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Inspection on 15/06/09 for Westmead Elderly Resource Centre

Also see our care home review for Westmead Elderly Resource Centre for more information

This is the latest available inspection report for this service, carried out on 15th 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The people who use the service feel they receive a good service, in safe and pleasant surroundings that is provided by a friendly, caring and efficient staff team. The care plans are up to date, person focused and people who use the service confirmed they are involved in planning their own care. The plans included all the areas required by the standards. The records inspected are well kept, accessible and easy to follow. The home is clean, tidy, odour free and reasonably well maintained. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2

What has improved since the last inspection?

Two requirements were made at the last random inspection in January 2009 regarding monitoring and accurate completion of health care charts and appraisal documentation for night staff. Both are met at this inspection. There are now a larger variety of activities provided within the home and better use of local facilities. The care planning has improved becoming more person-centred and the atmosphere in the home is much better with staff working as a team. The medication administration and recording is hugely improved.

What the care home could do better:

Key inspection report CARE HOMES FOR OLDER PEOPLE Westmead Elderly Resource Centre 4 Tavistock Road London W11 1BA Lead Inspector Wynne Price-Rees Key Unannounced Inspection 15th June 2009 10:30 DS0000036658.V375811.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 2 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 Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westmead Elderly Resource Centre Address 4 Tavistock Road London W11 1BA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7641 4595 020 7641 5781 nwaenie@westminster.gov.uk Westminster City Council Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (42), Old age, not falling within any other category (42) Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on the 5th September 2006, one named service user under the age of 65 years can be accommodated. The CSCI must be advised when the service user no longer resides at the home. 27th May 2008 Date of last inspection Brief Description of the Service: The home is registered to care for up to 42 elderly people who use the service of either gender. The home is registered to care for people who use the service with dementia and for those with mental health needs. The home is owned and run by Westminster City Council and is situated in the Westbourne Park area with easy access to transport links and local amenities. The home was purpose built in the 1970’s and is a two-storey building. There is a passenger lift fitted in the home making all areas in the home accessible to residents. The home is divided into four units, and each person who uses the service has their own bedroom, and there is a range of communal areas within the home. The fees charged can be obtained from the home. Details of what fees doe not include can be found in the home’s brochure. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection was unannounced and took seven and a half hours to complete during two days, on 15/06/09 and 16/06/09. During the course of the inspection people who use the service were spoken with to get their views of the service they receive. The Care Manager and staff were also spoken with, care practices observed, records and procedures checked and a premises tour undertaken. All key standards were inspected and this information was triangulated with that gathered since the previous key inspection to give the new quality rating. The home previously provided a selfassessment AQAA and the available information was compared to the inspection findings. An AQAA is a self-assessment document that is filled in by the home to show how it is performing against the minimum standards. Seven files of people who use the service were case tracked taken from all the units. Three of these had particular focus on meeting health care needs. Three staff files were also sampled. Twelve people who use the service and two visiting relatives were spoken with to get their views during the inspection. What the service does well: The people who use the service feel they receive a good service, in safe and pleasant surroundings that is provided by a friendly, caring and efficient staff team. The care plans are up to date, person focused and people who use the service confirmed they are involved in planning their own care. The plans included all the areas required by the standards. The records inspected are well kept, accessible and easy to follow. The home is clean, tidy, odour free and reasonably well maintained. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 6 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. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 7 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 are fully assessed to establish that their needs and wishes can be met before being given the opportunity to visit so that they can decide if they want to move in. EVIDENCE: “I was asked questions and told about the home before I came in”. “I visited before coming in”. The home has a written assessment policy and procedure that a sample of files seen and people who use the service we spoke with confirmed is followed. All Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 10 referrals come from Westminster City Council and full assessments are forwarded by Care Package Managers. The home then carries out its own face to face assessment and all the information is compared to identify if needs can be met within the registration requirements of the home. The home’s assessments are carried out with people who use the service to specifically establish what services they need, if they want them met at Westmead and if they can be provided. The home does not provide respite care. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 care plans are comprehensive with information in place that shows how staff support the people who use the service with their social, health, cultural, emotional, communication and independent living needs. People using the service are treated with respect and their dignity observed. EVIDENCE: “I am involved in my care plan”. “I meet with my key worker to review my plan”. “I always get my medication on time”. “Staff are very kind and respect me”. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 12 Seven care plans were sampled from different areas within the home. The format uses two files the first providing information required on a daily basis and the second containing more personal information. The second file feeds the daily one whilst not divulging unnecessary personal information. The daily files are easily accessible contain up to date information, including risk assessments and are reviewed monthly or as and when required. Identified care plan goals and risk assessments have matching numbering for easy identification. Daily notes are used to supply information for the reviews and are focused on describing what a person actually did during the shift. The care plan also includes night care. We looked at specific needs and wishes identified with goals set and matched them with daily notes and monthly reviews. This shows that the needs and wishes are being met and goals achieved. Health care needs are included within the care plans and reviewed monthly or as and when required. Everyone is registered with a GP. They also have access to community based health care services when needed. These include chiropodists, opticians and dentists. Regular two weekly liaison meetings take place between the home and community based professionals such as CPNs and District Nurses. A CPN is a Community Psychiatric Nurse. The medication administration records were checked for all people who are using the service. The records were up to date, correctly completed and any recording gaps had a written description on the rear of the records. This tells us the written medication policy and procedure is being followed. The medication description labels on the records not only state dosage and when to administer. They also describe symptoms, what may happen if not correctly administered and action to take. The controlled drug register was also checked and found to be correctly filled in with double signature entries. Each person also has a personal activities plan that they choose. People spoken with said they felt their dignity and privacy are respected and this is confirmed by care practices observed. Staff receive specific training regarding the importance of dignity and privacy and reference is made in the staff handbook. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 their preferences observed and their social, cultural, religious and recreational needs and interests met, meaning they have fulfilling lifestyles. They are encouraged to maintain contact with friends and relatives as they wish to enhance their social lives. EVIDENCE: “I like living here”. “I choose my own activities”. “I like joining”. I” enjoy visiting the pub where I have many friends especially when I am buying”. “I get my nails done”. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 14 “I go to the pepper pot”. “I visit my mother frequently”. “I like eating chocolate”. “The food is good”. “I don’t like going out in groups and enjoy going out for walks with staff”. The home offers a number of different activities with each person who uses the service having their own personal activity plan that they decide on with staff and the activities co-ordinator. When activities are identified by people who use the service staff integrate them into those available for the coming week. A number of new activities have been introduced including dog therapy, which is particularly popular, pub visits and picnics in the park. The home has also built up good relationships with local schools who invite people who use the service to events. Joint activities also take place with people from local sheltered housing schemes such as exercise classes and parties. There is also a thriving art group and a music project for people with dementia has taken place with a presentation by Princess Alexandra that was featured by the BBC. The home encourages people who use the service to pursue their interests and two are actively involved with the garden and two others visit the Pepper Pot lunch club. The home is beginning to introduce life history books to encourage further individual pursuits. These are also encouraged by further developing existing activities. One person did not speak much when they arrived. They expressed an interest in jigsaw puzzles and staff are using these sessions to encourage them to express their opinions more. Reminiscence sessions also take place in the garden when possible as this encourages a more relaxed atmosphere. Staff also discuss current affairs with people who use the service by distributing copies of the metro that the activities co-ordinator brings in daily. Visits take place outside the home principally a concert by the Connaught Opera at the Wigmore Hall. This opera also visits the home. The home is also compiling a list of befriending advocates for people who use the service that do not have any close relations. Relatives and friends visit the home whenever people who use the service wish providing it does not inconvenience others and two relatives visited during the inspection. People who use the service said they enjoyed the food and there was a good choice provided. It was well presented and plentiful during the inspection. The kitchens were clean, well-maintained, food appropriately stored and fridge and freezer temperatures checked and recorded. A recent health and safety inspection had two recommendations for a chopping board and fryer to be replaced and they have been. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 are listened to, complaints investigated with outcomes and they are protected from abuse. EVIDENCE: “I know who to complain to”. “I don’t have any complaints but if I did I know who to go and see”. “I feel safe living here”. People who use the service have access to the Westminster City Council complaints procedure. People who use the service and staff confirmed they have seen and understand. This was on display in the entrance hall. Any complaints made are recorded with outcomes. There were three complaints recorded since June 2008. Two have been thoroughly investigated with outcomes recorded and one is current. The complaints records are checked monthly as part of quality assurance to identify any emerging patterns. There were also numerous compliments letters and cards. There are currently seven Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 16 POVA investigations being conducted most of which have been concluded and are awaiting final reports. POVA is the protection of vulnerable adults. There is an adult protection policy and procedure that staff confirmed they have understood and all staff have received adult protection as part of induction with annual refresher courses provided by Westminster City Council. There is also access to advocates for people who use the service. Staff are CRB checked before starting work. CRB is the Criminal Records Bureau. There is a whistle-blowing procedure that staff confirmed they have access to and know how to use. Any monies kept on behalf of people who use the service are fully recorded with deposit, withdrawal, balance and receipt. A sample of money kept on behalf of people who use the service was compared to the records kept and tallied. