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Inspection on 17/12/09 for Meppershall Nursing Home

Also see our care home review for Meppershall Nursing Home for more information

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

What the care home does well

Some residents and a visiting relative spoken with expressed elements of satisfaction with respect to the quality of service offered at this nursing home. Their comments have been included in this report The home offers an information pack including the statement of purpose and a service user guide to all prospective residents and their representatives. This means that people are clear what they should expect if they decide to move in to the home. A pre-admission assessment of needs is carried out by a member of the management team to ensure that identified needs could be met on admission. The accommodation is spacious and a good standard of cleanliness was evident throughout those areas viewed. ‘The home is always kept clean’ said a resident. The standard of furniture and fittings, and decoration remains good. Parking is available for staff and visitors.

What has improved since the last inspection?

There are a number of requirements which have been addressed since the last key inspection report dated 07/08/09. Areas that have improved include: Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.2 A new training manager (Time shared with another sister home) has been in post since early November 2009. She has completed an audit of all training staff have received along with that, which is required for their future development. There are currently 7 ancillary staff who are receiving weekly lessons (8 week course provided by Skills for Life – UK Learning), in order to improve their numeric and verbal communication skills. A new management structure is being introduced to ensure that care and staff management systems including health and safety could be implemented to good effect. These changes have only recently been implemented and Inspectors feel it is too early to comment on their effectiveness. When medication remains from one cycle the remaining balance is being added to the new medication record, this enables it to be added to any new amount and provide a total number so that an audit can be carried out. However this was just an improvement in recording, our findings from this inspection evidenced that at times Nursing staff signed to say a medication had been given, when in fact it had not. The home has recruited an acting manager, a deputy manager, 4 registered nurses and a part time activities coordinator. There are no staff vacancies, which mean that the home does not need to rely on agency staff. A review of moving and handling equipment had been undertaken. This had been the responsibility of the home to act swiftly; they did not do this. To ensure the safety of the resident’s Central Bedfordshire Social Services had made sure this was done. What the service did do was purchase additional equipment. A review of staff competency is being carried out, and action must be taken where a deficit is identified

What the care home could do better:

There are 12 requirements and 4 recommendations arising from this report. These need addressing within the prescribed timescales. Residents should have a re-assessment of their needs carried out each month. This would provide staff with up to date details to ensure they are able to address the residents’ needs. The care planning within the home must be person centred, making sure there is guidance for each assessed need that staff can follow, in order to ensure continuity of care is given. Records of any accidents such as skin tears must be maintained and added to the resident’s care plan. This would enable staff to take action to protect the health interest of the resident.Meppershall Nursing HomeX10015 CQC Rebranded v5.doc Version 5.2 Protocols and specific guidance that nursing staff must follow when someone has a wound must be in place, this is to make sure the resident’s nutritional needs are re-assessed and a pain relief plan is in place. Medication must be administered to residents as prescribed by the doctor and appropriate medication administration records are maintained at all times. This is to ensure the health and safety of residents. Equally, regular monthly medication audits must be carried out and action taken as appropriate. This is to ensure that the recording, handling, storage, administration and disposal of medication are sufficient. Residents must be offered a variety of suitable, wholesome and nutritious meals of their choice. It is essential that all suspicions and/or allegations of abuse must be reported immediately to the local safeguarding team. This is to ensure the safety and protection of the residents. Staff must have knowledge of the English language. Staff must be able to speak to and understand the people living at the home and in turn the people living at the home must be able to understand and be able to communicate their needs to the staff. This is so their needs are met in a safe and consistent manner. All staff must receive training in the Mental Capacity Act and how it affects their work. This is so that they comply with it and ensure the protection of residents. Other specific training courses identified by the training manager, including care planning, diabetes and medication must be provided to staff, as appropriate. Some staff must complete infection control training. Residents must not be placed at risk. Staff’s care practice, including moving and handling must be closely monitored, remedial action taken where necessary and a record maintained. Recommendations The contract should reflect the name and signature of both the resident and their representative, as appropriate. This would demonstrate dignity and respect, and a more person centered approach towards the resident. The monthly review of the resident’s care plan should be regularised and updated to reflect any changes in health and personal care needs. All complaints should be recorded in a complaints record book; this would provide the manager an overview of any trends arising and take remedial actions as necessary. A regular programme of recorded one to one staff supervision should be reestablished. This would provide a robust support system for staff development and monitoring of care practices.Meppershall Nursing HomeX10015 CQC Rebranded v5.doc Version 5.3 Page 10

