organise. Care Homes for Older People Page 8 of 37 The information kept about people is good and is the right kind of information needed; this helps staff support people properly all of the time. A good choice of food and drinks are now available. This ensures that people receive a varied and nutritious diet. One person spoken to said, visitors are encouraged and made welcome. When staff come for a job at Belmont House all the right references and police checks are completed, this means that it is less likely that unsuitable staff are employed to work at the home.The environment of the home continues to be kept clean,well ventilated,free from any odours and maintained to a high standard. The expert by experience report regarding the environment stated the following: The cleanliness of the home is exceptional; there were no unpleasant odours or even a hint of one. All the bathrooms, disabled toilets, peoples rooms, communal areas were in excellent condition.The cleaning staff requires a special mention for keeping the home so clean. What has improved since the last inspection? What they could do better: Advice and further training regarding safeguarding people, should be sought from the local authority. This makes sure people are always protected from harm and that staff at the home are following the correct protocols. Care Homes for Older People Page 9 of 37 Current staffing levels at Belmont House should be kept under review to ensure tha they are sufficient to meet the needs of the people living at the home at all times,taking into consideration the lay out of the building. This will help to make sure that people who live at the home are well cared for and safe at all times. Further improvements should be made to the laundry service at the home as people told us that they were still experiencing problems regarding clothes going missing,ironing and so on.People living at the home need to have confidence in the laundry service provided. The supper arrangements at the home need to be looked at to ensure that people receive their supper at a reasonable time.This makes sure that people can have refreshments at regular intervals. 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 10 of 37 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 11 of 37 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. Peoples needs are properly assessed prior to admission, this makes sure that Belmont House is the right place for them to live Evidence: Belmont House is situated in the area of Starbeck which is between the towns of Harrogate and Knaresborough.The home is near to a number of local amenities that people can access if they are able to or wish to do so. The manager of the home confirmed that information continues to be made available to anyone interested in moving into the home and a copy of the homes statement of purpose is given to prospective residents.The statement of purpose was not seen at the time of the site visit.The manager said that no changes have been made to either the Statement of Purpose or the service user guide and that it continues to be available in different formats such as on DVD or audio cassette.People considering moving to Belmont House are encouraged to visit the home and spend a day there. Care Homes for Older People Page 12 of 37 Evidence: They can stop for lunch and tea and a trial stay is offered. Five peoples care records were looked at. All had good, clear in house pre-admission assessment information on file. Two peoples care records who had recently moved to the home,showed that an assessment had been carried out before the person had moved into the home. Assessments carried out contained details of every aspect of peoples daily life and health needs.Examples of the information included were daily living,dependency assessment, social interests, and the condition of peoples mental health. The manager said that the deputy manager and one of the unit managers carry out assessments before anyone moves into the home. She said that they visit people and get information from them as well as their relatives and other professionals to help them decide if they will be able to meet peoples needs before a place is offered.This was also confirmed by people living at the home at the time of the site visit.The inhouse needs assessment for one person seen had been partially completed by a relative. Although the home is registered for one hundred and six people, there were eightynine in at the time of the site visit. People who had recently moved to the home confirmed that they had been provided with all the necessary information before making a decision if Belmont House was suitable for them and able to meet their care needs.We noticed that one person had a Service User Guide in their room and that this included how to make a complaint. Ten surveys were received by the Commission. People told us that they received enough infomation before moving to the home and that they received a contract. Separate files are held in the administration office that held copies of terms and conditions or contracts for individual people. All of the files seen held contracts in them that had been agreed and signed by people living at the home or their representative. The home does not offer intermediate care. Care Homes for Older People Page 13 of 37 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. Peoples personal and healthcare is provided appropriately and sensitively according to individual needs. Evidence: Five care plans from different units were looked at in detail as part of the inspection. These are needed to describe the care and support people need to maintain some day-to- day control of their lives. They are also there for care staff to refer to and to check that the care they are providing is the right care. Those looked at were well written and sufficiently detailed for staff for them to provide the care people needed and wanted.They were written in a person-centred way such as what people can do on their own and what they need assistance with. This detail is good practice as it recognises that people are very different and care staff can support people to maintain these skills, rather than taking