Inspection on 17/06/09 for Shaws Wood

This is the latest available inspection report for this service, carried out on 17th June 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.

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Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report Care homes for older people Name: Address: Shaws Wood Shawswood Mill Road Strood Kent ME2 3RU     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: Elizabeth Baker     Date: 1 7 0 6 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Shaws Wood Shawswood Mill Road Strood Kent ME2 3RU 01634843745 01634399722 jayne.ansell@kcht.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Kent Community Housing Trust (KCHT) Name of registered manager (if applicable) Mrs Jayne Ansell Type of registration: Number of places registered: care home 36 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 36 The registered person may provide the following category/ies of service only: Care home only - PC 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 - OP Dementia - DE Date of last inspection Brief description of the care home Shaws Wood occupies a site in a quiet residential area of Strood. The service was originally built as a link service centre. The service was closed but has been re opened on a temporary basis specifically to accommodate residents living in a care home in Chatham. The original day care centre has not re opened. It is proposed Shaws Wood Care Homes for Older People Page 4 of 27 Over 65 0 36 36 0 Brief description of the care home will continue to run as a care home until July 2010 when the residents return to Chatham into a purpose built care home. In the interim the home is registered for 36 older people with dementia. Accommodation is situated on the ground and first floor. All bedrooms are for single occupancy. There are call bells and television points in each bedroom and passenger lift access between floors. There is allocated car parking and enclosed garden areas. The home is situated about a mile from the centre of Strood. Fees are currently £465.00 and £511.77 per week. Additional charges are payable for chiropody, hairdressing, newspapers and toiletries. Activities include exercises, reminiscence, board games, arts and crafts, knitting circle, gardening and one to one sessions. A mini bus is shared with an associated home for trips out. A Church of England service takes place fortnightly and fellowship meetings weekly. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: Allocated inspector Elizabeth Baker carried out the first key unannounced visit to the service on 17 June 2009. The visit lasted almost eight hours. As well as briefly touring the home, the visit consisted of talking with some residents and staff. Three residents and two carers were interviewed in private. Verbal feedback of the visit was provided to the registered manager during and at the end of the visit. At the time of compiling the report, in support of the visit we, the Commission, received survey forms about the service from four residents, two social and health care professionals and eight staff members. At our request the home was required to complete and return an Annual Quality Assurance Assessment (AQAA). Some of the information gathered from these sources has been incorporated into the report. Care Homes for Older People Page 6 of 27 Since transferring to this site in December 2008, there have been no safeguarding adult referrals made or investigated. We have not received any complaints about the service. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. 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 8 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 9 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can be sure the home can meet their assessed needs. Evidence: As required by our regulations, the home has a statement of purpose and service user guide. These documents inform prospective residents and or their advocates of the services and facilities provided by the home. For equality purposes, all residents, whether self funding or sponsored, are provided with a contract or terms and conditions. This is good practice. Not all prospective residents are able to visit the home prior to admission. Where this is the case their relatives or advocates usually visit on their behalf. Where practicably possible the registered manager and or team leaders visit prospective residents in their current place of occupation to determine whether the Care Homes for Older People Page 10 of 27 Evidence: home is suitable to meet the residents individual needs. Information is also sought from other agencies such as local authorities where a sponsor is involved in the placement. The information gathered is used to inform the resultant care plan. To help minimise any anxieties new residents may have on admission, a card and basket of toiletries are put in the residents bedroom as a welcoming gesture. Relatives or advocates are also encouraged to individualise the room to be occupied with some personal items. This is good practice. The majority of residents now living at Shaws Wood were transferred there from the providers associated home in Chatham. This was because the Chatham home was to be demolished and replaced by a new purpose built care home. The completion of this new home is expected in July 2010. The use of Shaws Wood as a care home is a temporary measure only. Residents and advocates are being kept informed of the progress. The home is not registered for intermediate care. Standard 6 is not applicable. Care Homes for Older People Page 11 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. Although not all care plans support this, the health and personal care needs of residents are generally met with evidence of good multi disciplinary working taking place. Evidence: For case tracking purposes the care records of four residents were inspected. Records included contracts, pre admission assessments, care plans and a range of supporting charts and risk assessments covering night care, environment, smoking, moving and handling and body maps. Some other charts are maintained separately elsewhere including weights and nutrition. For a resident with diabetes, a medical care plan component for this condition had been composed, although the information could have been expanded to include dietary needs and time and frequency of blood glucose readings. To support the plan a blood sugar glucose monitoring chart and insulin administration chart are maintained. However it was difficult to initially identify the documents as they are kept in another part of the care records. The care plan component did not inform the reader of this. Care Homes for Older People Page 12 of 27 Evidence: Daily records contained a mix of residents quality of day experiences and medical conditions. One particular entry referred to a resident being referred for an X-ray and details of the GPs visit to the resident about the problem was seen on the professional visit sheet. Sadly no specific care plan component for this medical condition had been developed. Care records contained good social history details and were generally reflective of