Key inspection report
Care homes for adults (18-65 years)
Name: Address: Tulip Gardens 5 Court Farm Way Selly Oak Birmingham West Midlands B29 5BW two star good service The quality rating for this care home is: 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: Donna Ahern Date: 1 1 0 8 2 0 0 9 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: ï· Be safe ï· Have the right outcomes, including clinical outcomes ï· Be a good experience for the people that use it ï· Help prevent illness, and promote healthy, independent living ï· 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: ï· 3 stars – excellent ï· 2 stars – good ï· 1 star – adequate ï· 0 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. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) 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: ï· Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice ï· Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 ï· ï· 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 Information about the care home
Name of care home: Address: Tulip Gardens 5 Court Farm Way Selly Oak Birmingham West Midlands B29 5BW 01214783505 01214783505 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : New Outlook Housing care home 8 Number of places (if applicable): Under 65 Over 65 8 8 0 0 learning disability physical disability Additional conditions: The maximum number of service users who can be accommodated is: 8 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) 8, Physical disability (PD) 8 Date of last inspection A bit about the care home Tulip Gardens is a purpose built home in a residential area of Selly Oak. There is private car parking within the grounds. The home is close to local bus routes. The home is single story with eight single bedrooms. There is a good range of rooms for people to use including lounge, separate dining room, training kitchen and activity room. To the rear of the home there is a well kept garden with easy access from the main home. The home provides support to eight people who have a learning / physical disability. A copy of the service user guide is available. This tells people about the home. The fees for the service range from one thousand three hundred pounds per week. The fees do not cover hairdressing, chiropody, aromatherapy and day trips. 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 Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home One inspector visited the Home and did the inspection in one day. The Home did not know we were going to visit. Before we visited we looked at the things we had been told about the Home. We also asked the manager to send us information about the home. We met and spoke to all the people who live there. We also talked to the manager and staff. We looked at the care plans, medical notes and daily records for three people. We looked around the Home and at records about staff and health and safety. We sent surveys to people living in the home and a survey for them to give to their relative or representative. We also sent surveys to staff. 16 surveys were sent back to us and what people said is written in this report. What the care home does well Each person has a care plan. This tells staff how to help the person. The people living there go out and do things they enjoy with staff that know them well. Staff spend time talking to the people living there so they feel valued. People can choose what they eat and drink. Their diet helps to keep them healthy. Staff do health and safety checks so the Home is safe for the people who live there. What has got better from the last inspection Staff have had more training so they know how to help the people living there. There is a new vehicle to take people out in the wider community. It is more suitable for people who use a wheelchair. There is a new television and computer equipment for people to enjoy. There is new bathing aids so people can be bathed safely. What the care home could do better If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Donna Ahern 77 Paradise Circus Queensway Birmingham W Midlands B1 2DT 01216005300 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 set out on page 4. The report of this inspection is available from our website http:/www.cqc.org.uk/. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. Details of our findings
Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the information they need about the Home so they can make a choice as to whether or not they want to live there. Before people move into the home their needs would be assessed to ensure they can be met. Evidence: The statement of purpose and service user guide include all the required information about the Home. They include pictures and photographs making them easier to understand. This ensure that people have the information they need so they can make a choice about whether or not they want to live there. The Home also has a talking notice board which provides people who have a visual impairment with information about the Home. Since we last visited four people had been admitted to the Home. The records of two of the people were looked at. We saw that comprehensive pre- placement assessments were in place.This should ensure that their needs could be met at the Home. Further assessments are completed after they have lived at the Home for a short while. Staff told us that peoples needs are more complex and this has provide some challenges to the staff team . They felt people had settled well. Records that we saw confirmed this. Individual needs and choices