over. Care plans also covered all areas of daily living. They included details such as bathing,dressing,daily records,body map,nutritional assessments,falls risk assessments,pressure ulcer risk assessment,dependency risk assesment,moving and handling risk assessment,personal hygiene and records of professional visitors Any changes to peoples health care needs are also recorded in Care Homes for Older People Page 14 of 37 Evidence: daily records contained within their care plan.Peoples care plans were well documented and written in detail and included their life history. Daily records for one person who had recently moved into the home, documented how they had settled into their life at the home.The care plans recorded peoples preferences with regard to getting up and going to bed. People spoken with said that this was followed wherever possible.Care plans seen had also been reviewed regularly. One person spoken to told us that the staff are good at listening and make sure their dignity and privacy are maintained. They said that when they first moved in (from hospital) they were being nursed in bed, because they had pressure sores. They said the care is very good and that they felt that they were improving.People who needed speacilist equipment such as airflow mattress and special cushions etc. had these in their rooms. Care plans had good records detailing both telephone and direct communication with healthcare professionals, like the family and specialist doctors, the community matron, speech therapist and dietician. Care plans were in place for specific health care needs. Care plans were clear about peoples personal care needs and how peoples health care needs were to be met by the home.There was clear evidence detailed in one persons care plan in how that persons health had improved since their admission into the home.There were comprehensive risk assessments completed on each care plan looked at which covered all areas of daily living. For people who require bedrails clear detailed risk assessments were in place about the use of bed rails and there was written consent.There were good records of peoples day-to-day care and progress and clear monitoring records of their: personal care, recreational activities, pulse and blood pressure, weight, health care professionals visits and relatives contact. There was also good, thorough assessments about eating and drinking.Additionally, information was summarised in weekly reports. Each person living at the home is registered with a General Practitioner. There are nine GP practices involved with looking after peoples health care needs.Other health care professionals are involved with peoples health care needs such as the chiropodist,district nurses,community psychiatric nurse and the tissue viability nurse.People living at the home attend Harrogate District Hospital for all A & E (Accident and Emergency) and for most out patient appointments. There was opportunity on the day to speak with the dietician - she was reviewing several people, who had previously been referred by the home. We also saw that the chiropodist was doing someones feet - in their own bedroom. Care Homes for Older People Page 15 of 37 Evidence: The homes medication system was looked at and was found to be maintained well.There were very detailed guidelines in place, where people were prescribed asand-when (PRN) medication. The home uses the Boots monitored dosage system. We looked at the controlled drugs on Springwater and on Promenade units.Three people were prescribed controlled drugs on Promenade unit. One person was prescribed Temazepam on Springwater unit and they were treating it as a controlled drug.Both units had proper, secure controlled drug cupboards which were stored properly.Both units had controlled drug books and a running total was kept, two staff signatures recorded each time any controlled drugs were received in the home, administered or destroyed. We checked the balances of the controlled drugs against the quantity recorded in both units and they were accurate. There was a syringe in the controlled cupboard on Sprinwater unit and the senior manager told us that this was being used to make sure the correct measures of liquid medication were being administered. Each unit keeps a separate, extra audit/monitoring record of the amount of controlled drugs handed over at each shift change. There were copies of medical alerts, the medication policy and a British National Formulary (BNF) in each of the medication stores. The room and medication fridge temperatures were regularly checked and recorded. Throughout the day staff were observed supporting people in a sensitive and respectful manner and people were spoken with politely.Staff were observed knocking on doors before going into rooms.The home operates a key worker system.Staff were observed using disposable aprons and gloves.This maintains and promotes good levels of hygiene control. In discussions held with people on the day and from the surveys returned people told us that they were well looked after People made comments such as: Well looked after. Commend the staff on Springwater for their kindness and a special thank you to the new manager who resolved an issue quickly and professionally on her second day. As far as I am aware Belmont gives the care and attention to my wife which I could no longer give at home. The care and everything. We are absolutely delighted with the care my parents receive. They are so much better cared for and understood than in their previous home. The staff are patient and delightful and my parents really like them. Only that we are thankful my parents can be together despite their problems - and that Belmont House is very good to them and for them. I am entirely satisfied with the care my relative receives who was for the first few months on the nursing corridor and the staff were all extremely caring. Belmont House has always appeared fresh and clean and because of my work I visit at different times. However I have always found the staff to be friendly and welcoming. One relative telephoned us to tell us that her mother had recently moved to the home Care Homes for Older People Page 16 of 37 Evidence: and