information gathered during our interviews with some residents. Specialist input is sought and provided from clinicians including GPs, district nurses and community psychiatric nurses. Residents also receive input from allied healthcare professionals such as dentists, opticians and chiropodists. To minimise traumas and anxieties some residents had during the relocation process, the registered manager successfully persuaded the local health and social care body in agreeing to retain the same district nurses serving the home in Chatham to provide the care at the new temporary location. The four surveys returned from residents indicated the residents always get the medical care they need. Residents were suitably dressed for the time of day and season, with attention to detail where this is important to them, including hairstyles and makeup. A hairdresser visits the home twice a week and residents like using the service. Residents spoken with indicated their dignity is protected when staff assist them with their personal hygiene needs. A dedicated room is used for the storage of medicines and associated sundries. The room is appropriately equipped and kept in good order. Records showed that the drug refrigerator temperature was being done on a daily basis, as good practice requires. However although the form required the room temperature to be done, this was not actually happening. Medication administration record (MAR) charts were inspected and had been completed as required. Some residents have been prescribed medicines to be taken on a when required (PRN) basis. For one resident with breathing problems, one of their two inhalers had been prescribed on a PRN basis. However there were no recorded instructions to guide the Care Homes for Older People Page 13 of 27 Evidence: carers as to when the PRN inhaler should actually be administered. The MAR chart did indicate the regular dose inhaler was being administered as prescribed. The resident complained of breathlessness during the visit. It was also identified on this visit that the home does not use pain charts to monitor the effectiveness of prescribed analgesia. It is good practice to do so. Although details of residents religions were seen in the records inspected, there are currently no care plans covering residents spiritual and cultural wishes and preferences in respect of death and dying. Whilst appreciating this is a sensitive subject, it is an important aspect of care and needs to be addressed. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Meals and activities offer both choice and variety. Residents are supported in attaining their lifestyle preferences. Evidence: Residents are able to choose from a range of activities some of which are provided within a group and others one to one. During the visit some residents were seen enjoying a board game, some where listening to a newspaper review and many joined in an afternoon quiz. Residents are encouraged to be involved in gardening and planting vegetables. Residents are supported in accessing outside clubs and religious services, where this is important to them. And other residents choose to stay in their own rooms to read or watch their televisions. Activities include exercises, reminiscence, sing a longs, bingo, BBQs, and a knitting circle. Three of the four survey respondents indicated there are always activities that they can take part if they want. The other respondent indicated there usually is. As well as weekly fellowship group meetings, a Church of England service takes place fortnightly. Other faiths and beliefs are catered for as requested. Residents also have the opportunity to meet residents from other homes within the Care Homes for Older People Page 15 of 27 Evidence: organisation. This includes the annual summer getaway in the gardens of a nearby priory. Families and volunteers are also invited. And an evening Christmas Service is arranged at Rochester Cathedral for residents to attend if they so wish. Residents are encouraged to personalise their rooms and those visited had been individualised to the residents own preferences. Residents said their visitors are made welcome and can visit at any time. Each floor has its own dining room for residents to use if they want to. Residents spoken with said they enjoyed their meals but one added that meals can become repetitive. Three of the returned resident surveys indicated the residents always like their meals. The other respondent indicated they usually do. Meals were not sampled during the visit but the lunchtime meal was presented in an appetising manner. Residents are weighed monthly or more often if there is an assessed need. Chair scales are used for this purpose and are regularly calibrated to ensure accuracy. This is good practice. 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. Residents and their advocates can be satisfied their concerns and complaints are listened to and acted upon. Evidence: A complaints procedure is displayed and includes details of the provider and us. Residents spoken with knew what to do if they had a complaint or were worried about something. All four surveys from residents indicated there is someone they can speak to informally if they are not happy. Sadly, however all the surveys from residents indicated they did not know how to make a complaint. A central record is kept of formal complaints and compliments. This is good practice. However it has not been the homes practice to keep a central record of all niggles and adverse verbal comments. Recording this information may help the home monitor trends for quality assurance purposes. The training matrix provided at the visit shows that staff have received adult protection training. The home has safeguarding policies and procedures in place, including Kent and Medway multi agency procedures. The AQAA records there have been six safeguarding referrals made and investigated. Since the last visit the registered manager and team leaders have attended Mental Capacity Act Awareness and Deprivation of Liberties Safeguard training. Other staff Care Homes for Older People Page 17 of 27 Evidence: will receive this training. This is important as the new safeguards may have implications on the homes current and future residents. Since the implementation of these new safeguards in April of this year, the home has not made any formal authorisation referrals. A resident said they like to keep up to date with world affairs and politics and like to vote in elections. Indeed residents living in their former Chatham care home had been supported to do this. However since the temporary move to the Shaws Wood site this has not been the case. As there will probably be a general election before the move back to the Chatham site, action should be taken to see if residents can be added to the local electoral list so they can vote, if they wish to. 