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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. 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. Staff have the information they need and a good understanding of how to offer care and support to each person, which should ensure peoples needs are met in a way they prefer. Evidence: We looked at three peoples care plans. Care plans explain what each person needs are and the care and support they require to make sure these needs are met. The files looked at had detailed information about how to meet peoples individual needs in relation to personal care, communication, health care, social activities, likes and dislikes. We saw minutes of reviews which include the person and people relevant to their care including family members and other professionals. This ensures that people’s needs are kept under review and makes sure that the Home can still meet their needs. Staff told us that some of the people who have been admitted more recently have more complex needs. They said they have received training and support so they know how to meet their needs. Staff told us they look at peoples care plans on a regular basis so they know how to support people. Staff were able to tell us information about how they meet peoples assessed needs, how they support people to be more independent and how to keep people safe. People told us who their key workers were. People said “X is my lead key worker she is ever so good. X is my key worker she talks to me about different things, staff talk to me about what’s in my care plan. We saw interactions between people living there and staff were generally friendly and relaxed. We saw staff engage well with people. People were encouraged to do things for Evidence: themselves and make decisions about how they wanted to spend their time. We saw risk assessments were in place that tells staff how they should support people to take risks whilst ensuring their safety as much as possible. Regular house meetings take place and we looked at the minutes of some of the meetings. People were asked about their views and comments on holidays, day trips, activities and menu planning. People told us We have residents meetings I chaired the meeting last Friday. We saw policies and procedures are in place to ensure that information about people is handled in a way so information is kept safe and only seen by people who need to see it. Clear guidelines are also in place for the handling of peoples post so they are supported to open and read their own post or if needed they are given the right support from staff to do this on their behalf. Lifestyle
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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. 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 people living there experience meaningful lifestyles so ensuring their well being. People are offered a varied and nutritious diet to help them stay healthy. Evidence: We looked at care plans and daily records to establish that people are leading meaningful lifestyles and taking part in activities that they enjoy. We also spoke to three staff members and observed care and support on the day. Care plans stated peoples cultural and religious needs. One of the people told us I like to go to church every Sunday. People are provided with opportunities to attend a range of activities and day time occupation. People attend day centres and local colleges. One of the people told us I do an exercise class on a Monday I go to the gym on a Wednesday and I like to go to craft lessons when the college is open. People told us that they had been on a recent trip to Blackpool and they had been to the Hippodrome theatre last week. Staff told us that suitable activities at home and in the community are still being explored for some of the people with more complex needs. One of the people told us “I get asked my opinion on my plans and outings. A new wide screen television has been provided in the lounge and a computer system has been installed in the activity room for people to use. Home based activities take place including art and Craft work. One of the people enjoys pottery and has attended classes in the local community. Lots of their work was appropriately displayed around the home. Evidence: People’s art work was also on display. People told us they enjoy doing this work. One of the people told us I like to make birthday cards for people. People told us they help out with household tasks and routines. People told us they can have a drink or snack when they want. One person said I sometimes help out in the kitchen I help make a cheese toastie. I scrub the vegetables for dinner and do some washing up. In addition to the main kitchen people have a training kitchen which can be used for making drinks and preparing snacks. The homes vehicle has been changed and is now a larger adapted vehicle which is more suitable for people who use wheelchairs. This will enable people to access a variety of community based facilities. People told us they also use ring and ride and local transport to access the local and wider community. People are supported to maintain close links with their family. We could see that family contact is discussed with people. On the care files we looked at there was good detail about how staff should support people to maintain these links. We saw that people freely access all areas of the Home. People told us they can have a drink or snack when they want to. Most people eat the evening meal at the same time; people told us they can eat their meal later if they want to. People told us The food is usually good We get nice food its fish and chips today. Records of food served are kept and show that people get a range of food so they maintain a healthy diet. Personal and healthcare support