liked Belmont House.The relative said, the home was an oasis in a desert. Belmont House have some very good staff (named staff) are absolutely exceptional. The relative also said that her brother who has visited the home said, that place is wonderful, they really care for people and we have got mum into a safe haven. We receieved four surveys from health and social care professionals who when asked what does the service do well told us: I always find Belmont House looks very clean and tidy. The staff are friendly and the unit managers are easy to communicate with. The office staff are extremely helpful. Offers a comprehensive level of residential and nursing care on one site. Service has improved recently, offering more activities. The nurses working directly with their residents make referrals to me directly that are appropriate and if they have concerns on aspects of care they do not hesitate to contact me. Two nurses who work on the nursing side are keen to attend the clinical updates that I organise. When asked what could the service do better? they said, Wherever I work it is always a shame when good staff leave Respond better to people with dementia care needs i.e. more one to one support. The managers should make every effort to allow the nursing team to attend study days/sessions that are free of charge. These study days incorporate PCT (Primary Care Trust) staff and creates a very good forum for joined up working. There is often no representative from Belmont House at these study days and given that this is indeed a very large home I feel this could be improved upon. When asked is there anything else you would like to tell us? they said, At one point I heard some grumblings about the food but that seems to have stopped now. My contacts with Belmont House have been mainly in respect of respite of people who are being assessed or reviewed for NHS Continuing Healthcare and those who already reside there but are seeking help in respect of costs. Relatives of people have expressed concerns about staffing, particularly on the EMI Nursing Unit which may have led to complaints about loss or damage of teeth, hearing aids a watch and clothing. Also personal care - shaving & haircuts have been sometimes neglected. This was discussed at the time with the Operations Director who said that this issue had been resolved sometime ago. The home has now employed a hostesswho works 8-4 and just goes around the home making drinks for people and their visitors. It was evident that people on all of the units had access to plenty of drinks including fruit juice on the day of the visit. Care Homes for Older People Page 17 of 37 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 who live at the home have the opportunity to participate in various activities and are supported by staff to carry these out. Evidence: People living at the home, relatives and visitors all confirmed that they are able to visit the home at any time. This ensures those who have relatives living in the area have the opportunity to maintain their social and family connections whilst living at the home.There is a new activities co-ordinator person employed, who people said when asked that he was very good. There is an activities board in the main hallway of the home. The home produces a weekly activities programme, a copy for that week was given to inspectors.The programme showed that there had been various activities on during that week such as coffee morning,music therapy,age concern - chair excercise,Thurday prayer and study,Pat Dog visit,games,TV,music,one to one with activities co-ordinator,Thursday Matinee at the Lounge Cinema with refreshments, Art & Flowers.We were informed by the operations director that there had been a Halloween Party on Saturday where staff had dressed in fancy dress which was enjoyed by all.During the morning on the day of the visit there was singing and playing of instruments on the Promenade Suite. People Care Homes for Older People Page 18 of 37 Evidence: were observed to be enjoying the sing a long and the playing of various instruments. In the afternoon there was a film show High Society in Courtyard suite which was well attended. When we were visiting the DE (N) unit we noticed that there were a lot of coffee table books with colourful pictures and pictures to help with reminiscence. There were activities, staff were also taking time to sit and talk with people. There were pictures on peoples bedroom doors, to help them recognise their rooms. There were pictures of toilets on the toilet doors. The deputy manager told us that there are more planned improvements for the DE (N) unit, like zoning with colour and themed walls. She was very enthusiastic. We were able to observe lunch on two of the units.People were observed on one of the units being assisted by staff and that equipment was made available to assist people to eat and drink more easily. Tea, coffee, fortified drinks and biscuits were brought around on a trolley mid morning, and there were snacks and lemon squash to drink on the side tables in the shared areas. People were helping themselves to biscuits and fresh fruit.We noticed fresh fruit salad being taken downstairs to the dining room for dessert. In peoples written records there were notes about their religion. In two care plans people were both described as Christian and their assessments included how often they attended church. There were also notes about members of their families visiting on a regular basis. Surveys returned from people living at the home told us that on the whole most people now enjoyed the food at Belmont House. When asked what does the home do well, one person said, Food, entertainment(activity),looks after me well. When asked what could the home do better people made the following comments: The food could be better with more variety. Activities (Bingo) could be played more often More consistent quality of food. New clothes protectors/bib the current ones are threadbare I enjoy playing games - cards, scrabble, dominoes etc - would like more organised sessions. I cant really think of anything When people were asked,is there anything else you would like to tell us they said, The food has improved