Inspection on 07/12/09 for Birdsgrove Nursing Home

This inspection was carried out on 7th December 2009.

CQC found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birdsgrove Nursing Home 22/03/10

Birdsgrove Nursing Home 21/01/09

Birdsgrove Nursing Home 30/01/07

Birdsgrove Nursing Home 07/02/06

Birdsgrove Nursing Home 29/09/05

Birdsgrove Nursing Home 13/12/04

Birdsgrove Nursing Home 04/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

Key inspection report Care homes for older people Name: Address: Birdsgrove Nursing Home Warfield Road Bracknell Berkshire RG12 2JA     The quality rating for this care home is:   zero star poor 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: Denise Debieux     Date: 0 7 1 2 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 41 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 41 Information about the care home Name of care home: Address: Birdsgrove Nursing Home Warfield Road Bracknell Berkshire RG12 2JA 01344422261 01344423629 birdsgrove@asterhealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Southern Counties Care Limited (Aster Healthcare) care home 87 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 to be accommodated is 87 The registered person may provide the following category of service: Care home with nursing (N) to service users of the following gender; Either whose primary care needs on admission to the home are within the following category : Dementia (DE) Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Birdsgrove Nursing Home is registered to provide personal and nursing care for up to eighty seven older people, twenty of whom may have a primary diagnosis of dementia. The home is situated on the borders of Bracknell in a residential area on the main thoroughfare to the village of Warfield. The home is divided into three wings determined by the development of the establishment over time. The Surrey Wing (23 places) was originally a large domestic home which has been converted, the Berkshire Wing (35 places) a purpose built two storey extension, and Care Homes for Older People Page 4 of 41 Over 65 0 87 87 0 2 1 0 1 2 0 0 9 Brief description of the care home the Kent Wing (20 places), a single storey extension built in the 1990s for residents with dementia. Fees range from £568 to £725 per week. This information was provided on 7 December 2009. Care Homes for Older People Page 5 of 41 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: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This unannounced visit formed part of a key inspection and was carried out on 7th December 2009. The acting manager was present as the representative for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the acting manager and any information that CQC/CSCI has received about the service since the last key inspection. The people who live at this home prefer to be referred to as residents. For clarity and consistency this term will be used throughout this report. On the day of this visit we met with all of the current residents, who were involved in the inspection and information was gained from seven on duty staff. Prior to the inspection, survey forms were sent to thirty residents, ten social and health care Care Homes for Older People Page 6 of 41 professionals and to twenty members of staff employed at the home. Survey forms were returned by eight residents, five social and health care professionals and ten members of staff. These survey forms were correlated and the results were shared with the acting manager during the inspection. Comments made on the survey forms, both positive and negative, were included in the correlation. Care was taken to exclude any comments that could identify the writer. Some of the comments made to us on the day of this visit and made on the survey forms are quoted in this report. The home sent us their annual quality assurance assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for residents living at the home. It also gives us some numerical information about the service. The AQAA was clear and gave us the information we asked for. Residents care plans, staff recruitment and training records, menus, health and safety check lists, activity records, quality assurance monitoring audits, medication records and storage were all seen and assessed on the day of this visit. We looked at how well the service was meeting the standards set by the government and have in this report made judgements about the standard of the service. We would like to thank the residents and staff for their time, assistance and hospitality during this visit and the residents, social and health care professionals and staff who provided additional information and participated in the surveys. Care Homes for Older People Page 7 of 41 What the care home does well: What has improved since the last inspection? What they could do better: At the last inspection there were nine requirements made. Despite assurances from the provider in June of this year, that all requirements had been met, we found at this inspection that six of the nine requirements had not been met. These requirements relate to: care planning and the accuracy of documentation; not meeting residents social care needs; staffing levels; staff recruitment practices and quality monitoring and assurance systems. At this inspection additional concerns were raised and new requirements and recommendations have been made. The provider must make sure that staff at the home are able to recognise incidents that could potentially be a safeguarding concern and take prompt and appropriate action. The provider needs to review the effectiveness of the organisations whistle blowing policy and identify why some staff members lack the confidence to raise concerns with the management. The provider must also make sure that new staff are appropriately supervised if they are allowed to start work pending receipt of an enhanced criminal record bureau certificate. The health, safety and welfare of residents is not being protected and the home is not being effectively managed. In line with our enforcement policy a management review meeting will be held and decisions will be made about the action CQC will take. This Care Homes for Older People Page 8 of 41 action may include enforcement action. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 41 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 41 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. Each resident is only admitted to the home following a needs assessment to ensure that the home can meet the residents identified personal and healthcare needs. This home does not offer intermediate care. Evidence: We were advised that, on the first enquiry from a prospective resident or their representative, the resident or their representative will be invited to visit the home. Following the initial visit to the home, and if the resident wishes to continue, the acting manager or one of the registered nurses will visit the resident and carry out a pre admission assessment to ensure that the home can meet the residents needs and wishes. In the AQAA, to demonstrate what the home does well, the acting manager stated that: All residents have a pre-admission and evaluation completed prior to admission Care Homes for Older People Page 11 of 41 Evidence: with input from interested professions. This forms the basis of the initial Care Plan. All prospective residents and their representatives are invited to visit the home prior to admission and to move in on a trial basis. This statement was supported by the findings on the day of this inspection. The care plans sampled during this visit each had preadmission assessments, carried out prior to the resident moving to the home. It was noted on one pre admission assessment that the section covering spiritual practices, cultural practices and hobbies/interests had been left blank, the acting manager told us that this information is gathered once the person has moved to the home. In order that the home can be sure they can meet all of a residents needs, it has been recommended that the home ensure that social care needs are always assessed prior to admission. Of the eight residents who returned survey forms, five felt they had received enough information prior to moving to the home, one answered no and two answered dont know. Care Homes for Older People Page 12 of 41 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health and personal care needs are met. The home has a plan of care that they, or someone close to them, have been involved in making but there is no evidence that the plan is used by the staff as a working document and the plan does not consistently reflect the care being delivered. Policies, procedures and practices are in place to ensure the safe administration of medication. Residents feel they are treated with dignity and respect at the home. Evidence: At the last inspection concerns were identified regarding residents care plans and a requirement was made. In June of this year the provider wrote to us to tell us what had been done to meet the requirement, in that letter the provider stated: The care plans for the service users within the home have been updated and invitations were sent to all families/advocates to take part in these reviews, some family/advocates did attend and take part and those who did so signed the various plans of care and risk assessments after full discussion, those service users who were able to do so signed all elements of their care plan. The plan does include social care needs as well as personal and health care needs. Daily entries are being made. Care Homes for Older People Page 13 of 41 Evidence: During this visit we sampled two care plans, one in depth. It was found that the requirement has not been met, although two elements had been, in that the plans sampled had been signed by relatives of the residents and the plans now included details of the social care needs of the residents and what action staff needed to take to meet their social care needs. However, the care plan sampled in depth was not up to date and there were some care plan entries that contradicted others. E.g. in one place it documents that, for medical reasons, the resident no longer gets out of bed, but in the night care plan the staff actions say that the resident gets out on her chair in the morning. The instructions in the hygiene care plan state that the resident usually wears shirt and trousers but we were advised by the acting manager that this no longer applies. The notes indicate that bed rest was introduced in August of this year, yet the monthly review of care plans for the hygiene and night care plans for September, October and November, say that the care plans remain ongoing/unchanged. Part of the previous requirement was that care plans must include the actions staff need to take to meet the need. Whilst the care plans all included actions, as described above the actions were not always accurate. This could potentially place residents at risk if staff members, that do not know the residents well, followed the instructions set out in the care plans. We were advised that all staff members are aware that this resident no longer gets out of bed, this would indicate that staff are relying on verbal information and are not working to the agreed care plans. The notes made by the nurses in their monthly review of care plans indicate that they are reviewing the care plan rather than reviewing whether or not the stated goal or desired outcome of the care plan has been achieved. The care plans contained detailed risk assessments with actions included to minimise any risks that had been identified. Some of these actions had been written by the nurses and other actions were pre printed on recognised pre printed risk assessments, e.g. the Waterlow score for skin and a nutritional screening tool. However, there was evidence that the actions set out to minimise identified risks had not always been followed. It was seen on the nutritional screening tool that pre printed instructions for high and very high risk scores were care plan and dietician. The resident had been scored as very high risk each month since August 2008, yet there was no record of a dietician being consulted. The acting manager explained that a dietician referral is not sought by the home when nutritional concerns are identified but that any concerns regarding someones nutritional status are first referred to the GP, who then assesses whether a dietician should be involved. It was suggested to the acting manager that the pre printed forms used at the home should be reviewed and amended to accurately reflect the practices at the home. It was also seen in the care plan that the resident had a documented weight loss of 11kgs over three months, with two months Care Homes for Older People Page 14 of 41 Evidence: in between when the persons weight was not recorded. We were advised that the scales needed to weigh this resident had been broken and it was felt that the person had not, in fact, lost weight but the discrepancy was due to the scales being inaccurate before they had realised they were not working. However, this was not documented in the care plan and there was no comment made in the nurses monthly care plan review when the monthly weight recording identified a potential large loss of weight. There was no evidence in the file to show that staff had been following the residents activity care plan, this is discussed further in the next section of this report. The staff make daily notes, with care assistants and registered nurses making their own entries on different recording sheets. These daily notes were sampled and, as identified at the last inspection, remain general in detail (e.g. ate and drank well; slept well; washed and dressed) and do not evidence that staff are aware of, or working towards, the identified goals set out in the care plans. Part of the morning medication round was observed and the medication administration records, medication storage, policies and procedures were all sampled and mostly found to be in order. When sampling the controlled drug register there was one page where, instead of entering the name of the drug at the top of the page someone had put the residents name