Inspection on 14/07/09 for Donness Nursing Home

This inspection was carried out on 14th July 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Donness Nursing Home 20/08/08

Donness Nursing Home 03/09/07

Donness Nursing Home 13/07/06

Donness Nursing Home 14/09/05

Donness Nursing Home 07/04/05

Donness Nursing Home 15/11/04

Donness Nursing Home 05/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Donness Nursing Home 42 Atlantic Way Westward Ho ! Bideford Devon EX39 1JD Lead Inspector Susan Taylor Key Unannounced Inspection 09:30 14th July 2009 DS0000026712.V376684.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. Donness Nursing Home DS0000026712.V376684.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 Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Donness Nursing Home Address 42 Atlantic Way Westward Ho ! Bideford Devon EX39 1JD 01237 474459 01237 479349 pydon@supanet.com 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) Mrs Yvonne Lesley Thelma Newton Mr Paul Christopher Newton, Mrs Esther Waldron Mrs Yvonne Lesley Thelma Newton Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 34 20th August 2008 Date of last inspection Brief Description of the Service: Donness is a detached, three storey property situated in the Westward Ho! area of Bideford which has been extended in recent years. It provides services for 34 people over the age of 65 years, with either personal or nursing care needs. It occupies an elevated position and offers far ranging views to the nearby coastline. There is a selection of communal areas on different floors of the building - this includes two dining rooms, three sitting rooms and a visitors lounge/quiet room. Private rooms comprise of four double rooms and twentysix single rooms, many of which have en-suite facilities. All areas of the home can be accessed by one of the two passenger lifts. There is a large sun balcony with lovely sea views. This provides the outdoor space for people to sit. Some private rooms also have a small balcony. A direct bus route to and from Bideford is available. The cost of care at the time of the inspection was £535 to £565 per week. Chiropody, toiletries, newspapers/magazines, personal items, clothing and hairdressing are additional costs which are not included in the fees. The provider is moving towards all inclusive fees, which would include most of these items. This is negotiated during the assessment process. The latest CQC report is in the front entrance of the home. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 5 Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience ADEQUATE quality outcomes. This was a key inspection of Donness Nursing Home under the ‘Inspecting for better lives’ arrangements. 2 inspectors and the regional lead pharmacist inspected Donness. We were at the home with people for 18.5 hours. We looked at key standards covering: choice of home; individual needs and choices; lifestyle; personal and healthcare support; concerns, complaints and protection; environment; staffing and conduct and management of the home. We looked at records, policies and procedures in the office. A tour of the home took place. We met 9 people that live at Donness and observed how staff looked after them. We met 9 staff and the manager who is also the registered provider. We sent surveys to 20 people living in the home and received 8 back. We sent surveys to 3 GPs and 4 other healthcare professionals and received 0 back. We also sent surveys to 15 staff and received 6 back. We spoke to 2 healthcare professionals. The comments from people, the results of surveys and our observations are in the report. In July 2009, the fees ranged between £535 and £565 per week for personal care. Additional charges are made for chiropody, hairdressing, newspapers and toiletries and these vary. The provider is moving towards all inclusive fees, which would include most of these items. This is negotiated during the assessment process. People funded through the Local Authority have a financial assessment carried out in accordance with Fair Access to Care Services procedures. Local Authority or Primary Care Trust charges are determined by individual need and circumstances. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk. We did a random inspection in January 2009, to monitor progress with the improvement plan that had been agreed with the provider/manager. A report of this visit has been published. We have been involved in safeguarding procedures, which highlighted concerns about the specific care of people that were living or had lived in the home in January and February 2009. As a result of this, named people were reviewed. We brought this key inspection forward to determine whether people’s needs are being met and to decide whether the home is being run effectively. The provider/manager is involved in the process and has been working in Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 7 partnership with professionals visiting the home to improve the care outcomes for people. What the service does well: New people interested in living at Donness are given good information about the service. This helps them to decide if they want to live there. People’s needs are assessed so that the team is sure that they are able to meet each person’s needs. Healthcare professionals tell us that the team work professionally and in partnership to ensure that individual health needs are met. People tell us that they have some choice in their day-to-day living. They enjoy a good range of activities that helps pass the time. Visitors tell us that they welcome at any time and the home has a warm, open and homely atmosphere. Relatives describe Donness as being “a palace” and tell us that their relatives have “improved” since living there. People tell us that the staff are friendly, work very hard and receive the training that they need to do their jobs properly. They describe staff as being “kind and very caring”. People tell us that they are aware of the complaints procedure and are confident that they are listened to. The home is very clean and kept in a nice, attractive condition. People are encouraged to bring in their personal and sentimental items. People tell us that the home is well run. Relatives tell us that Donness is “a first class home”. Staff tell us that “it is a really nice place to work in”. What has improved since the last inspection? We made 4 legal requirements at the last key inspection covering staffing levels, recruitment practice, record keeping and supervision of staff. The provider drew up an improvement plan to show us what they would do and we have monitored progress with this. Overall, the quality of the service is improving. People with complex nutritional needs are assessed to ensure that they get the right help, equipment and type of food that they need to be healthy. Care plans have been updated and are regularly reviewed. Therefore, people can be assured that the information about their needs is current for staff to follow. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 8 The complaint procedure has been updated so people have up to date information about contacting the Commission if they wish to tell us about concerns they have. Best practice is in place for washing linen at correct temperatures to ensure that the risk of infection to people is minimised. People have benefited from increases in the number of staff available to care for them. This is ensuring that individual needs are attended to promptly. Recruitment practice has improved, with all new staff being properly vetted before starting work in the home. This ensures that people are protected and cared for by staff with the right skills, experience and qualities. Qualified staff has done training so that they can begin to supervise staff in a more effective way. Once in place, this will ensure that staffs always follow best practice. What they could do better: There should be a clear plan detailing how/who is responsible for making decisions for people that are assessed as lacking capacity. This will ensure that decisions made are always in the person’s best interests and follow good practice. Although medicines are stored securely, people cannot be assured that there are safe systems in place for the management of the medicines. We have made a legal requirement about this. Staff could further enhance individuals experience and choices during the lunchtime meal with a few simple changes, such as offering a choice of juices, explaining what was planned for lunch, having pictorial menus in visible places for people to see. Hot surfaces need to be blocked in to ensure people are protected from the risk of scalding. The diversity of people should be taken into account with regard to the suitability of the environment. Best practice should be followed with regard to signage and painting of walls and doors. People should be able to access the results, in the form of a report, of any quality assurance measures and actions planned to improve the service. All of the staff must follow best practice when changing a person’s position to ensure this is done safely. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 9 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. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 10 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 Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 11 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): 1, 3, 6 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 are fully involved in the assessment process and information is gathered from a range of sources to ensure that individual’s needs are known. EVIDENCE: The home has a Statement of Purpose (SOP) a copy of which is displayed in the entrance hall and helps people to understand what the home offers and whether it is suitable for their individual needs. Information that the provider sent to us verified that a brochure is given to all people which sets out what the service will provide and includes a contract of terms and conditions, fees payable and other useful information to help people decide whether the home Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 12 is right for them. 100 percent of people have received sufficient information with which to make a decision about whether to move into the home. A relative wrote we visited and asked relevant questions before deciding to move their relation into Donness nursing home. Information sent to us by the provider verified that shared care assessments are obtained from health and social care professionals before people are admitted to the home. In this document they stated that ‘Essential admission records and assessments are obtained. At times I have had to contact care managers to inform them we have not as yet received the required information’. We looked at 4 care files to establish whether the care delivered was based on detailed assessment of people’s needs. Assessments were comprehensive and person centred. This included the person’s needs in terms of disability and medical background. Additional information gathered included a person’s preferences about bedtime routines and meals, significant relationships and social interests. Where appropriate the individual’s advocate had also been involved in the process. 2 relatives said they “were fully involved” in their relations care and that the provider/manager “is very approachable and kind”. Hazards had been identified for each person and the level of risk was clear with regard to issues such as tissue viability, falls, manual handling, mental health, behaviour and continence. Assessments had been regularly reviewed. We read a continence assessment and saw that appropriate aids had been obtained for one individual concerned. We looked at the file of an individual with dementia whose care plan stated that they were at risk of malnutrition because they needed assistance to eat at mealtimes to ensure that their nutritional intake was sufficient. A detailed assessment had been completed and regularly reviewed. We tracked the care of a person with a pressure sore. Their relative told us that this had only “happened recently”. We looked at the individual’s care file and nursing staff had regularly assessed the person using the ‘Medley’ tool to determine the level of risk of potential pressure damage the person might experience. The information highlighted that the person had been at very high risk as their health had deteriorated. Measures had been put in place to prevent any further pressure damage and we saw that the person was sitting on a pressure relieving cushion and had a zero pressure mattress on their bed. The manager verified that they had done Mental Capacity Act training in 2009. As a result of the knowledge gained, she had done mental capacity assessments for all of the people living in the home. We looked at 4 of these whilst case tracking people’s care. All 4 people had been assessed as lacking capacity. Whilst there was some information about this across the range of care plans, which each person had, there was no clear guidance as to who is responsible for making decisions on the person’s behalf in their best interests. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 13 For example, in 1 file a next of kin is mentioned in the notes as ‘having power of attorney’ and has signed an agreement for restraint to be used – bedrails and a wheelchair lap strap. We discussed this with the manager who said she would develop a mental capacity plan for every person that has been assessed as lacking capacity. This will ensure that detailed guidance about how a person’s best interests is to be considered and agreed is available to staff. Donness does not provide intermediate care therefore no judgement is made regarding standard 6. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 14 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): 7,8,9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care of people has improved as a result of increased staffing levels. Although medicines are stored securely we found that people cannot be assured that there are safe systems in place for the management of the medicines. EVIDENCE: We looked at duty rosters for June and July 2009, which demonstrated that the provider has increased the number of staff on duty since the last key inspection. Additionally, recruitment documents and duty rosters for July 2009 show that additional staff have been appointed, particularly for weekends and Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 15 evenings. We observed that staff did not appear rushed and there was a calm atmosphere in the home. 2 relatives made comments like “this is a palace” and “she has every attention she needs”. Therefore, this has improved the outcomes of care for people living in the home since we last did a key inspection. 8 out 20 surveys we sent to people using the service were returned. 100 of people tell us that the staff listen and act on their wishes. Similarly, their responses show that 100 percent of people are satisfied with the medical support they receive. They also tell us that they are treated well. A relative said that since moving into Donness the staff had got to know “XXX intimately well”. We were told that as a result of thorough assessment and involvement of the dietician, the volume of PEG feed that their relation was being given had been reduced and this had “significantly improved the quality of life” for that person. In daily records for all 4 of the people we tracked, we saw that other healthcare professionals such as the tissue viability nurse specialists, speech therapists and occupational therapists had been regularly contacted for advice and support. Healthcare professionals made positive comments about the care and told us that relatives are “very happy with the care” and that the manager is “quite open to advice”. 6 surveys were returned by staff working in the home. Their responses tell us that they always or usually have information about peoples needs. Communication is said to be always sufficient. We looked at 4 care plans for the people who we case tracked. These were very detailed and gave a good picture of the person’s needs. For example, a care plan written for a person with dementia highlighted that the individual had a strong religious faith that was important to them. Additionally, detailed information gave a clear picture of the behaviour they would see if the person was becoming stressed and what to do if this was observed. We met the person and observed that they were displaying this behaviour, and therefore appeared stressed. We saw staff engaging appropriately with this person in a kind and caring way. This had an immediate positive and calming affect on the individual who was then able to eat lunch and appeared to enjoy it. We looked at 2 other records of people that have pressure damage. 1 person’s records highlighted that they had been admitted to the home with severe pressure damage. Excellent records, including photographs demonstrate that this is healing and has required intensive treatment by the nursing staff. A healthcare professional commented that this “is a challenging wound, but is showing improvement and healing”. We met this person, who was being cared for in bed. They looked comfortable and well cared for. Additionally, they were lying on a zero pressure mattress in a nursing bed with covered bedrails. The care we observed corresponded completely with what we had read in the person’s care file. This is a good care outcome for the individual concerned. Information sent to the Commission by the manager/provider tells us that an Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 16 area for improvement is ‘Record keeping. Essential recording is maintained but at times events or comments recorded are not revisited/followed up.’ Additionally, ‘5 staff are working towards NVQ 2 & 3, 3’ which the manager/provider tells us should increase the number of skilled staff and enable more delegation to take place with regard to record keeping. One plan case tracked showed that reviews of the plan are not happening monthly, and that records do not always show clearly what is happening for example an entry is made about the individual having a swelling that needs to be followed up with their GP. The notes give no indication about whether this has happened. The registered manager was able to tell us what the outcome of this was, but this should be recorded as apart of individuals ongoing health care needs, to ensure that they are being fully met. Similarly, turning charts do not always reflect the actual care that is being given. For example, a person that had pressure damage had a ‘dressing plan’, which stated ‘2 hourly turns when in bed. The last recorded entry on the chart was dated 12/7/09, two days before the inspection. This means that people cannot be assured that their records reflect an accurate picture of their health needs. There was detailed guidance for staff in the individual’s file, highlighting that this person was at significant risk of developing pressure damage and what action should be taken to prevent this occurring. We observed that the person was initially sitting on a pressure relieving cushion before and during lunch, and then had their position changed afterwards so that they were lying in bed on a zero pressure mattress. We discussed the gaps in recording with the manager/provider, who is aware that this is still an area for improvement. Currently, turning charts and other working documentation like fluid charts are kept in the office. The manager said that a way forward would be for this to be kept in the person’s bedroom so that staff attending to the individual’s care needs, and the individual themselves, would have better access to the documentation. This