of late. We have a book to report how much we have enjoyed each meal, or about any complaints. Too much emphasis on food. The kitchen and dining area on Park Suite have been scheduled for improvement for 12 months. Still no sign of any action. There have been 3 manager in the last year, about to have our Care Homes for Older People Page 19 of 37 Evidence: 4th.The issue regarding improvements on Park Suite we were informed by the operations director that this work has now been completed. The expert by experience who accompanied the inspectors at the time of the visit has also completed their report on their findings on what life is like at the home, which they fed back to the manager and the operations director on the day . The expert by experiences findings were as follows: It was good to observe activities being carried out by the new activities co-ordinator (AC). This person had been in role for approximately 4 weeks. In the Promenade Suite which accommodates people with dementia I observed the AC with another member of staff engaged in musical activity with five or six people. The staffs enthusiasm in participation with the people was evident, this was good practice. The Promenade suite was situated on the second floor and I was somewhat concerned that people living there were unable to gain easy access to the outdoors, either to see the gardens or venture further with a carer. I later spoke with the AC who was very impressive with his evidence of showing me what was taking place in Belmont House. He showed me a letter/questionnaire he was giving out to all the people living there, also to relatives of people who were unable to fill in the details, to ascertain their likes and dislikes and what activities they liked to do before living in Belmont. He said this would help him to organise activities which suited groups of likeminded people. He also showed me a list of all the residents names and their birthdays, so that he himself could organise with the local florist to have flowers sent to them on their birthday. His talent and enthusiasm for his role came across as excellent. He said a list of activities is given out to each unit weekly. Whilst I was there I witnessed a Film Show presentation in the Residents lounge of the Courtyard Suite on the ground floor. It was well attended and I was pleased to see that some people had been included from the dementia unit. Ice cream and popcorn were available to all. The Plaza suite situated near the entrance and reception is where I was told the main activities take place, such as musical evenings, special events. But I found it hard to imagine more than 30/40 people being able to comfortably use the space available, bearing in mind some wheelchair users. This would mean that the majority of people would be excluded, also taking into consideration those people who were not well enough to attend an event. The hairdresser visited weekly and peoples own personal hairdressers attended also. People were now able to access the Residents lounge in the Courtyard suite and this was more user friendly than before. The local vicar attends to give a communion service once a month and calls in whenever needed; it appears there are strong links between Belmont House and the local community. A resident also told me that a lady from the church army calls in to see people. Two Care Homes for Older People Page 20 of 37 Evidence: people said that the evening supper trolley was always late coming round. However during the morning and afternoon, there is now a hostess who does the trolley round. This is an improvement from having to rely on carers to do the job and makes the service more reliable. One person I spoke with said he made a request to the AC for a Bible Study Group. This was now taking place and a notice to that effect was on the Notice Board in reception. I was informed it was also well attended by other people in the home. This very prompt action by the AC, to this request, was commendable. I believe from what I was shown that the events/activities which the AC has introduced within Belmont House will prove to be a major asset to everyone. He has achieved a great deal in the short time he has been there. With this kind of progress the lives of the people living there should become happier as a result. I observed members of staff around the home being friendly and helpful towards people. From talking to people and staff it was evident that there were quite a few new members of staff who had recently started working there. Service users, their relatives and a health care professional and member of staff all said that there had been a high turnover of staff this past few months. Also that this had been unsettling for everyone and the continuity of care had been interrupted as a result. The visiting health care professional said she had found that peoples needs had been overlooked because staff had not passed on information to her; she said this was as a result of staff leaving and new ones not knowing the procedures. It was said to me that staff on the Promenade suite (dementia unit) were few in numbers and at times it was difficult to find a member of staff inside this unit to gain entry. I understand there is to be a new unit manager starting imminently. I spoke with three service users, one relative and one visiting health care professional; these are their comments about daily life in Belmont. There have been communication problems with staff due to the high staff turnover, especially in the Promenade suite. I always ring the unit before I visit because otherwise it is hard to find a member of staff to let you in (visiting healthcare professional to Promenade suite). The supper trolley is late coming round, sometimes it is after 10.00pm and people have gone to sleep. Staff is very thin on the ground in an afternoon up here (Promenade suite) Of the activities coordinator it was commented: He is really good and I have spoken to him about what sort of things I like to do He has made a difference; I think it is great that they have someone to help them get involved in the various activities. (visiting Health care professional) I suggested a Bible Study group and he has been