Inspection on 14/09/09 for Forrester Court

This inspection was carried out on 14th September 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Forrester Court 27/10/08

Forrester Court 09/06/08

Forrester Court 21/06/07

Forrester Court 20/04/06

Forrester Court 11/01/06

Forrester Court 12/05/05

Forrester Court 11/11/04

Forrester Court 17/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

Key inspection report CARE HOMES FOR OLDER PEOPLE Forrester Court Cirencester Street London W2 5SR Lead Inspector Wynne Price-Rees Key Unannounced Inspection 14th September 2009 10:00 DS0000026014.V377549.R01.S.do c Version 5.3 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. Forrester Court DS0000026014.V377549.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 Forrester Court DS0000026014.V377549.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Forrester Court Address Cirencester Street London W2 5SR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7266 3174 020 7286 1068 manager.forrestercourt@careuk.com manager.burroughs@careuk.com Care UK Community Partnerships Ltd Vacant Care Home 110 Category(ies) of Dementia (110), Old age, not falling within any registration, with number other category (110) of places Forrester Court DS0000026014.V377549.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 the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia Code DE 2. Old Age, not falling within any other category Code OP The maximum number of service users who can be accommodated is: 110 27th October 2008 Date of last inspection Brief Description of the Service: Forrester Court is located off the Harrow Road, with good access to local shops and services and close to Royal Oak tube station. It is registered to provide care including nursing for up to one hundred and ten residents of either gender and recently it has been registered for up to sixty beds for people with dementia and fifty for older people. There are currently ninety-four people who use the service. The building opened approximately nine years ago and is purpose built. It is owned and run by Care UK and places are commissioned by Westminster Council and the PCT. The Royal Borough of Kensington and Chelsea commission some places in Kensington, the unit for people with early onset dementia. The weekly fees can be obtained from the home. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The unannounced key inspection took place over two days on the 14th and 15th of September 2009 and lasted a total of 14 hrs. We were accompanied by an expert by experience and their findings are included within the report. During the inspection, we spoke with people who use the service, relatives, management team and staff to get their views about the service provided. We also observed care practices. We tracked the care of eight people who use the service including their individual case files. Other records and documentation checked included care plans and risk assessments, staff files, health and safety documentation, medication, complaint and accident and incident records and quality assurance documentation. We also looked at a sample of staff files and we did a tour of the premises. This information was compared to the AQAA self-assessment document returned to us by the home when we requested it and other information we had received since the last key inspection. An AQAA is a self-assessment document that is filled in by the home to show how it is performing against the minimum standards. What the service does well: The centralised, computerised system with quicker and more focused staff access to information and improved standard of recording means the home continues to improve in most areas. A comprehensive rolling training programme is provided to enable staff to better understand the needs of the individual and provide an appropriate service. A wide choice of meals is available, with food freshly prepared on the premises. Individual likes and dislikes regarding food are met and the catering service is able to meet the cultural and ethnic needs of people who use the service. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.2 Page 6 The home is accessible and meets the specific needs of the people who live there. People who use the service live in a clean and well-maintained home, which is homely, and comfortable. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.2 Page 7 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 Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 8 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): 3 and 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 who use the service are fully assessed to establish that their needs and wishes can be met before being given the opportunity to visit so that they can decide if they want to move in. EVIDENCE: “I had the chance to visit before I moved in”. A sample of eight case files of people who use the service, taken from all units showed that there is a thorough assessment procedure that takes place before people move into the home and enables them or their relatives or other representatives to visit and decide if this is where they wish to live. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 9 If the person using the service is sponsored or proposed through a local authority full assessments are forwarded to the home by Care Package Managers to help them initially decide if a person’s needs can be met. After this a qualified member of the management team carries out a face to face assessment visit either in the person’s home or in hospital depending where they are. A further assessment then takes place on moving in. This feeds the initial care plan. The home does not currently provide respite care. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 10 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 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans are comprehensive with information in place that shows how staff support the people who use the service with their social, health, cultural, emotional, communication and independent living needs. Some risk assessments were not up to date. People using the service are treated with respect and their dignity observed. EVIDENCE: “Staff treats me with respect”. “I always get my medication on time”. “My health care needs are seen to”. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 11 The sample of eight care plans show that the health, personal and social care needs of people who use the service are addressed within them. The care plans are on a computerised system and contain needs, goals, how they will be achieved and monthly review evaluations. There are also daily progress notes that consist of two reports filled in by staff per twelve hour day shift and two night reports. These feed the monthly review evaluations, are up to date and contain information relevant for staff coming on shift. There are also twentyfour hour accident and incident reports that are used as part of the quality assurance system and the required legal notifications are made to the commission. The care plans are underpinned by risk assessments. On four units these were found to be reviewed monthly as directed by the organisational procedure. On one unit a sample of risk assessments are out of date whilst on another staff are following the old procedure of three monthly reviews. The care practices observed and documentation sampled demonstrated that the general health care needs of people who use the service are being met. People who use the service are registered with visiting GPs or can retain their own if practicable. They also have full access to community based health services such as local hospitals, district nurses, chiropodist, dentist and opticians. Arrangements are in place for these services to be made available in the home or for people who use the service to access them within the local community. The medication administration sheets were checked for all people who use the service and found to be accurately recorded. The medication on each unit is appropriately stored in locked cabinets. The controlled drugs registers for those units that require them are accurately kept and countersigned. The home has a policy and procedure regarding dignity and privacy that staff confirmed they have received training in and people who use the service say are followed. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 12 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 and 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. People who use the service have their preferences observed and their social, cultural, religious and recreational needs and interests met, meaning they have reasonably fulfilling lifestyles, although this could be improved by enhanced communication between staff and people who use the service. They are encouraged to maintain contact with friends and relatives as they wish to enhance their social lives. EVIDENCE: “We are all happy here apart from one or two odd people” “Another time I’m busy”. “The food is good”. Each person who uses the service has an activities programme with activities identified within care plans. Activities identified in the programmes include Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 13 passive exercise, music and cookery. A person who uses the service we spoke to told us a cheese and wine party took place on the Friday before the inspection and live music show is advertised for later in the month. A knitting activity took place on one unit some people were watching TV and reading newspapers on others during the inspection. On one unit for early onset dementia, three people who use the service were sitting in a small lounge silently with no activity taking place. When asked we were told that most people who use the service go out to day centres. Although this is not the case as they may be attending activities on different units, it highlights communication problems that some staff and people who use the service may encounter. The level and appropriateness of the one to one and group activities are not easy to ascertain as a number of the designated activities staff are off sick or on leave and therefore some activities that would normally take place either didn’t or were carried out by staff whose primary duties are not activity related although all care staff have a responsibility to provide activities for people who use the service. Group activities that have taken place include visit to the London Aquarium, pub outings and shopping. A catholic Mass is held in the church across the road and communion takes place for those who are unable to attend. Observation of staff care practices surrounding activities suggested there is some confusion over areas of responsibility with staff feeling the onus for providing activities lies with the activities co-ordinators. This is more apparent in units that provide nursing care. There is also some confusion about appropriate activities and their availability. Staff on one unit were asked about the home’s special events calendar and thought it must refer to another unit as they did not know what it was. A word spelling activity was taking place on a unit for elderly, mentally infirm people who use the service that was perhaps not the most appropriate as it may prove distressing. One person who uses the service said they would like more information about a proposed seaside outing and commented “They are very uninformative”. We asked a staff member who did not know. Currently meetings for people who use the service are not taking place although relatives meetings are. Each person who uses the service has a social history that has been compiled with them, is in paper form and kept on the unit they live in. The histories sampled are comprehensive with useful information for feeding care plans and providing appropriate activities. However there is difficulty in some instances in using the information to provide appropriate activities. It is stated in one social history that the person who uses the service doesn’t like bingo whilst their personal weekly activities programme states they attend bingo. The home provides a four weekly rotating menu that showed that balanced, nutritional choices are provided. The kitchens are clean, tidy and food is appropriately stored. The fridge and freezer temperatures are checked twice daily and recorded. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 14 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 and 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. People who use the service are listened to, complaints investigated with outcomes and they are protected from abuse. EVIDENCE: “I know how to complain and who to if I have to”. “I don’t like to complain and try and sort things out with staff whenever possible”. The home has a complaints policy, which is accessible to people who use the service within the home’s brochure. Most people who use the service say that they know how to make a complaint and to whom although they tend to prefer to sort any problems out with staff informally. There is a comprehensive computerised system in place for recording complaints that details action taken to investigate including the outcome. Nine complaints are recorded since 1st March 2009. All have been thoroughly investigated and resolved. The complaints records are checked monthly as part of quality assurance to identify any emerging patterns. There are currently no Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 15 POVA investigations being conducted. POVA is the protection of vulnerable adults. There is an adult protection policy and procedure that staff confirmed they have understood and all staff have received adult protection as part of induction with annual refresher courses provided by Westminster City Council. There is also access to advocates for people who use the service. Staff are CRB checked before starting work. CRB is the Criminal Records Bureau. One safeguarding issue is currently under investigation. There is a whistle-blowing procedure that staff confirmed they have access to and know how to use. Any monies kept on behalf of people who use the service are fully recorded with deposit, withdrawal, balance and receipt. A sample of money kept on behalf of people who use the service was compared to the records kept and tallied. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 16 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 and 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. A homely, clean and safe environment is provided for people who use the service to live in. EVIDENCE: A tour of the premises shows it is fit for stated purpose and reasonably well decorated. Due to the size of the building this is ongoing. Part of the garden area has been turned into a themed beach complete with boat and the home is in the final of the organizations best kept garden competition. The home was clean, tidy, well maintained and generally odour free. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 17 Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 18 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 and 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. There are suitably trained, competent and diverse staff employed in suitable numbers to meet the needs and wishes of people who use the service. Staff are properly vetted. EVIDENCE: Currently there are no staff vacancies. There is one vacancy for a Deputy Manager that has been advertised internally with interviews taking place the week after the inspection. The staff rota demonstrated sufficient staff are on duty at all times to meet the needs of people who use the service. A sample of staff files showed there is a comprehensive recruitment procedure operated that meets the requirements of the standards and means people who use the service are safe and their needs professionally met. All staff are interviewed, have CRB and POVA first checks carried out before starting work and must provide references that are checked against work history. Training records demonstrated that needs of people who use the service are met by well-trained staff in suitable numbers. This was generally reflected in the care practices observed and attitude of staff towards their responsibilities. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 19 The training records detailed induction training and subsequent courses undertaken as part of the rolling training programme. They include POVA, moving and handling, care planning, fire safety, health and safety, medication and dementia. Staff have access to an e box self-learning system that they can access at home. There is also a q product skills for life numeric and literacy course available. Approximately sixty-seven percent of staff has attained the NVQ level 2 award. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 20 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, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed in the interests of those who use the service and the quality assurance system is effective. Health and safety is well managed meaning that people who use the service live in a safe environment. EVIDENCE: The home has appointed a new Care Manager who came to post a week prior to the unannounced inspection and was undertaking induction. They accompanied us during the inspection to increase their knowledge base of the Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 21 home and how it runs. They have previously gained three and a half years experience as a care manager in their last post, have a degree in sociology, post graduate certificate in business management is an RGN and qualified NVQ assessor and internal verifier for care. A senior Support Manager is on site to support the new manager whilst induction is completed team. The quality assurance system is generally thorough and robust although it did not pick up that the risk assessments on one unit were out of date whilst another unit was reviewing risk assessments three-monthly instead of monthly as stated in the procedure. It is a computerised system that allows the organization’s clinical governance team to monitor records, as well as providing a range of management information about the service. Records showed the clinical governance team undertake rotating monthly audits on different aspects of care in the home. Complaints and accident and incident records are monitored daily and incidents appropriately notified to the Care Quality Commission. The quality assurance system contains identifiable performance indicators and action trigger levels. There is an annual business plan with set objectives and internal audits are carried out. These include monthly, unannounced regulation 26 visits with accompanying reports. Regulation 26 visits check that required quality service levels are met and are carried out by the provider’s representative. The home has a policy for the management of money of people who use the service. A lockable drawer is provided in their bedrooms to keep their valuables. Where required, the home’s administrator is responsible for the safe handling of money of people who use the service and appropriate records are kept. A safe is available to ensure monies are securely stored. The home has a maintenance team and health and safety records showed all required checks and fire drills are undertaken. These include up to date fire plan, weekly fire alarm checks and two weekly door closure and emergency lighting and hot and cold water. Other checks are carried for the heating system, nurse call system, ventilator extraction fans, floor coverings and lifts. Fire drills take place quarterly and fire fighting equipment is serviced annually with the last service in January 2009. Annual Pat tests of electrical equipment take place annually or when electrical equipment is brought into the home. The last annual test was in May 2009. Fridge and freezer checks are undertaken by catering staff twice per day. Daily checks of the building are undertaken to check for any health and safety risks to people who use the service. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12 (1) (a) & 14 (2) (a) 12 (1) (a) Requirement Risk assessments must be carried out and within the time frame stated by the organization’s procedure. Activities provided must reflect stated interests, likes and dislikes. Timescale for action 15/10/09 2. OP12 15/11/09 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 OP13 Good Practice Recommendations Meetings for people who use the service should be reintroduced. Forrester Court DS0000026014.V377549.R01.S.doc Version 5.3 Page 24 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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