should help staff to keep records up to date for people living in the home. We observed that staff always knocked on bedroom doors before entering bedrooms to help to protect their privacy. Similarly, people were treated with dignity. In surveys people verified that staff always listed and act on what they want. We found that the home has a dedicated medicine fridge. However the temperature records for this indicate that since 01/07/09 that on two occasions a temperature has not been recorded and on a further 3 occasions the recorded temperature is below 2C which is the minimum recommended temperature by the medicine manufacturers. Also only the current temperature is recorded so it was not possible to determine if the temperature had been below this figure on other occasions. This means that people cannot Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 17 be confident that medicines stored in this way will be safe or effective in use. We also found that some medicines, that require storage in a fridge before use, were being stored at room temperature so people could not be assured that they would be safe or effective in use. We also found that for one person that they had not received their prescribed medication at 3 day intervals as no stock was available in the home. We did see evidence that the home had rung the surgery on one date before the first missed dose but there were no further records of any effort being made to obtain a replacement supply. For another person we found that although a new supply of their medicines had been received into the home the previous day these were not administered and for one the chart was left blank and the other was signed as offered but not required although the stock was not in the trolley but in a bag in the treatment room. This means that people cannot be assured that they will receive their medicines as prescribed so affecting their well being. We found that there were some people prescribed medicines to be administered “when required”. For one of these people there was a sheet of paper titled “Interim Protocol” but this was not dated, not signed and gave no indication where the information had come from or when it was to be reviewed. There was no further information regarding this in the care plan. For other people we saw that medicines prescribed to be administered “when required” were administered regularly. For these people we could find no guidance about how or when these medicines were to be used. We could also find no information regarding the decisions taken when the administrations had occurred. This means that people cannot be confident that they will always receive their medicines in a safe and consistent way so affecting their well being. We found that some people their medicines were prescribed to be administered with a variable dose. For some of these the actual dose administered was seen to be recorded whilst for others there was only a record that an administration had taken place but no record of what had actually been administered. This means that people cannot be confident that they will receive their medicines in a consistent way and it is also not possible to feed back on the effectiveness or otherwise of the medicine to the prescriber. We also observed that when medicines were taken to people during the lunchtime round that several pots were placed on a tray at time. This is not in accordance with good practice guidelines and may lead to errors in administration. This is a practice that should be reviewed to eliminate the risk of errors in administration occurring. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 18 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): 12,13,14 & 15 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. Individuals’ social and diverse needs are reasonably well met, but could be improved to include more choices in everyday life. EVIDENCE: The routine of the home appears fairly flexible to suit most people’s individual needs. We observed some people having a late breakfast, and were informed by staff that they try to ensure that individuals who enjoy a lay in are supported to do this. Similarly people who want to get up early are enabled to do this. Individuals can choose where they eat their meals, either of the two dinning areas or their rooms if they prefer. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 19 The homes AQAA states ‘’Residents are encouraged to have control over their day to day lives where possible. A daily living care plan is completed to record personal choices such as times for getting up and going to bed, meal preferences, likes and dislikes, comfort aspects such as number of pillows, prefered drinks and bed time drinks and snacks, how they like to spend their time, favourite programmes, newspapers etc.etc. Personal life histories are requested and some current service users have a writen account of their lives. This is difficult to obtain for all residents due the lack of a historian. We are planning to address this in the near future. We employ specific staff to ensure that activities are available mon-fri, and provide outside entertainers at periodic times throughout the month. We encourage all our residents to join in as they choose. The activities are varied and take into account personal preferences, hobbies etc of the current clients. They are arranged as group sessions or on an individual basis. One resident is currently enjoying taking up reading again following a stroke. She recieves large print books, as she chooses, fortnightly. Another resident goes out once or twice a week for lunch with a friend and with his family on Sunday’s and to local events as he wishes. Another resident visits a weekly club on Friday’s. And we have a resident who goes out several times a week to various clubs and meetings/lunches, as was her usual habit when at home, depending on how she feels. A monthly planned activity rota is displayed which includes for example, craft work, flower arranging, games, talks, singing,music sesions, reminisence sessions etc.. A lay preacher or vicar attends every 3rd week to hold a service and give communion to those residents who wish to partake. Individual visits are also made by the local catholic priest and other denomination church representatives on regular occassions. These visits take place in the privacy of their own rooms or in the visitor lounge. Regular invitations are extended from the local church for residents to join in celebration services and gatherings.’’ We observed one activity session and spoke to the coordinator who plans these actvities. She said she tries to vary actvities to suit the individuals who choose to participate, and that where possible they try to also spend some time with people who do not come into the lunge areas from choice or because they are needing to be nursed in their room. Two people we spoke to said they enjoyed the actvities offered. The registered manager confirmed that the television reception was now Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 20 sorted and people could view different chanels in the communal areas or in their bedrooms. Only one person was waiting for their digital box to be sorted, this was due to a complication with their own TV. We spoke with three visiting relatvies who said that they could visit at any time and that they were made welcome. The registered manager has recently intorduced ideas for visitors to enable them to make visits more meaningful as they have devised a statement for visitors with suggestions to enhance the visiting experience e.g. Bringing a memorable or favourite object that will induce conversation, reading a poem or book or photographs that have meaning to the resident, bringing a recording of a piece of music, etc. It also gives suggestions for gifts (as we are often asked) such as fruit, appropriate toiletries, hosiery, underwear etc. The menu was looked at during this inspection. The home has a four weekly menu that appears to offer a varied and balanced diet that takes into consideration individual likes and dislikes as well as any special diets such as diabetic. It was difficult to ascertain the views of people we saw during lunchtime, but most did eat their lunch and appeared to enjoy it. One relative did say that although they had not tried the meals, their relative had not complained about the meals, and did appear to be maintaining a good weight. Another relative in a survey commented ‘since XXX has been at Donness he is more relaxed and eats much better’. The main meal is served at lunchtime and people who need assistance are given support in a kind and respectful way. We looked at the file of an individual with dementia whose care plan stated that they were at risk of malnutrition because they needed assistance to eat at mealtimes to ensure that their nutritional intake was sufficient. A detailed assessment had been completed and regularly reviewed. There was a detailed care plan about this, which we observed being followed at lunchtime. We saw the carer sitting next to the individual and had engaged the person fully in the activity of eating their meal. We did however observe some poor practice during lunchtime, one person being told that they must eat all their lunch, which caused then some distress and another person being told they were ‘naughty’, which is an inappropriate response to give to an adult. Individuals were not given a choice or alternatives in respect of the main meal offered or drink. One person did however say they did not want lunch and staff gave them toast, which they Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 21 said they wanted and afterwards said they really enjoyed. Staff could further enhance individuals experience and choices during the lunchtime meal with a few simple changes, such as offering a choice of juices, explaining what was planned for lunch, having pictorial menus in visible places for people to see. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 22 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): 16 & 18 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. Individuals’ views are listened to and acted upon EVIDENCE: The home have a stated complaints procedure and copies of this are posted throughout the home and are included in the homes information that is given to all people admitted to the home. The registered manager informed us that they have had no complaints or concerns from people living at the home or their relatives and believes this is because people are given opportunities to discuss any concerns with their key worker or nurse or with the manager, before they became a complaint. 100 of people responding in a survey verified that they knew how to complain and who to speak to if they were unhappy. Since the last inspection 2 complaints have been made to the Care Quality Commission regarding this Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 23 home. The manager/provider was asked to investigate the first complaint about potential abusive practice and did so promptly. This was not substantiated and the manager/provider sent us a detailed report to support this judgement. The second complaint has been dealt with through the Safeguarding procedures and highlighted a number of concerns about the specific care of people that were living or had lived in the home in January and February 2009. As a result of this, people were reviewed. Additionally, we brought this key inspection forward to determine whether people’s needs are being met and to decide whether the home is being run effectively. The provider/manager is involved in the Safeguarding process and has been working in partnership with professionals visiting the home to improve the care outcomes for people. Our observations during this inspection, demonstrated that people’s needs are generally well met and the overall service is improving. The staff having training in the Protection of vulnerable adults and those spoken to during the inspection were aware of who they should report any concerns they may have in relation to possible abuse. 100 of people responding in a survey felt that the staff always treated them well and listened to them. The home had a written policy and procedure for dealing with suspected allegations of abuse. We spent some time observing interactions between staff and people living at Donness. Staff engaged with people continuously at the right speed and demonstrated genuine warmth and attention, which people appeared to respond to and enjoy. The home holds small amounts of cash for individuals. We checked a sample of these. There were records of all transactions and the amounts counted were correct. The service user guide is transparent about extra charges that are levied to people living in the home. These include chiropody, daily newspapers and periodicals, travel expenses incurred by hospital appointments and private telephone connection and telephone calls and line charges. Recruitment practice has significantly improved and has ensured that people are cared for by properly vetted staff. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 24 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): 19,22,25 & 26 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. Donness provides people with a clean, safe and homely environment. EVIDENCE: During this inspection we looked at all communal areas including the kitchen, laundry and bathrooms, as well as some of the individual bedrooms. We spoke with one of the domestic staff who told us that they normally have three cleaners and a laundry person on during week days. The home is kept clean to Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 25 a high standard and there are no odours. The domestic staff are commended for their efforts in keeping Donness clean and fresh smelling. Some individual bedrooms have been personalised, and the home encourages people to make their own room their own space. In the AQAA they say ‘Residents are welcome and encouraged to furnish their rooms with personal items and furnishings which are cared for by us. They can receive visitors in their own room or use the visitors lounge or outside areas. Refreshments are always offered and provided free of charge at any time. A relative said that every effort had been made to ensure that “XXX has a wonderful view and comfortable room”, which “we have been able to personalise for her”. A varied selection of armchairs are provided by the home to maximise comfort and safety(reclining chairs). Some residents choose to have their own chair in one of the communal lounges. Similarly, information sent to us by the manager/provider stated ‘We have a varied selection of bed types, electric profiling nursing beds and divans, to suit peoples needs and choice. Radiators around the home are gaurded and rooms can be individually thermostatically controlled. All windows are compliant as to H & S regulations.’ The surrounding area/garden of the home is well maintained and provides a pleasant and colourful outlook for people and visitors, with patios and balconies providing safe and pleasant areas for them to enjoy. We observed that fire doors are fitted with magnetic door closures for safety. A key pad is present on the front door. This allows free access into the home but requires PIN to leave the home. Information sent to the Commission (AQAA) verified that ‘the system is explained to all new clients/advocates. All frequent visitors (family/friends) have knowledge of this PIN which allows them freedom to enter and leave at will. Following guidelines on the Mental Capacity Act we have sought views on continueing with this system. All persons concerned, visitors/advocates, clients and staff are comforted with the knowledge that wandering residents do not have easy access out of the security of the building, and can freely walk around the home. Due to the lay out of our home staff are always on hand to assist people/clients to access outside areas as and when they choose.’ The home caters for people with cognitive impairment, for example dementia. Therefore, to increase people’s orientation and awareness of the environment Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 26 we recommend that all bathrooms are clearly labelled as we found one that only had a number on it. Additionally, bedroom doors should have the individuals name and perhaps a photo or picture that helps them distingush which is their room. Domestic staff confirmed that there was sufficent cleaning products, equipment time and staff to ensure the home was kept clean and hygienic. 100 people responding in a survey verified that the home is ‘always’ fresh and clean. The homes AQAA gave us good information to show that they ensure a safe environment and that equipment is serviced on a regular basis. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 27 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): 27,28,29 & 30 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’s needs are being met by knowledgeable, skilled and caring staff. Recruitment practices have improved and are protecting people that live at Donness. EVIDENCE: At the last inspection we required the provider/manager to take account of the different dependency levels of people when setting staffing levels. Staffing levels have increased during the week, however in the duty rosters seen weekends are not covered by a hospitality carer or cook. This has meant that care staff and nurses have had to do meals in addition to care duties. The provider/manager sent the Commission an improvement plan, which stated that staffing levels had been increased to 2 Registered Nurses and 6-7 Carers every morning. In the afternoons, the plan stated that 1 Registered Nurse and 4 carers were rostered every day. We discussed our observations of the staffing levels with the manager/provider who provided clarification. We were shown recruitment documentation demonstrating that a permanent hospitality Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 28 carer has been appointed to work Fridays 2-6pm; Saturdays 8-11.30am and 26pm; and Sundays 8.30-11.30 and 2-6pm. Additionally a kitchen assistant has been appointed for weekends to work 10-2pm and 5-6pm. Also a carer that had retired from working nights had started working every Friday pm 48.30pm, Sat & Sun 4-8.30pm. Therefore, at the time of the inspection at weekends there are 5 carers and 1 Registered Nurse working on Mornings. During the afternoon, there are 4 carers until 4pm when another carer comes on duty therefore making 5 carers. We were shown recruitment documentation for another carer that had been appointed and due to start the following week. The manager said that another senior carer is returning from maternity leave in the next 3 weeks. Surveys from 8 people living in the home (the majority had been completed by relatives) tell us that there are sufficient staff and needs are met. Their comments include ‘carers listen to myself and sister when we visit mum’, and ‘we are very pleased with how xxx is being cared for’ and ‘xxx is in a first class nursing home and is given and lot of love and care.’ Similarly, surveys from 6 staff/80 verify that there is ‘always’ enough staff. Their comments include ‘matron never asks anyone to do something unless she has done it’, ‘I enjoy what I do’, ‘there is more equipment than any other home I have worked in’ and it’s ‘a really nice place to work in’. Our observations were that people generally experience good care outcomes and therefore improvement of staffing levels has ensured that needs are being met. We spoke to the provider/manager about recruitment and they told us that they had appointed 2 new staff since April 2009. We examined the files for these individuals to establish whether the recruitment procedure was robust and had been followed. CRB [Criminal Records Bureau] and ISA [Independent Safeguarding Authority] checks had been obtained for both staff prior to employment. Additionally, other pre-employment checks had been carried out properly. 