able to help me get it organised I think he is very nice, you can talk to him. On this occasion I had my lunch in the dining room on the Promenade suite (dementia Care Homes for Older People Page 21 of 37 Evidence: unit). All the tables were occupied. There were approximately 19 people. I sat at a table with three other people. One visitor was helping his relative to eat her meal. In this dining room there were two carers present, both had the task of delivering and taking away the food or plates when finished. I observed people eating their meal and they appeared to enjoy it. The deputy manager of the unit was overseeing the staff and people sat there, and at times went over to a table to check on someone eating their food. The two staff members who were serving were polite and friendly to everyone, but I did not think that there was enough dialogue or assistance to explain or ask what particular selection of menu people wanted. For example: I heard the staff ask people if they wanted Chicken a la King or Bubble and Squeak. Whilst this is good practice to be given choice I did think for the people in this unit, this was for some, a difficult decision to make. More appropriate ways of identifying the dish of the day should be made available; either plated examples of food or pictures. The person at the side of me was agitated and needed constant reassurance to eat her food, when reassurance was not given by me, this person left the table. A member of staff escorted her back to the table and respectfully and caringly reminded her to eat her food, but the carer then left her. Each time that I was unable to acknowledge her task of eating, (which I did twice, to see what would happen) the person left the table again and again. This showed that this person was not getting the assistance and encouragement to eat her food. I observed a board on the wall in this dining room, listing the names and room numbers of people who needed to be fed by a carer. Each carers name was at the side of each persons name and room number. I found this good practice that those who were not able to get to the dining room would not be forgotten about at meal times. I concluded from my observations that more dialogue/explanation was needed from the carers to encourage/assist some of the people to eat their food. Jugs of bitter lemon juice were on each table but no water. Everyone was offered a cup of tea after their meal. Later that day, I had the opportunity to speak with the Chef. I asked her if things had improved since our last visit. She said she was much happier now and had extra staff, including an assistant chef. She said they were now able to deliver food as stated on the menu. I did notice also that on the reverse of the menu there were snacks available, such as sandwiches and jacket potatoes and side salads. This has improved since the last inspection. There were two hot choices of food for both lunch time and tea time, as well as the snacks mentioned, along with two sweet dishes and yogurt. I did point out to her that all the desserts which were on offer that day were all cold ones. I asked her if it would be more appropriate to make available a hot pudding in Care Homes for Older People Page 22 of 37 Evidence: view of winter approaching. She was very amenable to this suggestion and said she would look at the menus again to try and make sure this would happen for future months. As I was on the Promenade suite it was difficult to gain comments on food quality/quantity from the people there. Care Homes for Older People Page 23 of 37 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 use the service have access to an effective complaints procedure and are protected from harm. Evidence: A comprehensive complaints procedure is followed and is made available to people and any other interested parties as it is contained in the homes brochure.The complaints procedure is also made made available to people as it is on display in the entrance of the home. The home records any complaints they receive.The last inspection carried out on the 6/5/09 raised some concerns from people that they did not feel that their complaints were listened to or were being addressed.Since that inspection people at this site visit were more confident that complaints were being listened to and were now being addressed. The home has received seven formal complaints since the last inspection.No complaints have been received by the Care Quality Commission.People when asked via surveys were clear as to whom they would speak to if they had any concerns or worries.People told us they knew how to make a complaint.People spoken to on the day said they would speak to members of staff or unit managers if they had any complaints. There is a policy and procedure in place with regard to safeguarding adults which includes the procedure to follow if there is a suspicion of abuse.Staff receive training in adult protection and safeguarding issues during induction training and further training when required. There have been several training sessions held regarding Care Homes for Older People Page 24 of 37 Evidence: Safeguarding. The most recent training in safeguarding was held on the 3/11/09. There have been no allegations regarding safeguarding made to the home or to the Care Quality Commission since the last inspection. A discussion was held with the new manager regarding staff receiving further safeguarding training from the Local Authority. The manager was advised to contact the local authority to assist the home with this specific training. We noted that there was information about the deprivation of liberty safeguards on the wall in the lift. This information keeps people informed of their rights. Appropriate recruitment procedures are followed, with references and Criminal Records Bureau (CRB) checks made to reduce the risk of unsuitable people working in the home. Peoples finances were found to be appropriatly managed at the last inspection. Therefore the management of peoples finances was not looked at on this occasion. The expert by experience report found the following: Of the people I spoke with, they said they felt more confident in having their complaints addressed by