by mistake. There were a number of entries on this page, where two nurses had checked and signed to verify the stock total. None had identified that there was no mention of the name of the drug that they were checking on the page. It is not clear how the nurses had decided what drug stock they were checking and countersigning. The management monitoring of systems, policies and procedures is addressed in more detail in the Management and Administration section later in this report. Residents feel they are treated with dignity and respect at the home. On the day of this visit we saw that staff addressed residents in a respectful way and had a caring attitude towards them. They were seen to knock on doors before entering, and one staff member hung a Care in progress notice on the bedroom door when she went in to carry out personal care tasks. On both wings, some doors had alternative names, these were the names which residents preferred. No residents raised any concerns about how staff treated them during the visit and one resident, when asked if he felt staff behaved respectfully towards him, replied: Absolutely. Surveys from residents and their families commented positively on the staff who work at Birdsgrove, with one noting The staff are all very friendly and helpful. Many are affectionate to my relative. Surveys returned from social and healthcare professionals had a more mixed response. Out of the five respondents, on the question relating to Care Homes for Older People Page 15 of 41 Evidence: whether the service respected peoples privacy and dignity, three ticked Usually; one ticked Sometimes; and one ticked Dont know. Some minor shortfalls, identified by one resident, were highlighted to the acting manager for her attention and action. Care Homes for Older People Page 16 of 41 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst improvements have been made in relation to organising group activities, the home is failing to ensure that all residents have the opportunity to take part in meaningful social activities that are based on their individual preferences and abilities. Residents are encouraged to maintain contact with their families, but would benefit by having more opportunities to be part of the local community, including the chance to go out from time to time. Residents are given some opportunities to exercise choice and control over their lives but this would be improved if there were more staff available to support them in activities not directly related to their personal and health care. Meals are well balanced and varied with individual choices and preferences catered for. Evidence: At the last inspection a requirement was made relating to enabling each resident to engage in meaningful social activities that are based on their individual preferences and abilities. In June, at our request, the provider wrote to us to tell us how this requirement had been met. In the response, the provider stated that there were now two activities organisers, and that the activities in the home now reflect all of the service users hobbies, interests and wishes where feasible. This statement was not Care Homes for Older People Page 17 of 41 Evidence: supported by the findings of this inspection and the requirement has not been met. A tour of the Surrey and Kent Wings enabled us to get an overview of arrangements for residents, with particular emphasis on how the service was enabling the residents with dementia to take part in fulfilling and worthwhile activities and have opportunities for social interaction. It was evident that progress has been made in relation to improving the group activities, with two activities organisers now employed by the home, and the acting manager said that they are currently undergoing distance learning training. Some care staff have had training in activities, and there is an activities plan in place, with records of how each resident has participated. The home was brightly decorated for Christmas, and the ongoing refurbishment will have real benefits for residents when completed. One activities organiser was in the Berkshire Wing doing manicures and assisting the hairdresser. The other activities organiser was off sick that day and so staff on Kent Wing were going to be doing activities with residents. The activities plan included folding clothes and washing plates; watching movies; music; and ball games. Staff said some residents go out to day care and the stroke club, and some are taken out by their relatives. Staff were seen to interact well with residents. One staff member who was accompanying us sat holding the hand of one resident who was sitting on her own. Four residents who took part in a ball game before lunch appeared to be engaged in the activity, and two other residents were being encouraged to look at some musical Christmas novelties. However, whilst staff were willing to engage with residents, they were too busy. There were three staff for eleven residents on Kent Wing, and they finished their morning work helping with residents personal care, and then serving drinks, at 11.15am. In the forty five minutes before lunch, they were able to start a ball game with one group, and a table activity with another, but the two care staff were called away to help a resident in their room, leaving one member of staff who was engaged with us. The two activity organisers both work six hours a day from Monday to Friday. Apart from the hours worked by the activity organisers, we were advised that staffing levels for the home are only calculated on meeting residents health and personal care needs, making sure there are enough staff to also meet residents social care needs are not included in these calculations. Care Homes for Older People Page 18 of 41 Evidence: Records of activities did not reflect residents hobbies and interests, and showed very little recorded activities sessions with each person. One resident no longer gets out of bed and in their care plan the activity organiser had highlighted the need to find activities that can be done in the residents room. However, there was no further reference to new activities being identified apart from a visit by the pat a pet dog. There was no evidence that other activities, identified in the care plan and needed to meet this residents social care needs, had taken place: e.g. daily music sessions, taste therapy. The acting manager said she would highlight to staff that activity sessions needed to be recorded. On arrival at the wing most residents were sitting, with no interest or stimulation, except the television which no-one appeared to be watching. On leaving the wing, forty five minutes later, they were still sitting with no interest or stimulation, except for the short interlude with the ball game. When asked on the survey form if the home arranged activities that they could take part in if they want, two residents answered always, one answered usually, four answered sometimes and one left this answer blank. Surveys returned from residents and health and social care professionals all highlighted the need for more social activities. In response to the question