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. The temporary accommodation creates a homely place for residents to live in. Evidence: Areas visited were fresh, clean, warm and tidy. Three of the four returned surveys from residents indicated the home is usually fresh and clean. The other respondent indicated the home is always fresh and clean. Prior to the temporary use of the home for the residents transferred from their Chatham home, Shaws Wood had been unoccupied for a number of years. In preparation of the re use of the care home, the home was redecorated throughout and made safe. The home has been furnished with furniture from the Chatham home but new curtains have been put up. All bedrooms are used for single occupancy and four have ensuite facilities. There are numerous toilets and assisted bathrooms throughout the home. All areas used by residents are connected to the call alarm system. And a passenger lift accesses all resident accommodation. Residents spoken with said their beds are comfortable. The home does not have its own range of pressure relief or preventative equipment, but this is obtained through district nurses on an assessed needs basis. The home has a range of lifting and transferring equipment including a mobile hoist, slide sheets and transfer belts. Indeed a resident was observed being transferred from his armchair to his wheelchair Care Homes for Older People Page 19 of 27 Evidence: by hoist. Throughout the manoeuvre carers explained to the resident what was happening in a re-assuring and non-patronising manner. This is good practice, as some residents may experience anxieties when being transferred this way. The home has a laundry in which residents personal clothes and general linen is washed. The laundry is equipped with industrial type washing and drying machines. Disposable bags are used for the safe washing of soiled linen. And there is one large washing sink. Disappointingly there is no dedicated hand wash sink. Whilst acknowledging the home will only be used for about another 12 months, the situation should be assessed and appropriate action taken to minimise any cross infection risks associated with staff using one sink for two purposes. Care Homes for Older People Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive care and support from a happy, enthusiastic, caring and trained workforce. Evidence: As well as care staff, staff are employed for cooking, activities, cleaning, laundry, maintenance and administration. The home is staffed 24 hours a day and a roster is kept. Throughout the visit staff were seen carrying out their duties in an unhurried manner. And all four returned surveys from residents indicated staff are always available when they need them. On occasions agency staff have to be used. However to make sure residents receive continuity of care, the home uses the same agency who endeavour to provide the same carers. To minimise the impact on residents of the move to this home, staff employed at the Chatham home transferred to Shaws Wood with the residents. Transport is provided and paid for by the organisation. This is good practice. The returned AQAA indicates that 85 of care staff are now qualified to NVQ level 2 or above in care. This is a very good achievement. Care Homes for Older People Page 21 of 27 Evidence: New staff are required to complete a three or four day initial induction. During this period they are required to shadow trained staff and read and familiarise themselves with policies and procedures. This is followed by an in depth induction which once successfully completed leads onto an NVQ level 2 course. The training matrix supplied in support of the visit records staff having received training in various subjects including care planning, diabetes, falls assessment, challenging behaviour, palliative care, dementia care, health and safety, first aid and fire. Staff interviewed said they had received training in subjects including medicine administration, adult protection and moving and handling. The personnel files of three staff members were inspected. References had been sought and obtained, POVA First accessed and Criminal Record Bureau checks undertaken. However although the files contained two references as is required, in one file no reference had been taken from former care or educational employers and in another case a To whom it may concern reference had been accepted. It was noted on this visit that the application form only requires applicants to state the last 10 years employment history. Our regulations require that full employment histories must be obtained and that where an applicant has previously worked with children or vulnerable adults, a reference from this source must be obtained. For residents protection it is the providers responsibility to make sure robust systems are in place. Care Homes for Older People Page 22 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well run home. Evidence: The registered manager has been a home manager for about seven years. Her qualifications include the Registered Managers Award, Certificate in Management and Certificate in Dementia Care Management. Residents and staff spoke openly during the visit about their experience of living and working at the home. The registered manager promotes an open door policy for residents, visitors and staff. The organisation has major development plans. It is because of this the Chatham home has been demolished and a new purpose built home is currently under construction. When completed and registered with us residents will return to Chatham. Residents are looking forward to this. Care Homes for Older People Page 23 of 27 Evidence: As part of the homes quality assurance system, the provider undertakes annual surveys. The results are analysed and made available. The organisation has achieved Investors in People status. Meetings and forums are facilitated so residents can discuss their views and opinions of the service being provided. Residents and their advocates are being kept informed of the new homes progress. Meetings are held for team leaders and care staff and records are kept of matters discussed. The providers representatives make regular regulation 26 visits to the home to make sure it is being properly managed. Staff interviewed said they receive supervision and have opportunities to discuss any matters with their line managers at any time. Records for residents and staff are kept with due regard to confidentiality. However as stated previously, the maintenance of care records made it difficult to obtain a coherent picture of residents individual medical problems and action being taken. This could cause a problem if an investigation into allegations of poor care needed to be carried out. The returned AQAA indicates the home has policies and procedures for staff to refer to when carrying out particular duties. We have subsequently been informed they were reviewed in April 2008. The home maintains personal allowances on behalf of residents. Individual records are kept and receipts obtained for purchases or services obtained for them. Cash balances are kept in individual wallets in a secure place and accessible to two key holders only. There are occasions when the home is asked to store small items of importance or value on behalf of residents. Where this is the case records are maintained. Care Homes for Older People Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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. 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