management. They were aware of the new manager who started that week. They were all consistent in their praise for the management team, some of whom had only been in place a few months. This was very re assuring to hear. These are the comments of two residents, one relative, and a visiting health care professional: I get on very well with the managers, they are always ready to listen and discuss any problems I have. The deputy manager (Promenade suite) is very helpful and understanding. I think we are going to have regular meetings with the manager to put our ideas forward. Just these past few weeks, it seems much better, my problems of communication regarding the needs of service users are finally getting resolved and they are passing the information on to me(visiting health care professional). The majority of peoples complaints were about the staff shortages and the laundry service. I was voluntarily given a long report, by a person living there, on the state of the laundry and where they thought the system was going wrong. The main issues detailed were clothes going missing, large communal washes containing everything and anything, receiving wrong items of clothing and clothes not being ironed correctly or not at all. I visited the laundry and met the laundry assistant, the House Keeper Care Homes for Older People Page 25 of 37 Evidence: and a domestic assistant. From my observations, there was now a better system in place than on my last visit there. There were boxes with room numbers on and coloured bags for each unit which identified which floor they had come from. A lost property section was clearly marked and once a month people were invited to come with a carer to see if they could find their item. Whilst the system seems better than it was, it still identifies a problem when people have to visit to search for their items of clothing. When speaking to the management at feedback, I was informed that a letter/questionnaire is being given out to everyone asking them to state if any of their items have been lost or damaged etc. This questionnaire will be a regular occurrence, so as to take the responsibility away from service user and put the onus on the laundry system to address the problem. Even though the laundry system is still not up to scratch, I am hopeful from the actions being taken that it will improve, and from these questionnaires, the comments of the service users will be taken notice of. It is very important for the sake of the dignity of the people living there that the staff get it right, so that people will wear their own clothes and not some other persons, and for them to look smart and presentable. These are some of the comments I received from three residents and one relative: I have seen an improvement this last month, the new staff are better - more caring. This past few weeks, things seem to have got better, staff are more helpful. It is not as bad as it used to be. I have seen other people wearing my relatives clothes. I wish they could get the laundry thing sorted.It is better now; if my clothes dont turn up I have got compensated. I was unaware that I could help with my relatives care plan, I have only seen it once. (this was stated by a relative whose relative had dementia). Care Homes for Older People Page 26 of 37 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. People live in a clean and comfortable environment which is maintained to a high standard. Evidence: The home is newly built and was only opened in November 2006, and has 106 bedrooms over three floors, which is split into five units, providing care for people with different needs. The furnishings throughout the home are to a high standard. Some of the bedrooms on the ground floor have patio doors leading to the garden. All the rooms have an en-suite bathroom, which have a toilet, wash hand basin and shower. Some rooms can accommodate two people. It was possible to look at some of the rooms available during the site visit when we had the opportunity to speak to people in their own rooms. People were spoken to throughout the day and rooms visited had been personalised with their own possessions. There are enclosed gardens to the rear of the building and enclosed courtyards within the building. Some people living at the home had patio doors leading onto their own patio. Care Homes for Older People Page 27 of 37 Evidence: There is a range of communal space where residents can meet with their families.There are communal bathrooms, which have the appropriate aids and adaptations.The corridors are wide and give ample space for wheel chair or electric chair use. The home was clean and fresh and decorated to a high standard. People who live at the home and relatives and visitors made positive comments about the cleanliness and said it was always clean and fresh.Eight surveys from people who live at Belmont House was returned to the Commision. People confirmed that the home is always fresh and clean.When asked what does the home do well? People made the following comments: The home is kept fresh and spotlessly clean. Keeps it and me clean, staff are very friendly. Clean,bright,nice staff. Belmont House has always appeared fresh and clean and because of my work I visit at different times. I always find Belmont House looks very clean and tidy. Gloves and aprons were available throughout the home. Peoples personal clothing and bedding is attended to in a separate laundry area.However at the last inspection on the 6/5/09 several people complained about clothes going missing. A visit was made to the laundry on that day and there appeared to be no system in place to deal with lost clothing.This has been addressed by the homes management team who continue to look at making improvements to the laundry service the home provides.The laundry was suitably equipped with industrial washers and dryers. The home employs a housekeeper and two laundry assistants. The expert by experience report regarding the environment stated the following: The cleanliness of the home is exceptional; there were no unpleasant odours or even a hint of one. All the bathrooms, disabled toilets, peoples rooms, communal areas were in excellent condition.The cleaning