What could the home do better one residents relative commented on their survey form: More staff. More activities. Clients are left to sit all day. In response to the question What does the home do well one resident commented: Activities, when time is given to it. But not enough time is allowed for this. Comments received from social and health care professionals when asked what the home could do better included: Providing more varied social activities that could benefit most of the clients., They should have more stimulation and residents should not be in their rooms most of the time, especially for their meals. and More activities. Increase staff-patient ratio. Staff outlined a number of contacts with the local community including a visiting pet, a gentle exercise to music practitioner, and an ex-member of staff who comes in to see residents. Some residents attend a day centre and the stroke club and we were advised that regular religious services are held by local representatives from the Roman Catholic and Church of England churches. Staff said visiting was open, and that families were made welcome. However, more community contact would benefit residents, for example if they could be taken out more. Staff and the acting manager confirmed that there had not been any outings for residents arranged by the home this summer. Surveys returned to us from residents showed they had had assistance from their relatives to complete these. Comments received from relatives on survey forms included: Friendly, helpful staff. Make residents comfortable., Tea making Care Homes for Older People Page 19 of 41 Evidence: facilities always available. and The staff are all very friendly and helpful. Many are very affectionate to my relative. We can visit any time of day. Residents are given some opportunities to exercise choice in their daily lives. On a tour of the bedrooms the nurse who accompanied us asked every resident if they would like a drink, and two people asked for something to eat. She passed on their food preferences to care staff to arrange this. One resident, discussing his favourite foods, said his favourite meal was a fry up and would like to have some eggs and bacon from time to time. Following the inspection this was discussed with the acting manager who said residents often have a Brunch on Saturdays and that cooked breakfasts are available. She said she would ask the cook to speak with this resident to make the arrangements. Some rooms visited had been personalised with residents photographs and memorabilia, and those rooms on the Kent Wing had familiar photographs on the door to help residents identify and personalise their own doors. On the Surrey Wing, many residents were in bed and unable to call for assistance. An hourly monitoring chart is in each bedroom and staff make regular checks on those residents who are not able to use their call bells. Many of the current residents are very dependent on support from staff and their choices will be limited by the availability of staff, for example to take them out if they wish to go, to support them in activities, and to provide them with opportunities for social interaction. From observations made during this visit, resident choice would therefore be very limited as care staff were fully occupied with care tasks. The activities organisers need the support of management to ensure that they are able to implement the work they have started on identifying and providing appropriate social activities for each individual resident. All staff need to be supported to ensure that they have the time and skills necessary to fully implement and work to the individual residents activity care plans already written. Ensuring that residents social care needs can be met needs to start at the pre admission assessment stage so that the home can be certain that they can meet all of a prospective residents needs, before offering them a place at the home. Menus sampled showed that the home offers a varied and well balanced menu, with residents able to choose alternatives if they do not want the dish that is on the menu on that day. The lunchtime meal was taking place during this visit and the food was well presented. Staff were available to assist those needing help with their meal and it was positive to note that some residents are starting to make use of the newly built dining areas on the Wings and were sitting in small groups, enabling more social interaction. Care Homes for Older People Page 20 of 41 Evidence: In the AQAA, to demonstrate what changes had been made at the home as a result of listening to residents the acting manager stated: Changes in menus ongoing and personal menus agreed with residents. Of the eight residents who returned survey forms, one said that they always liked the meals at the home, five answered usually and two answered sometimes. Care Homes for Older People Page 21 of 41 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If residents have concerns with their care, most residents, or people close to them, know how to complain. Policies and procedures are in place to protect residents from potential harm or abuse but the home needs to improve the recording of actions taken by management when any incident is identified that could potentially be a safeguarding concern and ensure that staff fully understand when safeguarding referrals should be made. Steps need to be taken to ensure that staff can feel confident to approach management under the homes whistle blowing procedure. Evidence: The home has a complaints procedure in place that is available to all residents and their relatives and is also included in the residents guide. Of the eight residents who returned survey forms, seven said there is someone they can talk to if they are not happy and that they knew how to make a complaint and one answered no. Staff surveyed all said that they knew what to do if someone has concerns about the home. There is a whistle blowing policy in place and the home have a copy of the latest Berkshire Safeguarding Adults Policy and Procedure. In the AQAA, to demonstrate improvements made at the home, the acting manager stated that: All staff have revisited Whistleblowing and POVA (protection of vulnerable adults) training has been undertaken in October/November 2009 with input from Bracknell Safeguarding Team. However, there has been an inconsistent management approach to whistle blowing Care Homes for Older People Page 22 of 41 Evidence: and concerns, with some staff having a lack of confidence in when and how to use policies and procedures. Since the last inspection there have been a number of concerns raised with us, and the local authority safeguarding team, from staff who did not feel they could approach the management at the home. Concerns have also been raised with us, and the local safeguarding team, by a visiting health professional and relatives of people living at the home, that they felt could not be taken up directly with the homes management. In one care plan sampled there were notes made by the staff of the resident having some unexplained bruising on two separate occasions. The bruises were