Key inspection report CARE HOMES FOR OLDER PEOPLE Meppershall Nursing Home 79 Shefford Road Meppershall Bedfordshire SG17 5LL Lead Inspector Neil Fernando Key Unannounced Inspection 17th December 2009 08:30 am X10015 CQC Rebranded v5.doc 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. Meppershall Nursing Home X10015 CQC Rebranded v5.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 Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meppershall Nursing Home Address 79 Shefford Road Meppershall Bedfordshire SG17 5LL 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) 01462 811224 01462 812027 gagroup@btconnect.com gacontracts@btinternet.com G A Projects Ltd Manager post vacant Care Home 84 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (49), Physical disability (5) of places Meppershall Nursing Home X10015 CQC Rebranded v5.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: Old age not falling within any other category - Code OP Dementia - Code DE Physical Disability - Code PD The Maximum number of service users who can be accommodated is 84 7th August 2009 2. Date of last inspection Brief Description of the Service: Meppershall is a purpose built care home with nursing on the outskirts of the village of Meppershall, in Bedfordshire. The home is registered to provide residential and nursing care for 84 people; 54 in the main nursing home and 30 in the dementia care unit. The main building (referred to as ‘the nursing home’) is built on two floors, and managed in four units, two on each floor. Each unit consists of a number of bedrooms (with either en-suite toilet and washbasin facilities, or washbasin in the bedroom), a sitting area, bathrooms and a nurses’ station. There is a dining room on each floor, and a large sitting room on the ground floor. There is also a main kitchen, a laundry and offices. There are lifts and staircases to access the upper floor, so the whole building, with its wide corridors and doorways is suitable for people who use wheelchairs. The accommodation was extended in July 2008 to provide a 30 place unit, which is attached to the existing home by a glass corridor. This building is known as ‘the dementia care unit’; the accommodation is on two floors accessed by a lift. There are 15 bedrooms, all with en-suite facilities, a lounge, dining room and bathrooms on each floor. There are also kitchen and laundry facilities, and a small office. There is a large day care facility attached to the nursing home, which is not Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.2 Page 5 included in the registration. This is operated by Social Services who currently open on one day a week for younger people with physical disabilities. The home is surrounded by large grounds with parking facilities for staff and visitors available. There is a large, secure garden with a paved patio which is accessed from the dining room of the dementia care unit. The rural setting means that there are views of the countryside from the home. The home has links with the local community and shares transport for people with its sister home. Hairdressing, newspapers, toiletries/tissues, and staff escorts to medical appointments are not included in the fees. People who have their own telephone are responsible for the bills. Information about this home can be obtained by phoning and visiting, and there is also an entry for this company on several care home websites. The fees for this service vary between £440 and £530, per resident per week; the exact fees are reflected in individual service contracts for the residents. Meppershall Nursing Home X10015 CQC Rebranded v5.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 0 star. This means the people who use this service experience poor quality outcomes. This unannounced key inspection was carried out on 17th December 2009 by two Regulation Inspectors, between 08:30 and 14:35 hours. G A Projects Limited is the registered provider. During this inspection we tracked the care of 9 people who live in this home including 6 people in the dementia care unit. This involved reading their records and comparing what was documented, to the care that was being provided. Documentation and records relating to staff recruitment, training and supervision, medication administration, complaints and health and safety in the home were also examined. We also spent some time in the communal areas, talking to staff and residents and observing the care practice. The service was given a 0 star rating at the key inspection undertaken on 25 February 2009. But following significant input and support by health and social care professionals over a six month period, improvements were noted at the last key inspection on 7 August 2009. Although there were areas identified for further improvement, none were considered a significant risk to any resident’s health and well being. The rating changed from 0 star to 1 star service. In October 2009 the local safeguarding team reported concerns about moving and handling practice, nutrition and wound care, and the number of staff who could not communicate with residents in the English language. Also, both the acting manager and deputy resigned on 2nd November 2009. During both our random inspections of the home on 2nd and 13th November 2009, significant shortfalls were identified and immediate requirements were made alongside other requirements. These requirements related to management arrangements, moving and handling equipment and staff competency, staff’s insufficient command of the English language and checks required prior to any staff starting work. Our key inspection on 17th December raised a total of 12 requirements. We also served the owner/responsible individual with a ‘Code B’ Notice, a procedure in line with the Criminal Procedure and Investigations Act 1996, and allowing inspectors to seize or copy any documents relevant to their investigation. The Notice was in respect of medication not administered for 2 residents. There has been a change of acting manager for the third time during a five month period. Care and staff management systems have not been implemented to good effect over a number of months. Staff have not received Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.2 Page 7 formal recorded supervision regularly and care practice has not been closely monitored and this has impacted on the quality of service delivery for residents. Pprotection incidents have not been reported immediately to the safeguarding team or Health and Safety Executive and wound management has been poor. Other areas that must be addressed include administration of residents’ medication, care planning and staff training. The trend emerging is that improvements are made but not sustained long enough to improve the quality of service delivery. The owner and management of the home must ensure a good standard of care for residents, continue to make sustained improvements and demonstrate their competency by operating the service safely so residents are not placed at risk. The new acting manager and owner acknowledge these shortfalls and said that now that the management team has a full compliment of staff, these shortfalls would be addressed as a matter of priority. Given the number of concerns arising, there is currently a complete embargo place on this service by the Central Bedfordshire social services. At the time of our visit there were 59 residents including 23 people in the dementia care unit accommodated, with 25 vacancies. The acting manager was available throughout the inspection and the