staff require a special mention for keeping the home so clean. On this visit I found there to be more people out and about in the home; some participating in an activity, others sat reading or watching television. The Courtyard suite which is residential was again very quiet, but whilst walking down the corridors, I could hear peoples televisions on and music playing. Situated in a small seating area in the Courtyard suite was Clyde the budgerigar, sat quietly on his perch. It was nice to see a small creature being allowed into the home to give pleasure to those who appreciated this. The dining tables in each unit were very well presented in their layout. The communal Care Homes for Older People Page 28 of 37 Evidence: areas were spacious, clean with comfortable seating. Everywhere was well decorated and even in the communal assisted bathrooms there were colourful large pictures on the walls, which made them more user friendly and took away that clinical appearance. I was eager to see the Residents Lounge, which last time was more like a board room and was told used more for staff meetings. I did evidence this at that time. But this time, the board room table had been turned into somewhere you could play board games or sit round and have refreshments. Flowers were on the table. Other furniture adorned the room to give more ambience to the people who would use it. There was also evidence of activities by the presence of boxes containing a variety games, videos,cds etc. This lounge now looked like it was being used for the correct purpose. I saw peoples rooms in the Courtyard Suite and Promenade suite whilst being shown around; some of the peoples doors were open. The Operations Manager said all were alarmed in the event of fire. All rooms were furnished to a good standard, had en suite facilities and also contained personnel possessions. Although some rooms still had a hotel type look. There was also a Visitors Room and a Hairdressing salon. Some of the ground floor rooms had access to patios and there were small garden areas surrounding the home where people could access. The home had been one of the finalists of the Harrogate in Bloom competition. I asked three residents, one visiting health care professional and 1 member of staff their views regarding living and working at Belmont House. This is what they said: They keep it very clean Its a pleasure to work in lovely surroundings I have no problems with the cleanliness Everywhere is bright and cheerful It is always a pleasure to come in here and not have any awful smells like some places Sometimes it is a bit too quiet (person on Courtyard suite) Care Homes for Older People Page 29 of 37 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. Staff in the home are sufficiently trained, skilled and in sufficient numbers to support people who use the service. However the home needs to constantly review their staffing levels to ensure peoples need are consistently met. Evidence: During the site visit the staff rotas show that there is normally the following staff working on the different units: Garden suite(nursing)which caters for 13 people.In the mornings there are 4 staff in total. 1 nurse 3 carers.In the afternoon there are 3 staff in total.1 nurse 2 carers. Courtyard Suite(Residential) caters for 25 people.In the mornings there are 5 staff in total. 1 nurse 4 carers. In the afternoons there is 1 Senior carer and 3 carers. Park Suite (EMI Residential)caters for 17 people. In the mornings there is 1 nurse and 3 Carers. In the afternoons there is 1 nurse and 2 carers. Promenade Suite (EMI nursing).Caters for 28 people. In the mornings there are 2 nurses and 4 carers. In the afternoons there are 2 nurses and 3 carers. Springwater Suite (general nursing)Caters for 7 people. In the mornings there is 1 nurse and 1 carer.In the afternoons there is 1 nurse and 1 carer. Night staffing arrangements are as follows: The manager said there are now 11 night staff staff on duty each night which includes a floater who works between floors.Ground Floor 1 nurse 3 carers. Middle floor 1 nurse 3 carers. Top floor 1 nurse 1 carer. The Operations Director said that they were to employ a night manager. The homes new manager confirmed that this has been done and the night manager is to commence Care Homes for Older People Page 30 of 37 Evidence: their post on the the 16/11/09. She also confirmed that 10 new staff had commenced working at the home. The hours did not include the managers hours or all the ancilliary staff at the home such as domestic staff, kitchen staff,maintenence person, housekeeper and admin staff. We looked at five staff records to make sure the home were employing suitable people for the job. We found all the necessary pre-employment checks had been carried out prior to the new workers starting in post.All records showed completed application forms, two written references, CRB (Criminal Record Bureau) checks had been obtained. Individual training files are held for staff. None of the 3 nursing staff whose records we saw have yet had medication refresher training. However, we saw the list of staff who had it, and the list of planned training. About half of the trained nurses have had medication refresher training on 07/10/09 and there are further training sessions booked for 17 & 18/11/09. The home has just commenced a competence assessment for staff regarding administration of medication. We saw evidence of one of the staff whose file we looked at had completed this. The new manager told us that Wednesdays are going to be regular training days and that core training will be covered in the morning and service led training in the afternoons. We saw the training record folder, and there was evidence that a lot of training has been done on the core areas over the past year or so. Head of Departments meetings now take place daily. A staff meeting was last held on the 16/10/09. Staff meetings are now held in each of the units. People living at the home and relatives made positive comments about the staff and care at the home such as: Staff on the whole are very good and i am well looked after. Staff are very good. Commend the staff on Springwater for their kindness and a