well documented and notes showed that the residents relatives had been informed. However, these incidents of bruising had not been referred to or discussed with the local safeguarding team and, although there was a note that on one occasion the bruises had been reported to the acting manager, there was no further documentation to show that the cause of the bruises had been looked into or that explained how the decision had been reached to not contact the safeguarding team. While there is no suggestion that the bruises were a result of possible abuse, the home must ensure that the local safeguarding procedures are followed at all times and that detailed notes are recorded of actions taken when concerns are raised with the management. A requirement and a recommendation has been made. The need to improve record keeping practices is addressed in more detail in the Management and Administration section of this report. Since the last inspection there have been a number of management changes at the home, resulting in the staff not having a stable management team since the end of April. At the beginning of October, the previous registered manager returned to the home, as acting manager, to oversee the management of the home, although this is only a short term measure. Staff spoken with during our visit told us they were pleased the acting manager had returned and that she is approachable and listens to them. One staff member commented on their survey form that the acting manager: is lovely and good to staff, understands and is able to solve most of the difficulties. Care Homes for Older People Page 23 of 41 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 provision of communal lounge/dining areas on Berkshire Wing and the recent and extensive refurbishment of the home, when completed, will offer much improved facilities for residents to socialise and dine together if they wish and will provide all residents with clean, pleasant and homely surroundings in which to live. Evidence: At the last inspection concerns were raised that promised building works to improve the homes facilities had not been carried out and that residents and staff were not being kept up to date with the plans, and a requirement was made. In order to meet that requirement the provider drew up a plan of works, with clear start and finish dates and the plan was posted on the homes main notice board. Since then the planned work has been carried out and is nearing completion. These improvements have included the resiting and provision of a new main kitchen, and the provision of two lounge/dining rooms on Berkshire Wing. This work has involved extensive rebuilding of those areas. Now that the main construction work has been completed, work is underway to redecorate and refurbish all communal areas, replace the carpets in the hallways, stairs and communal areas and to redecorate and re-carpet some bedrooms where needed. On the day of this visit we were shown around all areas of the home. The furniture and furnishings were seen to be of a good quality and many bedrooms were seen to Care Homes for Older People Page 24 of 41 Evidence: have been personalised with residents own personal items and mementos. The new lounge/dining rooms were bright and well laid out and will offer much improved facilities for residents to socialise and dine together if they wish. Laundry facilities are sited in the basement with washing machines suitable for the needs of the residents at the home. At the last inspection it was found that residents were not always being provided with a means of calling for help if needed and a requirement was made. This requirement has been met. Following the last inspection, each resident was assessed for their ability to use a call bell, and, where it was assessed that they were not able, or would have difficulty using a call bell, hourly monitoring sheets were introduced so that staff can evidence that they have visited the resident at least once an hour throughout the day and night. On the day of this visit, during a tour of the home, we found that residents that were able to use call bells had them within reach and that residents who could not use the call bell system had been checked at least once an hour. We were advised that the registered nurses check the monitoring sheets periodically throughout the day and take action if visits are not recorded. This ongoing monitoring by the registered nurses also meets a second requirement made, that the system put in place to ensure that residents have access to a means of obtaining assistance when needed, is adhered to and successful. The provider and staff at the home are to be congratulated on the steps they have taken to reduce the disruption to residents and visitors while the improvements to the home are being made. Care Homes for Older People Page 25 of 41 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are not available in sufficient numbers, at all times, to fully meet the personal, health and social care needs of the residents. Staff recruitment practices at the home continue to place residents at risk of potential harm and/or abuse. Residents are cared for by staff who get the relevant training. Evidence: At the last inspection a requirement was made that the provider review staffing levels to ensure there were enough staff to meet all the personal, health and social care needs of the residents. In June of this year the provider wrote to us to tell us what had been done to meet the requirement, in that letter the provider stated: Staffing levels meet the needs of the current service users and the Acting Home Manager adjusts her staffing levels to meet the current needs of her service users and the lay out of the Home. This statement is not supported by the findings of this inspection and the requirement has not been met. As described in the Daily Life and Social Activities section of this report, the home is not meeting the social care needs of the residents, with strong indications that this relates directly to the staffing levels at the home. We were also advised that staffing levels are only calculated on meeting residents health and personal care needs, making sure there are enough staff to also meet residents social care needs are not Care Homes for Older People Page 26 of 41 Evidence: included in these calculations. There are three shifts at the home, the morning shift runs from 8am to 2pm, the afternoon/evening shift runs from 2pm to 8pm and the night shift is 8pm until 8am. Each Wing is staffed individually with current staffing levels being as follows: Berkshire Wing (currently has twenty eight residents) has one registered nurse and six care assistants on the morning shift and one registered nurse and five care assistants on the afternoon shift. Surrey Wing (currently has seventeen residents) has one registered nurse and four care assistants on the morning shift and one registered nurse and three care assistants on the afternoon shift. The night staff consists of one registered nurse and two care assistants on each of the three wings. From the information given to us at the last inspection, the above