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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements in place generally ensure that the personal care and health needs of individuals are met so ensuring their well being. Evidence: Tulip Gardens accommodates people who have a range of care needs. Ages range from late teens to sixties. Within this some people have specific and complex health care needs. All of the people have varying degrees of learning disability and visual impairment. Care plans looked at had information about how to meet peoples personal care needs. People were dressed in individual style that was appropriate to their age, gender, the weather and activities they were doing. We saw guidelines were in place for supporting people with their care needs during the night. Some additional information should be included so it is clear how staff are checking on people and why. Care plans detailed peoples preferences in relation to gender care so they receive support with personal care in a way that they prefer. We saw that each person has a Health Action Plan in place which should help to identify peoples health needs and what needs to be done to meet these needs. Some of the people require assistance to move using a hoist. We saw that assessments were in place telling staff how people must be moved safely. Staff told us that they were trained to use the equipment and we saw that the equipment is serviced and tested so it is safe to use. We saw that people receive support from other professionals such as physiotherapists and speech and language therapy. These people can advise and support staff on how they work with people so people’s needs are met. We saw detail of health and medical appointments and the outcome of these. This will ensure that people’s health needs are monitored and followed up. Evidence: Some people have equipment in place to prevent sore skin. We could see on their care plan what equipment is in place and what staff should do to prevent sore skin and keep the person comfortable. However separate risk assessments had not been completed which would clearly state what the risks are and what action the Home is taking to prevent sore skin developing. We looked at the arrangements in place for supporting people who have epilepsy. People had epilepsy management plans in place and staff had completed epilepsy training. Staff told us what they would do to keep people safe following a seizure. We looked at the arrangements for managing peoples medication. Medication is kept in a locked cupboard in the office. Staff had signed peoples individual medication administration record (MAR). This indicates that people have received their medication as prescribed. A record of medication coming into the home and returned to the community pharmacist had been kept which means that staff can check that medication has been given correctly and stored securely. We saw that only staff who have received medication training give out medication. Some staff new to the home were waiting to complete this training. We spoke to the manager about some medication errors that had been reported to us and she confirmed that these had been dealt with thoroughly, through the homes procedures. Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. 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. There are effective systems in place to listen to and respond to complaints about the service. Arrangements are in place so people should be protected from harm. Evidence: The complaints procedure was available on display in the Home. An easy read version was available so it was easier for people to understand. We have not received any complaints about this Home. One complaint had been made directly to the service and had been dealt with. One safeguarding matter had been dealt with under the safeguarding procedures and the matter was closed following a meeting with Birmingham Social Services. The manager discussed both these matters with us during the visit and demonstrated a commitment to follow the procedures fully so peoples well being is protected. Staff spoken with demonstrated a general understanding of their duty to safeguard people and how to report concerns on to the manager or senior managers in the organisations. Safeguarding guidelines and the whistle blowing procedures were available in the office for staff to refer to. We looked at training records to determine that training in safeguarding vulnerable adults had been provided. Some of the people due to their disability can display behaviour that can be difficult to manage in a group setting. We saw that records are kept of any such incidents and details of the action taken to support the person during and after the incident. The manager and two senior staff has attended Deprivation of liberty Safeguards and Mental Capacity act training and care staff have been booked onto training dates scheduled over the forthcoming months. 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. 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 live in a homely, clean, safe and comfortable home that meets their individual needs. Evidence: The home was decorated to a satisfactory standard and there were no maintenance matters of concern at the time of our visit. A recent visit from environmental services awarded the Home the highest standard for kitchen and food hygiene ensuring good standards are in place so people are not put at risk of infection. There is a good range of communal areas for people to use. There is a spacious lounge, dining room and activity room. In addition to the main kitchen the training kitchen provides an additional meeting and seating area. The Home is purpose built and all on one level. Corridors and doorways are spacious and allow people with specific mobility needs to move around the Home safely. Peoples bedrooms were personalised and reflected peoples individuality. Two people showed us their rooms and told us I like my room look at my new television on the wall. I like my room and like to spend time in here. All bedrooms have a wash hand basin. There are three toilets a bathroom and shower room. A specialist bath has been fitted in the bathroom so that peoples personal care needs can be met safely. There is limited moving space in the bathroom to transfer from a wheelchair to the bath. The manager was exploring how the bathroom could be further developed to meet peoples needs well. The rear garden is very well maintained with paved and grass areas and raised beds where people have been supported to plant bedding plants. level access allows people to make full use of it. The manager told us about the plans to build a sun house which would be developed as an additional communal space for people to enjoy. Evidence: 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. 