special thank you to the new manager who resolved an issue quickly and professionally on her second day. As far as I am aware Belmont gives the care and attention to my wife which I could no longer give at home. We are absolutely delighted with the care my parents receive. They are so much better cared for and understood than in their previous home. The staff are patient and delightful and my parents really like them. Three surveys were returned from staff who work at the home.When asked what does the service do well?They said, Gives a good quality of care to all clients/patients. Care Homes for Older People Page 31 of 37 Evidence: Good training days for staff and keep you up to date in any changes that have happened/happening. Belmont House has a good atmosphere, the residents are mostly happy, although I feel if we had more activity organisers their lives would be more fulfilled and therefore happier. The staff work very hard to maintain good standards of care. When asked what could the service do better they said, More activities for residents. Have more input from the staff about care for the residents, food ideas and activity ideas. Have more staff on duty, somedays so we can sit and chat to the clients when needed. Employ more staff to accommodate activities. When asked is there anything else that you would like to tell us? they told us, I believe Belmont House could be a lovely home for all but needs input form both staff and clients. Also be earlier when training is due. Since I have been at Belmont House, just over 2 years there have been 5 managers, a lot of the staff who started at the same time as myself, feel our working environment isnt stable, and the whole atmosphere of both staff and residents Im sure would benefit from a permanent manager. Care Homes for Older People Page 32 of 37 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. People benefit from a home in which their needs and wishes are now put first. Evidence: The manager has worked at Belmont House for 4 days and is to appply to be registered with the Commision. She is to receive regular support from the organisations Operations Manager. At the last inspection carried out on the 6/5/09 a number of concerns had been raised with the Commision. These had been mainly about the food,the lack of activities, lack of staff and poor care practices. Since that inspection no concerns have been raised to the Commision. People spoken to on the day and surveys returned from people living at the home and their relatives spoke highly about the home. The manager said that a quality assurance system is in place. The home carried out a Quality Audit and sent out surveys in April 2009.The manager said that a residents meeting had been arranged for the 6/11/09. Information provided from the AQAA Care Homes for Older People Page 33 of 37 Evidence: (Annual Quality Assurance Assessment) and the examination of selected health and safety documents show that regular checks to electricity and gas and fire safety equipment are undertaken. A range of other records was seen such as care plans, staff files, supervisions records and health and safety records. Records seen were up to date and well maintained. Accidents are recorded as required and accident books on the individual units are maintained in line with the requirements of Data Protection. Peoples finances were not checked at this site visit as they were checked at the last inspection carried out on the 6/5/09. Evidence at that inspection confirmed that peoples financial interests are safeguarded by the systems the home has in place. Staff meetings have now commenced being held on each of the units. The last staff meeting was held on the 16/10/09. Head of Department meetings now take place daily. The expert by experience report found the following: The Inspector asked me to give my feedback to the new Manager and also Operations Director. I gave them praise for the exceptionally clean, spacious environment and also the great asset they had in the new Activities co-ordinator. The consistency of meals and trolley rounds was a good improvement also, but I brought to their attention the late arrival of the supper trolley in the late evening. I told them my three main issues of concern were for the reported shortages of staff especially in the Promenade suite, the laundry system and further training in dementia care for staff on Promenade suite, especially in the dining room. Whilst everyone present acknowledged that the laundry system had improved since the last inspection, it still needed further management to address the ongoing problems. The Managers also gave assurances that something is going to be done for the menus in the Promenade suite, for example, pictures or sample dishes to show the people there, and further dementia training for members of staff. The managers present acknowledged my comments, and their positive responses gave reassurances that these areas would be targeted for further improvement.I thanked everyone for their time given to me for my inspection. Care Homes for Older People Page 34 of 37 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 35 of 37 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 15 The supper arrangements at the home needs to be looked at to ensure that people receive their supper at a reasonable time.This makes sure that people can have refreshments at regular times. Advice and further training regarding safeguarding people, should be sought from the local authority. This makes sure people are always protected from harm and that staff at the home are following the correct protocols. The manager of the home needs to continue looking at ways to improve the laundry service. This will make sure that people living at Belmont House are satisfied with the laundry service that is provided by the home. Staffing levels at the home should be kept under continuous review to ensure that people who live at the home are having their needs fully met at all times. 2 18 3 26 4 27 Care Homes for Older People Page 36 of 37 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. 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. 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