figures equate to an overall increase in care staff numbers of one person per each twenty four hour period for the same number of residents as were living at the home on the day of the last inspection, with the extra person working on the night shift. Of the eight residents who returned survey forms, three stated that staff are always available when needed, four answered usually and one answered sometimes. The home shows a strong commitment to supporting staff to obtain further qualifications with over 50 of care assistants holding a National Vocational Qualification (NVQ) level 2 or above in care. At the last inspection concerns were identified in relation to staff recruitment practices and a requirement was made. In June of this year the provider wrote to us to tell us what had been done to meet the requirement, in that letter the provider stated: A detailed check did take place on all personnel files the day after the last inspection and all staff currently employed have all the relevant documents and checks completed. Those staff involved in recruitment of staff are fully aware of the need to adhere to the legal requirements. This statement is not supported by the findings of this inspection and the requirement has not been met. During this visit the files of two recently recruited members of staff were sampled. Both files were seen to contain proof of identity, two references and a completed application form. However, the home had not verified the applicants reasons for leaving previous employment with vulnerable adults; had not been obtaining full employment histories and both had gaps in employment that had not been explained or explored, with a gap of fourteen years in one file and six years in the other. For both applicants it was seen that the home had applied for an enhanced Criminal Care Homes for Older People Page 27 of 41 Evidence: Record Bureau (CRB) prior to the applicants starting to work at the home. A Protection of Vulnerable Adult (POVA) first check had been obtained for the person that started before October 2009 and a new Independent Safeguarding Authority (ISA) Adult first check had been obtained for the person that started after October. (The POVA list was replaced by the ISA Adult list in October of this year.) At the last inspection it was reported that the home were not aware that staff can only start work pending the return of a full CRB certificate in exceptional circumstances and only then if all other recruitment information is in place. The provider was advised in the last report to refer to the Department of Health POVA guidance for full details. The same situation has been found during this inspection. The two new applicants are both working at the home pending the return of a full CRB certificate, there is no explanation of what the exceptional circumstances were and the home have not obtained all the required recruitment information and documents. This is explained further on the CRB website: ISA Adult First checks are available in only very exceptional circumstances. For England these are described in Department of Health (DH) guidance as, where a care worker may be allowed to start work in a care home before a CRB check has been issued. Such cases are permissible only where it is necessary to take such action because of a real danger that staffing levels will otherwise fall below numbers required to meet statutory obligations. The acting manager confirmed that this was not the case for the two new applicants. Also at the last inspection it was found that the home were not aware of, and had not put in place, additional measures that are required when they allow people to work at the home pending the return of a full CRB. At that time copies of the CSCI guidance explaining these additional measures were left at the home for their guidance. At this inspection we found that the home have again failed to put these measures in place, the two new applicants do not have a named staff member who is on duty at the same time as them as far as is possible and who would accompany the new worker if they escorted residents away from the home. A new requirement has been made. It is concerning that there has been no improvement to the homes recruitment practices since the last inspection. These practices are continuing to place residents at risk of potential harm or abuse. Staff induction is in line with the mandatory Skills for Care common induction standards and we were advised that staff are supervised until they have completed their induction. Staff are booked on additional training and updates as the courses become available. Of the ten staff members who returned survey forms, nine answered that they are given training which is relevant to their role; helps them Care Homes for Older People Page 28 of 41 Evidence: understand and meet the individual needs of the residents and keeps them up to date with new ways of working. One member of staff added a comment that the home: Ensures that we are trained in all caring needs and other mandatory subjects such as health and safety, fire etc. and another staff member commented: Plenty of training and courses to do for staff. In the AQAA, to demonstrate what the home does well, the acting manager stated that: Our training figures continue to improve and new staff are progressing well in their Common Induction Programme/NVQ Programmes. This statement was supported by the findings on the day of this visit. Of the eight residents who returned survey forms, three said that the staff always listened and acted on what they said, four residents answered usually and one answered sometimes. When asked on the survey form what the home does well, comments made included: take care of me; generally a good caring attitude and the staff are all very helpful and friendly. One social and health care professional commented: The staff are caring and co-operative with family members. Care Homes for Older People Page 29 of 41 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a lack of organisational monitoring of the running of the home and a lack of organisational support to the staff team in the absence of a competent registered manager. The health, safety and welfare of the residents is not being fully protected and the home is not being effectively managed. The quality assurance and monitoring systems in place at the home are not effective in evaluating and ensuring that the home is providing a good quality service for the residents or that the requirements of current legislation and the homes policies and procedures are being followed, in practice, by the staff. Policies and procedures are in place to protect residents financial interests. Evidence: Policies and procedures are in place to protect residents financial interests. The acting manager stated that the home does not handle the financial affairs for residents. In May of this year the previous registered manager moved to another position within the organisation and a new manager was appointed for the home. At the beginning of Care Homes for Older People Page 30 of 41 Evidence: October the new manager left and we were notified that