owner/responsible individual was present from 11.15 until the end of the inspection. What the service does well: Some residents and a visiting relative spoken with expressed elements of satisfaction with respect to the quality of service offered at this nursing home. Their comments have been included in this report The home offers an information pack including the statement of purpose and a service user guide to all prospective residents and their representatives. This means that people are clear what they should expect if they decide to move in to the home. A pre-admission assessment of needs is carried out by a member of the management team to ensure that identified needs could be met on admission. The accommodation is spacious and a good standard of cleanliness was evident throughout those areas viewed. ‘The home is always kept clean’ said a resident. The standard of furniture and fittings, and decoration remains good. Parking is available for staff and visitors. What has improved since the last inspection? There are a number of requirements which have been addressed since the last key inspection report dated 07/08/09. Areas that have improved include: Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.2 Page 8 A new training manager (Time shared with another sister home) has been in post since early November 2009. She has completed an audit of all training staff have received along with that, which is required for their future development. There are currently 7 ancillary staff who are receiving weekly lessons (8 week course provided by Skills for Life – UK Learning), in order to improve their numeric and verbal communication skills. A new management structure is being introduced to ensure that care and staff management systems including health and safety could be implemented to good effect. These changes have only recently been implemented and Inspectors feel it is too early to comment on their effectiveness. When medication remains from one cycle the remaining balance is being added to the new medication record, this enables it to be added to any new amount and provide a total number so that an audit can be carried out. However this was just an improvement in recording, our findings from this inspection evidenced that at times Nursing staff signed to say a medication had been given, when in fact it had not. The home has recruited an acting manager, a deputy manager, 4 registered nurses and a part time activities coordinator. There are no staff vacancies, which mean that the home does not need to rely on agency staff. A review of moving and handling equipment had been undertaken. This had been the responsibility of the home to act swiftly; they did not do this. To ensure the safety of the resident’s Central Bedfordshire Social Services had made sure this was done. What the service did do was purchase additional equipment. A review of staff competency is being carried out, and action must be taken where a deficit is identified What they could do better: There are 12 requirements and 4 recommendations arising from this report. These need addressing within the prescribed timescales. Residents should have a re-assessment of their needs carried out each month. This would provide staff with up to date details to ensure they are able to address the residents’ needs. The care planning within the home must be person centred, making sure there is guidance for each assessed need that staff can follow, in order to ensure continuity of care is given. Records of any accidents such as skin tears must be maintained and added to the resident’s care plan. This would enable staff to take action to protect the health interest of the resident. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.2 Page 9 Protocols and specific guidance that nursing staff must follow when someone has a wound must be in place, this is to make sure the resident’s nutritional needs are re-assessed and a pain relief plan is in place. Medication must be administered to residents as prescribed by the doctor and appropriate medication administration records are maintained at all times. This is to ensure the health and safety of residents. Equally, regular monthly medication audits must be carried out and action taken as appropriate. This is to ensure that the recording, handling, storage, administration and disposal of medication are sufficient. Residents must be offered a variety of suitable, wholesome and nutritious meals of their choice. It is essential that all suspicions and/or allegations of abuse must be reported immediately to the local safeguarding team. This is to ensure the safety and protection of the residents. Staff must have knowledge of the English language. Staff must be able to speak to and understand the people living at the home and in turn the people living at the home must be able to understand and be able to communicate their needs to the staff. This is so their needs are met in a safe and consistent manner. All staff must receive training in the Mental Capacity Act and how it affects their work. This is so that they comply with it and ensure the protection of residents. Other specific training courses identified by the training manager, including care planning, diabetes and medication must be provided to staff, as appropriate. Some staff must complete infection control training. Residents must not be placed at risk. Staff’s care practice, including moving and handling must be closely monitored, remedial action taken where necessary and a record maintained. Recommendations The contract should reflect the name and signature of both the resident and their representative, as appropriate. This would demonstrate dignity and respect, and a more person centered approach towards the resident. The monthly review of the resident’s care plan should be regularised and updated to reflect any changes in health and personal care needs. All complaints should be recorded in a complaints record book; this would provide the manager an overview of any trends arising and take remedial actions as necessary. A regular programme of recorded one to one staff supervision should be reestablished. This would provide a robust support system for staff development and monitoring of care practices. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 10 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. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 11 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 Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 12 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): Standards 1, 2, 3 and 5. Standard 6 is not applicable to this service. People using the service experience adequate quality outcomes in this area. Information available to people prior to admission about the home is sufficient to assist them in making a decision on whether to move into the home. Reassessment of people’s needs and dependency levels is not consistent in frequency, to ensure staff would know if they had the skills and experience to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the previous key inspection in August 2009 it was assessed that the home provided a good level of written information on the services that it provided. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 13 Prospective residents and their representative are encouraged to visit the home, meet with staff and have a meal with the other residents, prior to deciding whether to move into the home. Two residents spoken to confirmed that they or their relatives had visited the home before moving in. ‘My daughter visited Meppershall, I accompanied her on the second visit’, said one resident. They also complimented staff for taking time to show them around and explain how the home operates. The home continues to provide a good level of written information on the services that it provides and continues to have an information pack for people who are interested in moving into the home. This document had been updated; information included the qualifications of staff, room sizes and how to complain. Copies were seen to be available in both areas in the home. Feedback from people living at the home indicated that they were aware of it and its contents. We viewed a random sample of care files for 9 residents including 6 in the dementia care unit. Each resident is issued a contract that, although basic, does state the terms and conditions of their stay at the home. The contracts in the care files on the dementia unit did not include the name and signature of both the resident and their representative, as appropriate. The owner and manager understand the need for remedial action as this would demonstrate dignity and respect, and a more person centered approach towards the resident. We looked again at the paperwork the home has in place about the assessment of needs of the people who live there. On examining 9 individual care records we saw that pre-admission assessments of people’s needs remain on the files. When people move in, the staff assess their level of dependency using various assessment tools, a persons needs should then be re-assessed each month. Assessment documentation was in place for people that had moved into the home recently. However, the re-assessment of needs had not been carried out for the three residents in the nursing unit in September or October 2009. Intermediate care is not offered at the home. Standard 6 is therefore not applicable. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 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): Standards 7, 8, 9 and 10. People using the service experience poor quality outcomes in this area. Inconsistencies in the standard of care planning, support and record keeping means not everyone receives continuity of care and the support that they need to meet their needs in full. Management of medication is poor and places people at risk of deterioration in their health. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Requirements had been made regarding documentation including care plans at the February/March 2009 key inspection when the service rating was poor. We then reported at the key inspection in August 2009 that there had been improvements in the home, however we stated at that time ‘The level of input Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 15 by health and social care professionals has been significant, and their input and support should be acknowledged as a considerable source of the improvements seen at this inspection’. We made clear that the owners and management of the service now had to demonstrate if they could sustain those improvements seen in August 2009. In late October 2009 the Central Bedfordshire safeguarding team raised issues with us concerning moving and handling practice, nutrition and wound care, and the number of staff who could not communicate with residents in the English language. During both our random inspections of the home on 2nd and 13th November 2009, significant shortfalls were identified and immediate requirements were made alongside other requirements. Immediate requirements made regarding management arrangements, moving and handling equipment and staff competency, staff’s insufficient command of the English language and checks required prior to any staff starting work. Reports of these inspections are available upon request and their findings are used as part of our judgement of the service. At a serious concerns meeting in November 2009 we were informed by a representative of Central Bedfordshire Council that through a review of care plans they had undertaken in November 2009, they believed that care planning for 43 of the 49 care plans they looked at were inadequate. Care records were examined within both units at this inspection. For the purpose of case tracking we looked at the care plans for the 9 people selected by us. The 6 care plans viewed in the dementia unit were noted to be of a satisfactory standard, reflecting the health and personal care needs for each of the 6 residents. However, not all of the care plans for the 3 people selected in the nursing unit were individualised or person centred. One example to support this was one person who required daily pain relief had an entry, ‘administer as prescribed by GP and monitor for effectiveness’. There were no entries to indicate when, what type or frequency. Records show that monthly reviews had been undertaken regularly for the 6 residents we case tracked in the dementia unit but the same had not occurred for those 3 people in the nursing unit. Within the nursing unit of the home written entries within the care files evidenced that some people had access to health care professionals when they needed. One person due to weight loss had been seen by a dietician. Staff had contacted the G.P and asked for this referral to be made. However, one person with a personal protection plan through the local authority had sustained a skin tear on four separate occasions. The documentation surrounding these repeated skin tears was incomplete and demonstrated a lack of follow up by management. Only one accident form had been completed regarding one incident of injury; entries surrounding the others indicated that no one knew how they happened. The nurse in charge was not able to explain the reasons for all the skin tears and no referral had been made by the home under the Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 16 safeguarding protocols; we made the referral to the safeguarding team after this inspection. Concerns had been raised and a requirement made at the February/March 2009 inspection that clear guidance was available to the nursing team on the approach to wound care. At a random inspection in June 2009 the new acting manager indicated that a monthly audit of who had a wound was not being carried out and the Tissue Viability Nurse had contacted the home to ask why they had not returned their monthly audit to her. One person in the nursing unit was selected for case tracking because of their wound care