2 written references had been obtained. Therefore, people are protected because recruitment procedures have improved and are robustly followed. Information sent to the Commission by the provider/manager stated ‘Several staff are working on ASSET courses (C & Gs), 3 staff are doing Dementia Care, 2 staff are doing Palliative Care, and 2 staff are training in Hospitality and Catering services. An RN,on nights, is attending several training days arranged through Boots the Chemist. Several training session have or are about to take place covering; Health& Safety, Safeguarding Adults (POVA),Mental Capacity Act, Deprivation of Liberty Safeguards, Manual Handling, First Aid and Ressusitation, Continence care, Nutrition and MUST, Liverpool Care Plan (GSF), Communication and Dementia. Various other topics are covered In House on a continual basis.’ Additionally, 85 percent [18] of staff have done an induction that meets Skills for Care standards. 9 staff has a NVQ in care, and 5 staff is in the Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 29 process of doing this award. 77 of staff have or are in the process of doing the NVQ award in care. Therefore, people living in the home are cared for by experienced staff with the knowledge and skills to meet individual needs. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 30 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): 31,32,33, 35, 36, 37 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The quality of the service people receive is improving. However, there are gaps in Health & Safety knowledge and practice, which may put people living in the home at risk of injury. EVIDENCE: The Registered Manager has run the establishment since 1981. She is a Registered Nurse (General) and has the Registered Managers Award. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 31 Throughout the inspection we found the manager to have a good understanding of her role. After the last key inspection in August 2008 we asked the provider/manager to send the Commission an improvement plan showing how matters highlighted in the report would be addressed. This is a legal document and we did a random inspection on 9th January 2009 to ensure that requirements had been complied with. We wrote a report about this, which is published. Our judgement was that the quality of the service had improved with regard to staffing, recruitment and record keeping. We also saw good care outcomes for the people living in the home that we followed up. As discussed under the ‘Complaints and protection’ section, a complaint has been dealt with through the Safeguarding procedures and highlighted a number of concerns about the specific care of people that were living or had lived in the home in January and February 2009. As a result of this, people were reviewed. Additionally, we brought this key inspection forward to determine whether people’s needs are being met and to decide whether the home is being run effectively. The provider/manager is involved in the Safeguarding process and has been working in partnership with professionals visiting the home to improve the care outcomes for people. Our observations during this inspection, demonstrated that people’s needs are generally well met and the overall service is improving. The legal requirements we have made focus on the medication systems. Although medicines are stored securely we found that people cannot be assured that there are safe systems in place for the management of the medicines. We are confident that the provider/manager has taken action to improve this issue in light of the detailed feedback given by the Regional Lead Pharmacist. The manager gave the Commission a detailed picture of the current situation in the service, in a document entitled AQAA (Annual Quality Assurance Assessment). Supporting illustrated what the service has done in the last year, and explicitly how it is planning to improve. We did observe some aspects of good practice, including the assessment of mental capacity and care plans were more detailed, had been reviewed and demonstrated that people were involved in this process. 8 people responded in a survey and their comments tell us that people are generally satisfied with the facilities and services they receive. The comments included ‘carers listen’’ ‘xxx seems very happy’, ‘everyone is so kind’ and ‘we’re very pleased with how xxx is being cared for’ and ‘xxx is in a first class nursing home and is given a lot of love and care.’ Similarly, 2 relatives that we met made comments like “she’s well cared for, this place is a palace” and “they know her intimately” and “have improved her quality of life”. The provider/manager is described as being “very approachable”. Healthcare professionals tell us that she is “very professional” and asked them and other specialists for advice. Similarly, the staff is described as “caring” and “give a lot of love to XXX”. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 32 6 surveys tell us that staff believe the home is ‘well run’ and that they ‘always’ receive the support they need. Similarly, 100 verify that they regularly receive training that is relevant, provides them with new ways of working and appropriate knowledge. We spent lengthy periods observing interactions between people living in the home. The atmosphere was open and friendly. We looked at financial records for four people that live in the home. All were accurate when cross checked with the balance kept for safekeeping. Entries had been signed for. Receipts corresponded with entries for items such as outings, magazines and toiletries. Secure facilities were in place to safeguard personal documents and money. As discussed previously, there were gaps in information about care and therefore do not provide an accurate record of the care received, which continues to be an area that needs improvement. Daily records, such as turning charts were incomplete. Therefore, policies and procedures have not been followed and the rights of people living in the home have not been promoted. Comprehensive Health & Safety policies and procedures were seen, including a poster displayed near to the office stating who was responsible for implementing and reviewing these. Staff we spoke to told us that they had been regular training. We were shown the induction pack and saw that completion of this had been recorded in the files we looked at. We