the previous registered manager had taken over the role as acting manager on a temporary basis until a new manager could be appointed. During this inspection the manager explained that this is for a short time only and she is only overseeing the management of the home, the deputy manager and the registered nurses are carrying out the majority of the management tasks with the acting manager offering support and guidance when needed. A new manager has not yet been identified or recruited. Some members of staff spoken with, on the day of this visit, explained how this had been a very difficult year with no clear sense of direction for the team and a number of changes in management styles. Comments received from staff on survey forms included: To set goals. Act on what we need to improve, maintain positive views, get standards raised, and morale, as it is low at this present time., Be seen by outside people that we do do our best. and Have a firm management structure without changes. Despite the lack of a permanent, skilled and competent manager, the staff team have worked together trying to provide consistency for the residents and to ensure that a good standard of health and personal care for the residents is maintained. A number of staff have left the home in the past few months and new staff have been recruited, adding extra pressure on the team during this difficult time. The staff are congratulated on their continued commitment and their hard work in this area over the past seven months. At the last inspection three requirements were made that directly related to the management of the home and the need for effective quality assurance monitoring. One was that the management must monitor the systems put in place to ensure that residents are able to obtain assistance when needed. As described earlier in this report, the registered nurses are monitoring the new system and ensuring that the hourly resident checks are taking place. This meets the requirement and we found that the system was working on the day of this visit. Another requirement was made that the management must put in place a system to monitor that staff are following the requirements for care planning, meeting residents assessed needs and reducing potential risks. In June of this year the provider wrote to us to tell us what had been done to meet the requirement, in that letter the provider stated: There is a quality assurance system in place to monitor that care plans are current and appropriate to the service users assessed needs. We found that the system in place is not effective and the requirement has not been met. In one care plan we sampled, there was a care plan audit sheet dating from January of this year. Care Homes for Older People Page 31 of 41 Evidence: However, this was only an audit of whether or not certain documents were present in the care plan and was not a quality audit requiring the accuracy of the documentation to be assessed. As described earlier, we found a number of areas in a care plan which were not up to date or accurate but the monthly reviews by the nurses had stated that they were. We were shown an Overview Audit which had been carried out in September. This audit is carried out every three months and covers many different areas, including the residents care plans. The acting manager had carried out the September audit and explained that three or four care plans are sampled each time. Given that these audits are only carried out four times a year, and given the number of beds at the home, this system does not enable the provider to obtain a complete picture of the quality of the care plans, to judge whether residents personal, health and social care needs are being met or that their safety is being protected. None of the above quality monitoring systems had been effective in identifying that the care plan sampled was not up to date; the residents social care needs were not being met; staff were not working to the care plan and that the documentation was not to the standard expected of the homes own policies and procedures. A recommendation has been made that the provider review, with the registered nurses, the Nursing and Midwifery Councils latest guidance on record keeping. Health and safety monitoring check sheets were sampled and found to be mostly well maintained and up to date. However, at the last inspection we reported that: There are a number of fridges around the building on each unit. The inspector was advised that staff are aware that only unopened meal supplements are to be kept in these fridges but the inspector found food (e.g. sandwiches, opened milk, yoghurt) in one and there is no effective system in place to ensure that staff are complying with the management instructions on the use of these fridges, which are not monitored or included in the fridge temperature recording required for food storage fridges. During this visit we found that this situation had not changed. We again found food in one of the fridges in one wing. There were unopened yoghurts that had a use by date of the 29 October 09 and a large carton of milk that is used in a milk machine. This fridge had no means of recording the temperature and is still not included in the homes daily monitoring of fridge freezer temperatures. The acting manager told us that the rules had not changed since the last inspection and that staff should not be keeping these items in these fridges. During our tour of the home we noted a clinical waste bin that was badly rusted. The hinge to the lid was rusted through and no longer attached to the bin. We were shown an infection control audit carried out in October that stated: foot operated pedal bins, which are clean and in good working order are available for clinical and offensive waste. It is concerning that this audit had not identified that the bin was in a bad Care Homes for Older People Page 32 of 41 Evidence: state of repair and also concerning that staff had continued to use the bin for disposal of clinical waste. At the last inspection it was identified that, although policies and procedures were in place, there was no effective management monitoring to ensure that staff were aware of and working to the homes policies and a requirement was made. In the letter sent to us in June of this year the provider stated: The Registered Manager and the Acting Home Manager are aware of the need to monitor staff and to be aware of the need to comply with any legislation. In addition to the infection control concerns identified above, we have described a number of areas in earlier sections of this report where the homes policies and procedures are not being followed. For example: spiritual practices, cultural practices and details of hobbies not being obtained at pre admission assessment; care plans not being up to date and not always accurate; the controlled drug register incorrectly completed; staff not following care plans in relation to social care needs; staff not following the whistle blowing policy; staff not always following the local safeguarding procedures; poor staff recruitment practices. The requirement has not been met, there is