needs. There were 3 care plans in place relating to this including the current one dated 12/11/09; all 3 plans stated that regular repositioning should be carried out, but none indicated the actual frequency and what setting any pressure relieving equipment should be set at. Wound assessment charts and diagram/comments/size sheets that indicated a change in dressings had been made on certain days, but the nurses completing these assessments to show the current state of the wound had not done so correctly. On 24/10/09 it stated frequency for dressing change was ‘every other day’, this was not done until 29/10/09. We examined the storage, receipt and administration of medication in the nursing unit. We found the following shortfalls: i) The medication record for one resident showed that 5 doses of a medication were not given when nurses had signed to say that it had in a 25 day period. ii) The medication record for another resident showed that 9 doses of a medication (taken through a PEG feed) were not given when nurses had signed to say that it had in a 25 day period. Given the history of non compliance to previous requirements made on medication and the seriousness of the above incidents, we served the owner/responsible individual with a Code B Notice, a procedure in line with the Criminal Procedure and Investigations Act 1996, and allowing inspectors to seize or copy any documents relevant to their investigation. We are now looking at our wider legal options to secure the improvements required. We made a referral to the Central Bedfordshire safeguarding team regarding these matters. On 22/12/09 they informed us that following a visit to the home they identified a lack of clarity on some of the medication records they had seen; they asked for all medication to be audited that week. A further visit was undertaken by the Central Bedfordshire Contracts Compliance team on 30/12/09 as a follow up from the safeguarding team visit. They requested that the deputy manager “to concentrate on medication audit and implementing good practise within the home and all staff to receive update on medication training”. The physical appearance of the 16 people we met in both the nursing and dementia care unit appeared satisfactory. People’s hair looked combed, their Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 17 clothes were neat and tidy and no remnants of food were noted to be on anyone’s face or clothes. Observation at this visit showed the 7 staff seen in both areas of the home to approach and engage with people in a courteous manner. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 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): Standards 12, 13, 14 and 15. People using the service experience poor quality outcomes in this area. Shortfalls in care, support and monitoring people nutritional needs leave people at risk of dehydration and insufficient nutrition. Inconsistent approach to social activities means some people do not receive the support or motivation they need. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home currently employs 2 activities coordinators who provide a total of 44 hours input per week. The owner said that a third person has been recruited to start on 06/01/10 to provide activities for residents for 16 hours per week. As reported at the previous key inspection several of the people living within the nursing unit of the home reported that they felt there were a good amount Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 19 of activities available to them in arts and crafts. On the day of this inspection an activities coordinator employed by the home held a craft session and this was observed. She gave out pictures of the three wise men for people to colour in. We observed throughout her session that when anyone called her, including the inspector, she did not answer them. At one point she came over to where the inspector was sitting, she did not communicate with them and then moved the papers they were working with away without explanation. One of the residents asked her on 5 occasions what were the names of the 3 wise men as he could not remember, she did not answer. The inspector stood up to gain her attention for the resident, she then replied, “how would I know I’m not a Christian” and walked away from the gentleman. On speaking with this person afterwards they explained that they found some of the staff very helpful and kind, yet others ignored him he felt due to language barriers that they did not understand him and he did not understand them. All residents spoken with on the dementia care unit said their visitors are made welcome. We had the opportunity to speak with the relatives of one person at this inspection within the nursing unit. They advised that generally they were satisfied with the home stating that they felt the environment was good, but that their relative did often complain about the standard of food. In late October 2009 we were alerted by the Central Bedfordshire safeguarding team of a referral that they had received concerning a person living at the home; a major concern was the lack of nutrition that they had received. Further information was sent to us following their review of this in November 2009 advising that the hospital had stated that on admission to hospital from the home, the person had been severely dehydrated. We looked at nutrition as part of the random inspection undertaken on 02/11/09 and noted inconsistencies in the way staff documented nutritional intake. Within the dementia care unit every person had an individual chart in place, however one chart we looked at had no entry made onto it since 30/10/09. It was noted for this person did have a drink and they were able to confirm that they were neither hungry nor thirsty. Within the nursing unit this was all written in a book, there was no total intake reconciled so no balances were available to determine if the person had received sufficient fluid intake. At a random inspection on 2nd November 2009 we observed one staff member trying to take two main meals from the lunchtime menu at the same time to two people, who needed the staff members full support to eat their meal. We observed that another staff member repeatedly tried to explain why they should not do this, as the one person’s meal would be cold by the time the staff member had supported the other person. The staff member did not understand due to a language barrier, the other staff member said “we are banging our heads against a brick wall when they don’t understand.” Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 20 Observation of the support provided to another person was made around the lunchtime meal; again it was observed due to a language barrier the resident took a limited amount from one carer. We then observed another staff member come along who was able to converse with the resident; they were then assisted to sit up and then ate a bowl of ice cream. On 27/11/09 a visitor to the home made contact with us and they said that “Residents - They tell me that food is cold; the portions are not sufficient; that much of the dishes are not made on site and are unsuitable. A number of them refuse to eat them and go hungry. Otherwise, the Home appears to be well run”. We spoke with 6 residents on the dementia care unit and they echoed satisfaction regarding the quality of food, bar 2 people; one resident said ‘Needs greater variety of food sometimes but overall enjoyable food’ and ‘Hot soup would be nicer occasionally’, said another resident. The new acting manager and nursing staff advised at this inspection that they were working towards ensuring consistent record keeping and approach between the dementia care unit and the nursing unit. We did not inspect the main kitchen on this occasion. We viewed a certificate on display in the main entrance hall showing that the home had been awarded four out of five stars for their most recent food safety inspection by the environmental health department. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 21 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): Standards 16 and 18. People using the service experience poor quality outcomes in this area. This service has a complaints policy on display and easily accessible to residents; however all protection matters have not been reported immediately to the safeguarding team, which means some residents have been placed at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Previous inspections have established that the home has satisfactory written complaints and safeguarding procedures; however they have not always been followed. There is information available in the home to show anyone how to make a complaint if they are not satisfied with any aspect of the service. Details on the subject are also included in the service user’s guide. Residents spoken to said they would speak to a member of staff or the manager if they were not happy with something. Another resident also named the staff member they would speak to. Example of comments from residents spoken with include: Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 22 ‘I’m happy at present, I have no complaints’, ‘Staff often tell me that I could complain but no complaints from me’ and ‘I haven’t had any cause to complain’. Two staff spoken with said that they are aware of the procedure on complaints and echoed confidence that any complaints would be responded to swiftly and sensitively. Any complaints received by staff are recorded in the resident’s case file. Case files viewed for three residents indicated that concerns raised were quickly dealt with in accordance with the company’s complaints procedure, and the complainants informed of the outcomes in writing. It is however recommended that all complaints should be recorded in a complaints record book; this would provide the manager an overview of any trends arising and take remedial actions as necessary. There have been a number of safeguarding incidents, which have occurred since the last key inspection on 7 August 2009; the safeguarding procedures have not been followed in some cases. Examples include a resident sustaining a fractured leg when they had been dropped using a hoist by a staff, repeated skin tears of a resident in bed all day and an assault between two residents; none of these incidents had been reported to the local safeguarding team. The owner told us that part of this was due to the inability of the previous manager to respond to protection matters; however the current Acting manager had also failed to report a person who had sustained multiple skin tears. It is essential that all suspicions and/or allegations of abuse must be reported immediately to the local safeguarding team. The Central Bedfordshire social services have developed personal protection plans for all 59 people living in the home. This reflects the council’s level of concern and its aim to ensure the safety and protection of residents. There is currently 75 staff employed by the home. Evidence shows that 80 of staff have completed training on Safeguarding of Vulnerable Adults; a training matrix examined shows that arrangements are in hand for the remaining members to receive this training on 16 January 2010. However completion of this training alone will not ensure a higher level of safety for residents. A high percentage of staff is already trained and a policy has been in place, neither has resulted in protecting the residents. A change in practice is required, a need to review the understanding and competency of staff is required and a system in place to identify any shortfalls immediately. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 23 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): Standards 19, 21, 23, 24, 25 and 26. People using the service experience good quality outcomes in this area. Residents living at Meppershall Nursing Home benefit from a comfortable, clean environment that is well maintained. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We undertook a brief tour of the premises to include 9 bedrooms, 2 lounges, 2 dining rooms and 2 bathroom facilities. The premises were noted to be well maintained; no hazards were noted. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 24 All bedrooms in the main building have either en-suite toilet and washbasin facilities, or washbasin in the bedroom; all bedrooms in the dementia care unit have en-suite toilet and wash basin facilities. The standard of decoration and furniture and fittings in those areas viewed is good. Residents expressed a great deal of satisfaction with their physical environment. Those spoken with are very happy with their bedrooms and they said that they are able to bring their personal possessions and belongings. Evidence of furniture, mobiles and other personal effect brought by residents was seen in the bedrooms viewed. ‘My bedroom is comfortably furnished as you can see’, reflected a resident. The home was kept fresh and pleasant and a high standard of cleanliness was evident. ‘The home is always kept clean’ said a resident. The home is surrounded by large grounds with parking facilities. There is a large, secure garden with a paved patio area, which is accessed from the dining room of the dementia care unit. Staff reported that the garden is well used by residents during the warmer season. Evidence shows that protective clothing, gloves and hand washing facilities are provided. Cleaning schedules are in place and domestic and clinical waste is disposed of satisfactorily. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 25 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): Standards 27, 28, 29 and 30 People using the service experience poor quality outcomes in this area. Management is not sufficient to ensure that all staff employed has the needed levels of competency to keep residents safe at all times. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Information from the duty rota examined and discussion with staff, the manager and owner indicated the following: For the 36 residents living in the nursing unit there was 9 staff including 2 registered nurses available during the day and 8 staff including 2 registered nurses working the night shift. For the 23 people living in the dementia unit there was between 5 and 6 staff available at all times, including a Registered Mental Nurse. There are 10 registered nurses working at the home on a permanent basis. The acting manager and deputy manager are also available and work during the day. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 26 Looking at numbers in isolation, the number of staff on duty appears to be sufficient to provide the care needed for the number of residents. However account must be taken of the varying levels of competency and abilities of staff as indicated throughout this report, and the consequences this has had on the standard of care delivered. Therefore the number of staff on duty that has the skills and competency to meet the needs of the residents is not sufficient. Since August 2009 there have been 3 Acting Managers and 3 Deputy Managers. Leadership, direction, supervision and monitoring of performance of staff have not taken place in this time. Serious failures in care delivery have not been acted upon, reported correctly or followed up as detailed within the health and personal care section. An immediate requirement was made on 13th November 2009 about recruitment. The home had been using an agency to provide nursing cover in the home, this service was unregistered and there was no evidence of checks having been made as listed in schedule 2 of the Care Homes Regulations. The owner said that following the recruitment of 4 registered nurses, all vacancies have now been filled and consequently agency staff are not being used. Recruitment files examined for 4 staff members show that the necessary checks and information are all in place; this includes application forms, at least two written references, POVA First and CRB (Criminal Records Bureau) checks, training records and health declarations. The home currently employs 75 staff. A significant number is from overseas of which, approximately 66 are from Eastern Europe. The way in which the home recruits overseas staff is monitored via the Home Office. The random inspection report dated 2nd November 2009 reported on incidents where care staff had placed individual residents’ welfare and safety at risk due to poor verbal communication skills from staff members. One of the examples was a staff member trying to take two main meals at the same time to two people, who needed the staff members full support to eat their meal. We observed another staff member repeatedly trying to explain why they should not do this, as the one person’s meal would be cold by the time the staff member had supported the other person. Comments from the staff at that time described the difficulties they had as so many staff were not able to communicate sufficiently. In addition as described within the Daily Life and Social Activities section, residents also reported concerns about a language barrier and the effect this had on them An immediate requirement had been made on 2nd November 2009 for staff to have knowledge of the English language so that residents’ needs are met in a safe and consistent manner. The owner advised that he had ended the employment of staff identified at that visit and there were currently 7 ancillary (Domestics) staff who are receiving weekly lessons (8 week course provided by Skills for Life – UK Learning), in order to improve their numeric and verbal Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 27 communication skills. Acknowledgement is given that this training has commenced, however as evidenced there remains a need for further action to be taken by the service in this area to improve outcomes for the residents. A full time training manager has been recruited about 6 weeks ago and she works at Meppershall and another sister home. She has undertaken an audit of all training completed by staff and any further training necessary for their future development. She showed us a training matrix she has produced. Evidence indicates that new staff members receive 2 full days induction training when they start working at the home. They also complete their induction booklet over a 2 week period, which is finally signed off by both the allocated supervisor and the new member. Specific training completed includes Medication, Aggression and Violence and 20 members have completed a Dementia course. Care planning training is scheduled to occur within the next 3 months. All staff must receive training in the Mental Capacity Act and how it affects their work. 15 of the 41 care staff including seniors have completed a national vocational qualification (NVQ) at level 2 and another 18 members are currently undertaking the same training at level 2 or 3. Training has been good’ and ‘Staff are presently doing their NVQ training, you know, said two staff members. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 28 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): Standards 31, 33, 35, 36, and 38. People using the service experience poor quality outcomes in this area. The high turnover of managers at this home has resulted in failure to provide consistency in leadership and failure to provide the care that residents need. The homes management systems are not effective, monitoring of care practice in particular; this had placed residents’ safety at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 29 The registered manager of Meppershall Nursing Home resigned in October 2008. Since then there have only been acting managers. One acting manager resigned in September 2009, another acting manager was appointed and they resigned in November 2009. At a random inspection on 2nd November 2009 we made an immediate requirement for the owner to make sure that there are management arrangements in place at the home on a day to day basis, as alongside the resignation of the acting manager the deputy manager had also resigned. Including the current acting manager, there have been 3 acting managers in post in the last 5 months. The new acting manager has been in post since 7 December 2009 and a deputy manager, since 8 December 2009. The acting manager said that she previously held a registered manager’s post in a nursing home for older people, including dementia. She holds a registered qualification in nursing and City and Guilds – Management and Care. She said that she intends to submit an application to the Care Quality Commission for the registered manager’s post at Meppershall. We did not verify her background or performance record at this inspection. Within the past 4 months there have been 3 Acting Managers and 3 Deputy Managers. Leadership, direction, supervision and monitoring of performance of staff have not taken place in this time. Serious failures in care delivery have not been acted upon, reported correctly or followed up. Further non