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A homely, clean and safe environment is provided for people who use the service to live in. EVIDENCE: “I like living here”. “I feel this is my home”. “The decoration is a little worn”. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 18 The home has a warm and welcoming environment with a lot of smiling faces. New carpets have been put down in communal areas and dining-room chairs are on order. The home is also steam cleaned every three months and a premises tour showed it is kept clean and tidy with cleaners coming in. Although the decoration meets the standards it is looking tired and some of the furniture is scruffy. The home has access to a rolling training programme and this will be attended to as part of it. It has nice internal gardens that people who use the service have access to and there are plans to set up a café for people who use the service, visitors and staff in part of the building with garden access. Many people who use the service were making good use of the garden sitting out and listening to music when we visited. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 suitably trained, competent and diverse staff employed in suitable numbers to meet the needs and wishes of people who use the service. Staff are properly vetted. EVIDENCE: “The staff are very kind”. “Like everything else in life some staff are better than others but mostly they are very good”. “They help me when I need it”. “We go to the pub”. “Nothing is ever too much trouble”. “Staff are the best bit about living here”. “Sometimes they seem a bit stretched”. The day and night staff rotas demonstrated there are enough staff on duty at all times to meet the needs of people who use the service, although one Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 20 person felt that sometimes they seemed a little stretched. There are vacancies for two residential care managers, one night team leader, 30hr care assistant post and a room carer that the home are looking to recruit to. These posts are being covered by staff acting up or agency cover. There is a comprehensive recruitment procedure operated by Westminster City Council that meets the requirements of the standards and means people who use the service are safe and their needs professionally met. All staff are interviewed, have CRB and POVA first checks carried out before starting work and must provide references that are checked with a work history. Staff are issued with a code of conduct and practice during induction training and have access to a rolling training programme. This includes mandatory training in basic food hygiene, health and safety, fire, manual handling and first aid. 90 of staff currently holds NVQ level 2 awards, six have achieved level 3. NVQ is the national vocational qualification. Staff also have full access to training provided by Westminster City Council. The home operates a training matrix to keep fully up to date with required training for each staff member and qualifications already held. Supervision takes place six to eight weekly or more frequently as required and annual appraisals are held with personal performance plans. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 home is well managed in the interests of those who use the service and the quality assurance system is effective. Health and safety is well managed meaning that people who use the service live in a safe environment. EVIDENCE: “The manager is helpful and gets things done”. “The managers are good and listen to you”. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 22 The Care Manager came to post on 5th January 2009 and already a number of extensive improvements in the quality of service have taken place. They hold the NVQ level managerial qualification and are currently undertaking a degree. They also have eight years managerial experience. The quality assurance system is thorough, robust and incorporated as part of the overall council one. It contains identifiable performance indicators and action trigger levels. There is an annual business plan with set objectives and internal audits are carried out. These include monthly, unannounced regulation 26 visits with accompanying reports. Regulation 26 visits check that required quality service levels are met and are carried out by the provider’s representative. Weekly health and safety checks take place throughout the building and are fully documented. Any problems are recorded, reported and there is a designated health and safety officer. The fire fighting equipment was checked on 8th July 2008; fire alarms and doors are randomly tested weekly and fire drills take place monthly. PAT tests take place annually or when electrical appliances are introduced to the home and fridge and freezer temperatures tested and recorded twice per day. PAT tests are tests of electrical appliances to make sure they are safe and the last annual check was in November 2008. Full records are maintained of any monies held on behalf of people who use the service that include deposit, withdrawal, balance and receipts. Financial abuse is included in the safeguarding vulnerable adults training that staff receive. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The home should make sure redecoration and changing furniture that is looking tired is to the forefront of the rolling programme of works. Westmead Elderly Resource Centre DS0000036658.V375811.R01.S.doc Version 5.2 Page 25 Care Quality Commission South East The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 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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