still no effective management monitoring system that makes sure that staff are working to the homes policies and procedures or that the home is compliant with all relevant and current legislation. We were advised that many of the management tasks have been delegated to the deputy manager and the registered nurses at the home, with many of these tasks involving the quality assurance monitoring of the home. It must be noted that, while the provider may chose to delegate management tasks in the absence of a registered manager, the legal responsibility and accountability remains with the registered provider. It is concerning that, despite the assurance of the provider in June of this year that all previous requirements had been met, we found at this inspection that six of the nine had not. Care Homes for Older People Page 33 of 41 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 7 15 The registered persons must 31/03/2009 ensure that all service users have an up to date plan of care setting out actions that staff need to take to meet the needs of the service users. The plans must include social care needs as well as personal and health care needs. Daily notes need to evidence that staff are following the actions set out in the plan to meet the service users needs and reduce any potential risks to their health or wellbeing. The home also needs to evidence that service users or their representatives have been involved in and agreed to their plan of care. This requirement also applies to National Minimum Standard 8. In order that service users can be confident that they or their representative will be fully involved in the planning of their care, that all aspects of their personal, health and social care needs are met and that the care provided is consistent and takes into account their personal wishes and preferences. Care Homes for Older People Page 34 of 41 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 2 12 16 The registered person must 21/06/2009 provide facilities for recreation and make arrangements to enable each service user to engage in meaningful social activities that are based on their individual preferences and abilities, particular attention should be paid to those with dementia, cognitive impairment, sensory impairments and physical disabilities. In order that service users can be confident that the home can meet their social care needs and takes steps to reduce the risk of social isolation. 3 27 18 The registered person must 21/02/2009 ensure that staff are available in sufficient numbers, and at all times, to meet the personal, health and social care needs of all service users. The registered person must ascertain and take into account the number of staff needed to provide the level of supervision indicated by the difficulties presented by the layout of the building and the numbers of service users who are unable to use the call bell system if they need assistance. In order that service users can be confident that their personal, health and social Care Homes for Older People Page 35 of 41 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 needs will be met and that the home is staffed so as to protect and promote their health, safety and independence. 4 29 19 The registered person must 21/02/2009 ensure that all staff involved in recruitment are fully aware of, and adhere to, the requirements of the Care Homes Regulations 2001 as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004 and ensure that no person is employed to work at the home without all the required checks and documents having first been obtained. In order to protect the service users from the potential risk of harm or abuse. 5 33 10 The registered person must ensure that there are methods in place for the manager to monitor that staff are aware of and complying with the policies and procedures of the home and any legislation that applies to the running of a care home. In order that service users can be confident that the home is run and managed in their best interests and in a 21/03/2009 Care Homes for Older People Page 36 of 41 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 way that protects and promotes their health, safety and independence. 6 33 24 The registered person must 21/02/2009 put in place a quality assurance system to monitor and ensure that staff are following the requirements for care planning, meeting assessed needs and reducing potential risks, as set out in the Care Homes Regulations 2001 and their own policies and procedures. In order that service users can be confident that the home is run and managed in their best interests. Care Homes for Older People Page 37 of 41 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 18 13 The registered person must 07/01/2010 make arrangements to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person must ensure that actions taken, when any incident is identified that could potentially be a safeguarding concern, are fully recorded. The registered person must also ensure that staff are able to recognise potential safeguarding concerns and fully understand when, and how, safeguarding referrals should be made to the Bracknell Forest Borough Council safeguarding team and ensure that any concerns are referred without delay. In order that residents can be confident that the home Care Homes for Older People Page 38 of 41 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 safeguards them from abuse and neglect and takes prompt and appropriate action to follow up any concerns. 2 29 19 Where the registered person 07/01/2010 permits a new worker to start work pending receipt of an enhanced criminal record bureau certificate, the registered person must: appoint a member of staff the staff member who is appropriately qualified and experienced to supervise the new worker; so far as is possible ensure that the staff member is on duty at the same time as the new worker; and ensure that the new worker does not escort residents away from the care home premises unless accompanied by the staff member. In order to protect the residents from the potential risk of harm and/or abuse. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 3 It is recommended that the registered person ensures that social, cultural and spiritual needs are always included in Care Homes for Older People Page 39 of 41 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 the information gathered prior to a resident being offered a place at the home. So that prospective residents can be confident that the home can meet their social care needs as well as their personal and health care needs. 2 18 It is recommended that the registered person reviews the effectiveness of the organisations whistle blowing policy and consults with the staff to identify why some staff members lack the confidence to raise concerns with the management. It is recommended that the registered person review, with all registered nurses, the Nursing and Midwifery Councils latest guidance on record keeping. 3 37 Care Homes for Older People Page 40 of 41 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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