reporting of safeguarding matters were identified at this visit, serious shortfalls in medication administration and poor wound care practice. The acting manager reported that she has been given a copy of the action plan prepared by the owner in response to the requirements arising from the last key inspection on 7 August 2009 and the random inspections on 2 and 13 November 2009. She said that the owner visits daily and she feels well supported by him. ‘Our management team is now complete and things will improve’, said a staff member. The home has quality assurance procedures, which are carried out on twice yearly basis. Questionnaires are sent out to all residents and their relatives to seek their views regarding different aspects of the service; this was last completed in June 2009. The owner also completes a monthly report on the conduct of the home, the last having occurred in October 2009; a copy of the visits reports is kept at the home. On this occasion, we did not examined monies the home keeps on behalf of residents. The last key inspection in August indicated that monies checked and administrative records maintained were in order. Records examined show that fire drills, weekly tests of break glass points and checks of equipment are carried out as required. As indicated earlier, the local safeguarding team informed us of their concerns regarding poor moving and Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 30 handling practice at the home. Despite staff receiving moving and handling training, various incidents indicate that some staff were not putting their training into practice. A board with details about type of sling, moving and handling and the number of staff required is available in each of the 6 rooms viewed. In one case it also stated that a nurse must be present with 2 other care staff when the resident is being transferred. Staff members spoken to said that the remaining 25 bedrooms in the dementia care unit have been fitted with this board; they reflect the occupants’ requirements details for moving and handling. The plan is to extend this to all bedrooms on the nursing unit. An Occupational Therapist-Senior Practitioner visited a few weeks before our Key inspection and she had completed assessment for a number of residents who require further assessment. She indicated that moving and handling risk assessment needs to be more detailed in terms of make of sling, type, size, loops on the sling that need to be used and how the sling should be fitted. Staff have completed their mandatory training, bar 7 members who have not received training in Infection Control. The training manager said that this would be addressed as a priority. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 31 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 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X 3 X 3 3 3 3 STAFFING Standard No Score 27 1 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 2 X 1 Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 32 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 OP3 Regulation 14 Requirement Every resident must have a reassessment of their needs carried out each month. This would provide staff with up to date details to ensure they are able to address the residents’ needs. Care planning within the home must be person centred, making sure there is guidance for each assessed need that staff can follow to ensure continuity of care is given. (Outstanding requirement – Timescales of 30/09/09 & 13/11/09 unmet). A comprehensive record of any accidents such as skin tears must be maintained and added to the resident’s care plan. This would enable staff to take action to protect the health interest of the resident. Protocols and specific guidance that nursing staff must follow when someone has a wound must be in place. Timescale for action 31/03/10 2. OP7 15 (1) 28/02/10 3. OP8 17 (1) 05/02/10 4. OP8 12 (1) 05/02/10 Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 33 5. OP9 13 (2) This is to make sure the resident’s nutritional needs are re-assessed and a pain relief plan is in place. (Outstanding requirement – Timescales of 30/09/09 & 13/11/09 unmet). Medication must be administered to residents as prescribed by the doctor and appropriate medication administration records are maintained at all times. This is to ensure the health and safety of residents. (A Code B Notice served immediately). Medication audits must be carried out and action taken as appropriate. This is to ensure that the recording, handling, storage, administration and disposal of medication are satisfactory. Residents must be offered a variety of suitable, wholesome and nutritious meals of their choice. All suspicions and/or allegations of abuse must be reported immediately to the local safeguarding team. This is to ensure the safety and protection of the residents. (Outstanding requirement – Timescales of 13/11/09 unmet). Staff must be able to speak to and understand the people living at the home and in turn the people living at the home must be able to understand and be able to communicate their needs to the staff. X10015 CQC Rebranded v5.doc 17/12/09 6. OP9 13 (2) 05/02/10 7. OP15 16 (2) (i) 05/02/10 8. OP18 12 & 13 05/02/10 9. OP28 13(6) & 18 05/02/10 Meppershall Nursing Home Version 5.3 Page 34 10. OP30 18 This is so their needs are met in a safe and consistent manner. (Outstanding Requirement – Timescales of 10/11/09 unmet) All staff must receive training in the Mental Capacity Act and how it affects their work. This is so that they comply with it and ensure the protection of residents. Other training identified includes medication and care planning. Residents must not be placed at risk. Staff’s care practice, including moving and handling must be closely monitored, remedial action taken where necessary and a record maintained. 31/03/10 11. OP38 13 (4) (5) & (6) 05/02/10 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 OP2 Good Practice Recommendations The contract should reflect the name and signature of both the resident and their representative, as appropriate. This would demonstrate dignity and respect, and a more person centered approach towards the resident. The monthly review of the resident’s care plan should be regularised and updated to reflect any changes in health and personal care needs. All complaints should be recorded in a complaints record book; this would provide the manager an overview of any trends arising and take remedial actions as necessary. A regular programme of recorded one to one staff X10015 CQC Rebranded v5.doc Version 5.3 Page 35 2. OP7 3. OP16 4. OP36 Meppershall Nursing Home supervision should be re-established. This would provide a robust support system for staff development and monitoring of care practices. Meppershall Nursing Home X10015 CQC Rebranded v5.doc Version 5.3 Page 36 Care Quality Commission Care Quality Commission Eastern Region 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. 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