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. Recruitment practice is robust and protects the people who live there. Staff receive the training they need to carry out their role effectively and meet peoples needs. Evidence: We watched the way that people interacted with staff on duty, which indicated that good relationships exist between people living there and the staff supporting them. People we spoke to knew who their key worker was. People told us The staff are really good I like X I can talk to her . We looked at the staffing rota for the week of the visit and the previous week. Staffing levels have been increased to between four or five on duty during the day. Extra staffing is needed to meet the more complex needs of people now living there.The manager told us that they are in the process of appointing new staff and they are currently using bank staff until these posts are appointed to. We spoke to four staff during this visit who demonstrated that they had a good understanding of peoples individual needs. We asked staff about meeting the needs of people who have come to live at the home more recently. Some staff have only worked a short time in the Home they were very enthusiastic about their work and felt that peoples needs are well met. Staff who have worked at the home for a while told us adjustments have been needed so that they can meet the more complex needs of the people who have come to live there more recently. Staff told us they have received the training and support to meet peoples needs. Staff told us in the surveys I feel the home is very well run and organised. I haven’t identified anything that I feel could be done better and We get relevant training to cater for service users and ensure basic needs are met We spoke to staff about the training they had received and we looked at the staff training Evidence: records to confirm they have the training they need to meet the needs of the people living there. This include mandatory training and training specific to peoples needs including Epilepsy, manual handling and safeguarding The AQAA told us that there are 17 staff and 13 of these have NVQ level 2 or above. This should contribute towards ensuring that the staff team have effective knowledge of social care. We looked at staff recruitment records for the two most recently employed people. Criminal Records Bureau checks (CRB) had been made and written references received before employees began work so that people were protected from the risk of having unsuitable staff work in the Home with them. Staff told us that they have supervisions and records seen confirmed this. This should ensure staff have the opportunity to reflect on their practice and consider their individual training needs. Regular staff meetings take place, which provide an opportunity for staff to discuss good practice and development issues. Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. 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. Arrangements in place ensure the well being of people living in the Home. People’s views about the home are asked for and acted upon. People are protected by safe working practices. Evidence: The manager has a number of years experience. She has the Registered manager’s award, NVQ level 4 and has continued to keep her knowledge up to date by attending further training as required. The manager is very much a hands on manager and was involved with direct contact and discussions with people living there and also directed staff in their role. Recommendations we made during the visit were responded to positively. The recommendation we made at the previous visit had been met. Demonstrating a commitment to meet standards. The needs of the people who live at the Home is now more complex. The manager has responded to these changes positively and has supported the staff team so they have the skills to meet peoples needs. The manager was able to tell us how the home will continue to be developed so that peoples needs can be well met. The provider carries out visit to the home to monitor and report on standards. In house audits across all areas of the home take place weekly and monthly ensuring good standards are maintained and people live in a good home. Peoples views are sought directly and through advocates. The AQAA told us that the organization produces an annual report and business plan. Evidence: The AQAA told us that policies and procedures are kept under review so that staff have the guidance they need to do their job safely and in line with up to date practice. We looked at some health and safety records including fire appliances and equipment we saw that these are checked and serviced regularly. The AQAA informed us that gas and electrical equipment had been serviced as required. A work place fire risk assessment was in place detailing the managers responsibility to safeguard people and was due to be reviewed. The manager agreed to deal with this so that arrangements in place continue to protect people. Are there any outstanding requirements from the last inspection? Yes ï£ No ï 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 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 Description 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 Description 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 2 19 Risk assessments should be in place detailing how the Home prevents the break down of sore skin. Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) 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. - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!