toured the building and observed that cleaning materials were stored securely. Records of accidents were kept and showed that appropriate action had been taken. The fire log was examined and demonstrated that fire drills, had taken place regularly. Similarly, the fire alarm had also been regularly checked. People living in the home told us that the alarm was regularly. Certificates verified that an engineer had checked the fire alarm. First aid equipment was clearly labelled. Maintenance certificates were seen for fire alarm and electrical systems. The provider had verified in information sent to the Commission that a local electrician had inspected both the electrical system and appliances. We read a handling plan for an individual, which stated that 2 staff always had to use equipment, eg a sliding sheet to help the person change their position in bed. We were shown a sliding sheet in the bathroom opposite the person’s room. However, when we observed 2 carers changing this person’s position in bed they did so using an ‘under arm lift’ to move the individual. This is unsafe practice and may cause injury to the individual and carers. We discussed this observation with the provider/manager and asked them to demonstrate that all of the staff had had manual handling training in the last 3 years. Certificates showed that 9 staff did manual handling training in 2009 and the same training was provided in 2008. However, the provider/manager was unable to demonstrate that the 2 staff we had observed had had this training in the last 3 years. Therefore, people that need assistance to change their position cannot be assured that this is done in the right way that is safe. We have made a legal requirement about this. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 33 We spoke to staff during the inspection, who told us that 1:1 supervision sessions were infrequent. We looked at 2 personnel files; a record of a supervision session had not taken place in 2009. Information from the provider also highlighted that this was still an area for improvement and verified that training for senior staff responsible for doing this had taken place. Senior staff verified that they had had this training and that they now have responsibility for managing teams. Group supervision is taking place, for example one team is being taught how to do tissue viability assessments. Senior staff said that the next step was to set up a programme of formal 1:1 supervision for all of the staff in their team. We have repeated a requirement about this because there are still areas like record keeping and manual handling (as discussed above) that need to be addressed with staff through the supervision. The implementation of formal supervision will ensure that staff deliver best practice when caring for people living in the home. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 34 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 3 x x 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 2 2 2 Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 35 Are there any outstanding requirements from the last inspection? YES 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. 1. Standard OP9 Regulation 13(2) Requirement The provider must ensure that there is a safe system in place, to have medicines available to administer them in accordance with the directions of the professional prescribing them. This is so that people receive their medicines as prescribed. The provider must ensure that the actual dose administered is recorded when a medicine is prescribed with a variable dose. This is so that the effect of the medicine can be monitored and fed back to the professional prescribing it. The provider must ensure that medicines are stored within the temperature range as specified by the manufacturer. Arrangements must also ensure that medicines when opened are used within the timescale as indicated by the manufacturer. This is so that people can be assured that they will be administered medicines that are safe and effective. DS0000026712.V376684.R01.S.doc Timescale for action 17/09/09 2 OP9 13(2) 17/09/09 3 OP9 13(2) 17/09/09 Donness Nursing Home Version 5.2 Page 36 4 OP9 13(2) 5 OP36 18(2)a The provider must ensure that 17/09/09 there are clear protocols and guidance available for those medicines prescribed to be administered “when required”. This is so that people can be assured that they will receive their medicines in a consistent manner in response to their individual symptoms. The provider must ensure that 31/10/09 staff has regular formal one to one supervision so that their care practice is reviewed and their training and development needs are identified and planned. This will ensure that best practice is followed by staff caring for people. This is repeated from the last inspection, with an extension to the timescale to allow this to be fully implemented. 6. OP38 13(5) The provider must ensure that all staff have had up to date training about manual handling. This will ensure that best practice is followed when people’s positions are changed in a safe way that avoids any risk of accident or injury to individuals. 30/09/09 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 OP3 Good Practice Recommendations There should be a clear plan detailing how/who is DS0000026712.V376684.R01.S.doc Version 5.2 Page 37 Donness Nursing Home 2. OP9 3. OP15 4. 5. 6. OP25 OP22 OP33 responsible for making decisions for people that are assessed as lacking capacity. This will ensure that decisions are made in the best interests of individual’s concerned. The method of transport of medicines should be reviewed in accordance with current guidance and best practice advice to ensure that people’s health and safety is maintained. Staff could further enhance individuals experience and choices during the lunchtime meal with a few simple changes, such as offering a choice of juices, explaining what was planned for lunch, having pictorial menus in visible places for people to see. Pipework in downstairs bathroom should be blocked in to ensure people are protected from hot surfaces. Bathrooms should be easily recognised, with a sign and good practice would dictate that the doors should be painted a different colour. The home should ensure that the results from and quality assurance surveys are collated and made available to individuals who live in the home and to CQC. Donness Nursing Home DS0000026712.V376684.R01.S.doc Version 5.2 Page 38 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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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