Inspection on 30/09/09 for Northwood House

This inspection was carried out on 30th September 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Northwood House 28/09/07

Northwood House 03/10/06

Northwood House 27/02/06

Northwood House 20/06/05

Northwood House 17/01/05

Northwood House 07/09/04

Northwood House 22/01/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Northwood House 28 London Road Sittingbourne Kent ME10 1NA one star adequate service The quality rating for this care home is: A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jo Griffiths Date: 3 0 0 9 2 0 0 9 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. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983   Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Information about the care home Name of care home: Address: Northwood House 28 London Road Sittingbourne Kent ME10 1NA 01795472464 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Kent Assessment & Training Services Ltd Name of registered manager (if applicable) Mrs Linda Ann Tebb Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 7 0 care home 7 learning disability Additional conditions: The maximum number of service users to be accommodated is 7. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection A bit about the care home The Home is a detached property with accommodation for service users on two floors and office accommodation on the third floor. The home is situated on the outskirts of Sittingbourne approximately one mile from the town centre providing access to shopping and all public amenities. The Home provides accomodation and support to adults with learning disabilities who may have challenging needs. The Home is registered for seven service users. The manager is registered in respect of Westdene in addition to Northwood House. Westdene is located next to Northwood house. Fees are charged according to individuals assessed needs. Current fees range from £1200 to £2000 per week. Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home This was a key inspection of Northwood house that took place on 30th September 2009. The inspection was carried out jointly with the organisations sister home, Westdene, which is located next door and is managed by the same manager. The inspector carried out the inspection of both services between 10.30am and 4.30pm. Prior to the inspection visit the manager completed and returned the Annual Quality Assurance Assessment (AQAA). This was received within the required timescales and provided useful information for planning the inspection. The manager was not present during the visit around the home, but met with the inspector later in the day and gave feedback on improvements made within the service. Some of the staff were spoken with and one service user was involved in the inspection. Some records were seen and the inspector had a look around the home. What the care home does well The service provides people with plenty of opportunities to go out in the local community for activities. The house is located near to the town and community facilities. The people that use the service are involved in decision making in the home through one to one meetings with their keyworkers and through house meetings. The staff work closely with service users to provide emotional support as well as support with daily living skills. Most of the staff team have completed the NVQ award. Everyone living in the home is supported with household tasks and cooking. They choose the meals they would like on the menu each week and have a daily choice of foods and what activities they wish to do. What has got better from the last inspection Some areas of the home have been redecorated and refurbished. What the care home could do better The service does not always provide person centred support, for example, due to the needs of one person in the house people have their bedrooms locked during the day and they do not have access to them without staff support. Service users cannot go into the kitchen and help themselves to a drink or snack as the kitchen is kept locked. The systems in place for monitoring service users well being and for monitoring the quality of the service are not effective as records are made, but often no action is taken or recorded as a result. Staff do not have the training they need to safely support people before they are required to work unsupervised with service users. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Jo Griffiths CQC Southeast Citygate Gallowgate Newcastle Upon Tyne NE1 4PA Email: Southeast@cqc.org.uk 03000 616161 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 set out on page 4. The report of this inspection is available from our website http:/www.cqc.org.uk/. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with the information they need about the services in the home. People have an assessment of their needs before they move to the home and are assured these needs can be met. Evidence: The home has a Statement of Purpose and Service User Guide that gives people information about the services provided in the care home. Both documents were reviewed in August 2008. The Service User Guide has been given to all people living in the home and is presented in a written format, but with some supporting pictures to help people with communication difficulties. The Service User Guide states people have a right to have a key to their own bedroom. The manager told us that service users were initially offered keys to their bedroom door, but either did not want a key or have lost them and not requested a replacement. The bedroom doors were locked at the time of the inspection and staff had the keys. Staff on duty said this is due to the needs of one service user and that service users can ask staff to unlock their room for them if they wish during the day. Two assessments were seen during this inspection. These show that service users holistic needs are assessed to ensure they can be met before they move to the home. There has been one breakdown of placement due to a change in service user need. This person is being supported to find a new service by their care manager and the manager gave an update on this. Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users have a care plan that ensures their day to day needs are met, but they would benefit from clearer systems for staff to follow to support people with any challenging behaviours they may display. Service are involved in the running of the home and are supported to make decisions in their day to day lives. Risks to service users have been assessed, but the agreed actions have not always been followed and risk assessments have not always been updated. There are some restrictions to service users in accessing areas of the home. Evidence: Essential lifestyle planning documents are used by the service to give staff information about the needs of the person and the way they prefer to be supported. Some of the documentation. The manager said that all risk assessments are being reviewed at present. Some of the language that staff use in relation to challenging behavious is not clear. There were frequent references to service users displaying behaviours with no clear detail of what this means. Staff were asked what this means and they said that it refers to behaviours that may be considered challenging or aggressive. The records, incidents forms, show that staff adopt these terms without really giving consideration to the Evidence: function of individualised behaviour. There were also a number of examples seen where it had been recorded on the incident form that the person had displayed behaviours, but that it did not state what these behaviours were or what action was taken in relation to this. The service does not currently have an effective system for monitoring or following up on incidents of aggressive or challenging behaviour. Some service users have their own bank accounts and any money they hold in the home is securely stored and accurate records are kept. There has been one safeguarding referral made in relation to theft of service users money. This is currently being investigated by the police. Staff said that service users have the opportunity to participate in the monthly house meeting and have a monthly 1-1 session with their keyworker. They are involved in the weekly menu planning for the home. Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to participate in activities that meet their social needs and which they enjoy. They are supported to access community facilities. Some of the practices in the home are not person centred and do not promote individuals independence. People using the service enjoy their meals and have a balanced diet. Evidence: Individuals are supported to take part in a range of activities within and outside of the home. This includes going shopping, swimming, going to college, eating out, going to the nightclub and visiting family and friends. When at home people are supported to help prepare meals and do their laundry. They can relax and watch TV in the lounge, but they do not have unrestricted access to their own bedrooms or their own belongings. This has been reported under the environment section of this report. The records of activities show that people are generally busy and have lots of opportunities to go out into the local community. On the day of the inspection a number of people were being supported to go out. None of the service users are currently in employment and the manager said this is not being explored with them at present. Evidence: The menu is planned by service users with staff support on a weekly basis. The menu provides a guide to meals in the home, but is flexible to allow individual choice on a daily basis. The planned menus provide variety and a balanced diet. Service users do not have unrestricted access to foods and drinks as the kitchen is kept locked. The manager said that staff had been instructed not to lock the kitchen door and that she would address this. People using the service said they are happy with the meals and said they enjoy the activities they do. They confirmed that they have lots of opportunities for going out. The manager said that none of the people using the service had been on holiday yet this year as it had not been agreed where to go. Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service have their health and personal care needs met. People using the service have their medication managed safely, but would benefit from being supported to self medicate where possible. Evidence: Everyone using the service has a health action plan. Staff said that they keep these up to date following health appointments up to date by the keyworker. This could be further improved by encouraging service users to take control of their own health action plan and booking their own health appointments. Records show that people have their health needs met in a timely manner. The support that individuals require with their personal care is outlined in their care plan. Staff said that they encourage people to be as self managing as possible. All personal care support is provided in private. Service users medication is administered by trained staff in the home. The storage of medication is secure and the records seen had been completed accurately. None of the service users are currently managing their own medication or working toward this. People using the service should be given the opportunity to develop their skills in this area through their person centred plan. Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are safeguarded by procedures for reporting any allegations of abuse. People using the service know how to make a complaint if they need to. Evidence: The home has a safeguarding adults policy and a whistle blowing procedure for staff to follow in the event of allegations of abuse in the home. Staff spoken with understood what constitutes abuse and how to report any allegations. There have been two safeguarding allegations made since the last inspection and these are currently under investigation. The staff files that were seen did not evidence that the procedures for recruiting new staff fully safeguard service users, however, it was later advised by the manager that this is in relation to the sister home, Westdene, only. This has been reported under the staffing section of this report. The home has a complaints procedure and all service users have been issued with a copy in picture format. Staff said service users have regular opportunities to share any concerns they may have, through the monthly house meetings or one to one sessions with their keyworker. The manager said that there have been no complaints received about the service since the last inspection. Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is maintained to an adequate standard and meets the needs of those that live there. Service users would benefit from an annual programme for decoration of the home. Service users have bedrooms suitable for their needs and access to sufficient shared space and bathroom facilities. They would benefit from more attention to giving the house a homely feel. Service users do not have unrestricted access access to their bedrooms or their kitchen. Evidence: The home is maintained to an adequate standard. There is no maintenance plan for the ongoing decoration and refurbishment of the home, but a handyman is employed to undertake any work identified by the manager. The home is kept clean. There are sufficient numbers of bathrooms and shower rooms for service users to use near to their bedrooms and some people have ensuite facilities. Some of the bathrooms are bare and quite clinical in appearance. This does not present a pleasant and homely environment for service users. The home is registered for more people than there are bedrooms and the manager said that this was because some people used to share a room. The manager said that bedrooms are no longer shared and that the home can now only comfortably accommodate five people. The registered provider must ensure that a variation to the registration of the home is applied for in respect of the change to the numbers that can be accommodated in the home. Three people have vinyl flooring in their bedrooms. the staff said this is for the Evidence: management of continence. The two peoples care plans that had been reviewed did not have a risk assessment to show that this was required and that there is no alternative option. The care plans did not contain suitable plans for supporting people to manage their continence. Service users have their toiletries locked away in the COSHH cupboard. Staff said this was because one service user would present a risk to other people in the home if they had access to these. However, individuals all had their bedroom doors locked and staff were unsure why the toiletries could not be kept in their bedrooms. Service users do not have unrestricted access to their bedrooms. The rooms are locked due to the needs of one individual and this restricts the service users from accessing their own rooms when they wish. Service users do not have a key to their bedroom door or a front door key. There is a coded keypad to the front door. The manager said that if a person was assessed as safe to go out independently they would be issued with a front door key and the keypad code. There is a large lounge, although this has a patch of damp to one corner. The kitchen is appropriate to the needs of the service users, but is kept locked. The rear garden is overgrown and not pleasant for service users to use. Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are safeguarded by the homes procedures for recruiting new staff. Staff do not receive the training they need to safely support service users before they are required to work without supervision. Service users benefit from staff that have completed the NVQ award. Evidence: Service users spoken with said they feel there are enough staff on duty to meet their needs. At the time of the inspection there were three staff on duty and staff were available to support people out to activities when they requested this. The manager told us, in the AQAA that appropriate checks are made for all employees working in the service. On the day of the inspection the staff on duty said that they are employed across the two services, but that they usually work predominately in one service. The staff files were examined for three new employees that had been recruited to the service, although the manager later informed CQC, after the inspection, that these staff members predominately work in the sister home next door, Westdene. There were some checks that had not been evidenced in the files that were seen and the manager said she would rectify this immediately. The manager has told us that the files relating to staff that work only in Northwood House contain the relevant checks. New staff complete an in house induction. This was seen for two new employees and these had been fully completed in one day. The manager was asked whether it would be possible to fully cover the topics in the induction in detail in one day and she said this would not be possible. The manager said that the new staff would be registered for the Learning Disability Qualification. Evidence: Staff attend a one week training programme when they join the organisation. This covers all core training courses they need to undertake including safeguarding adults, first aid, moving and handling, infection control, food hygiene and fire safety. The three new staff in the home had not yet been booked for this training and the manager said it can take up to three months before they complete the courses. This means that some staff are working in the home without having received the training they need to safely support service users. Staff without the training were seen to be working without adequate supervision with service users. The majority of staff employed in the home have completed the NVQ award in care. Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed by a person that has achieved some of the qualifications necessary to undertake the role, however the home is not currently being run in a person centred way. The systems for monitoring the quality of the service and the welfare of service users are not effective. The health and welfare of service users is generally promoted and protected, but some attention is required to risk assessment processes to ensure they are person centred. Evidence: The manager of the home has completed the Registered Managers Award and is working toward completion of the NVQ level 4 in care. The manager has completed training in person centred planning and said that this was being arranged for other staff in the home. Some of the practices in the home restrict the rights of service users due to the needs of others and cannot be considered person centred. The manager must develop effective systems for monitoring the wellbeing of service users and ensure that any records maintained in the home serve a purpose and that action is taken to address any changes in need. The manager must ensure that the service is run in a person centred way and that the quality of the service is monitored and developed. The manager must ensure that new staff are appropriately supervised until they have Evidence: received the training they need to carry out their roles. Risk assessments must be reviewed, as planned by the manager, to ensure that they are relevant and provide care in the least restrictive way possible. Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 15 12 The registered provider must 31/12/2009 ensure that routines in the home are person centred. To ensure people are supported in the way they prefer and need. 2 24 23 The garden must be adequately maintained and safe for service users. 30/12/2009 To ensure service users have access to safe and comfortable outdoor space. 3 24 23 The home must have a planned programme for maintenance and decoration of the home. 31/12/2009 To ensure a pleasant and safe environment for service users. 4 25 22 Service users must have not 31/12/2009 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action have access to their bedrooms restricted due to the needs of another service user. To ensure people can access private space when they wish. 5 26 23 Service users must have suitable and comfortable floor covering in their bedrooms that meets their needs. 30/12/2009 To ensure their bedrooms are comfortable. 6 28 16 Service users must have access to suitable kitchen facilities and food and drink when they wish. 30/12/2009 To promote service users independence. 7 35 18 The registered provider must 31/12/2009 ensure that staff receive the training the need to support service users before they work unsupervised. To safeguard service users. 8 39 24 The registered person must 31/12/2009 ensure that effective systems are in place for monitoring the quality of the home and developing the service in a Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action person centred way. To ensure service users receive a high quality service. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 6 It is recommended that there are clearer systems for reporting and monitoring any challenging behaviour service users may display. Helpline: Telephone: 03000 616161 or 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). 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