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Inspection on 24/09/09 for Pine Heath Nursing Home

Also see our care home review for Pine Heath Nursing Home for more information

This inspection was carried out on 24th September 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

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

The home provides a bright and welcoming environment for people to live. There is an ongoing redecoration and refurbishment programme that has been started and the carpets are to be replaced throughout the home. This will greatly improve the current areas of the home that appear worn and shabby. The staff group were going about their duties in a confident and relaxed manner with due consideration for the dignity and well being of people living in the home. There was a note on the general notice board from a resident to thank the staff for all their hard work and support during the difficult times when the lift has stopped working. The lunch time was undertaken in a calm way and there were no signs of the fact that staff had to take meals to rooms for those unable to use the stairs while engineers checked the lift. Meals provided by the home are appetizing and served from a hot station in the dining room directly to each person. Previous discussions with residents has confirmed that they can eat whatever they choose, even when this is just for one person, it is provided.

What has improved since the last inspection?

The previous requirements have either been fully completed or are in progress. This is the reason for two repeated requirements to appear as these will be closed on full completion. The first floor lounge has been re carpeted and redecorated and one person living in the home commented that this now provides a lighter and more enjoyable room to sit in. Previous practices in the home meant that some information could be read by any family members or visitors as this was in a public area. This is no longer the case and this information is now securely retained in the room where medication is stored.

What the care home could do better:

The completion of risk assessments for all areas that could potentially pose a risk to people must be completed. This would be for areas of the care home and also for any support that may be decided upon, ensuring that risks are identified and minimized or avoided completely. The recording on care plans remains very minimal and not as detailed as these should be. However, we were told about the new system for care planning that will enable and support the recording of fuller and more appropriate documentation. The care and support provided is set out and described in individual care plans. Therefore the success of the care being provided by the home depends on this detail, as this sets out the exact actions for staff to undertake and must therefore be fully recorded on these files.

Key inspection report Care homes for older people Name: Address: Pine Heath Nursing Home Cromer Road High Kelling Holt Norfolk NR25 6QD     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Brenda Pears     Date: 2 4 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 26 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Pine Heath Nursing Home Cromer Road High Kelling Holt Norfolk NR25 6QD 01263711429 01263711488 diane.varrall@virgin.net Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Diamond Care (UK) Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 42 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Pine Heath is a care home providing personal care and accommodation for older people, some of whom may have dementia. The home is located on the main road between Holt and Cromer. The home consists of a two-storey building. Most of the rooms are single and of a good size. There is a passenger lift to allow easy access to all communal areas and private space. Communal space is limited, with the lounge accommodation half of what it should be for the number of registered places. However a large room just off the registered accommodation has been made into an activities room and is bright and airy. Activities take place in there every day. The grounds are attractive and extensive though would benefit from some concrete walkways so service Care Homes for Older People Page 4 of 26 Over 65 42 42 0 0 2 9 1 0 2 0 0 8 Brief description of the care home users could enjoy them more. The fees depend on the level of care provided and on the size of accommodation accepted. A copy of the last inspection report and service user guide can be obtained on request. Care Homes for Older People Page 5 of 26 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 Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection undertaken on the the 24th September 2009 and started at 10.30am. The focus of this inspection was on the previous requirements, on the core national minimum standards and on the quality of life for people who receive support in the home. The methods used to complete this inspection consisted of looking at the care a resident receives and the records that support this. Information was provided to us by the home on an assessment form known as an Annual Quality Assurance Assessment (AQAA). During the visit to the home we spoke to the manager, deputy manager, six residents and with members of staff. These methods and previous findings all inform the outcomes of this report. Care Homes for Older People Page 6 of 26 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 7 of 26 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 26 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments are undertaken before any decision to move into the home is made, ensuring the home is able to meet the needs of any new resident. Evidence: We looked at four care plans that did show us that assessments are undertaken for any person considering a stay in the home. The manager was undertaking one such assessments on the day of this inspection. We spoke to one person who is in the home for a short stay and they had just been supported by the care staff to have a walk around the grounds. Discussions with this resident showed that they are happy and enjoy being as independent as possible. Care Homes for Older People Page 10 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans do not currently reflect all the care that is provided or required and this is currently being addressed through the introduction of new care plans. Medication is stored, recorded and handled appropriately. Evidence: We were told that care planning has been discussed and a new format identified but these have not yet been implemented. At our last inspection the care plans were lacking detail and contained only basic information in all areas. The home has since looked for a better format for care plans and a representative from the local authority quality monitoring office was in the home to assist with this development. We were told that the new format would be introduced over the next few weeks and further discussions were undertaken with the manager. These discussions were regarding the need to monitor and support staff during this time to make certain that the new care plans contain all required information and that staff fully understand how these should be maintained. We saw an example of the new format and the manager described some of the improvements in recording that are planned. This means that Care Homes for Older People Page 11 of 26 Evidence: the current care plans remain scant and do not accurately reflect the care that is needed or that is being provided by staff. For example, daily records of how the person has spent their day only contain early morning and evening care provided. The direct action taken by staff to support the resident is described but we could not find any evidence of daily interactions or any discussions between staff and the resident at any time. However, we did see staff supporting residents and interacting in a considerate and polite way, residents also told us that staff are very good and while the lift has been out of order that staff have worked very hard to help everyone. Care plans did not show that the lift has been out of order or how care and support has been maintained during this difficult time with some residents having to stay in their room. The sheets for various sections of the care plans are now more orderly and fixed into the file instead of being loose as found at the previous inspection. We also saw two care plans that now have an additional sheet for staff to record how the person had spent their day and give additional information. This additional sheet was not found on all care plans. We found risk assessments on care plans but these did not cover all areas that required such an assessment. For example, the use of bed rails is identified as being needed on two of the care plans we read. A risk assessment covering this practice was not found on these care plans. One resident who has physical discomfort when seated does spent a great deal of time in or on their bed. The care plan stated the times this person was assisted to bed, but did not set out the reason for the frequency of time spent in bed. There was no information regarding this condition. However, the manager and staff are aware what support is needed and there was a lengthy discussion about this being fully recorded on the new care plans. Care plans have been placed in each room where personal care is provided and staff explained that this may be the reason that personal care is all that is being recorded. The folders in each room do contain private and detailed information about the person that needs to be stored securely away from general use. The manager explained that care plans are in rooms to ensure the appropriate information is at hand for staff. A review of accident records was undertaken and we were able to cross check this against relevant care plans that did contain the details regarding any accident and that the person was subsequently observed following such an incident, with Care Homes for Older People Page 12 of 26 Evidence: appropriate medical support obtained when needed. Records and discussions with residents clearly evidence that healthcare professionals and health care services are accessed for residents in the home. The deputy manager explained that all spot checks regarding medication practices are now identified on the medication administration record (MAR) sheets to evidence when these are carried out. The medication room now has a key pad for entrance and is not just left open at all times as previously found. We were shown an additional sheet on files in the medical storage area that provides some personal information and not just medical needs. These have been added since the last key inpsection was carried out. The medication cabinet was orderly and organised. There are hand washing facilities including paper towels and pump soap available for staff in this room, supporting the control of infection and appropriate hygiene when handling medication. The local pharmacy has now included pain relief medication in individual dispensing boxes where possible and pain relief is recorded on medication administration records to allow for any audit that may be required. However, while dates of opening is recorded on any boxes and also on eye or ear drops, dates of opening are not being recorded on boxes of pain relief. The deputy manager said this would be addressed and that any areas needing attention would be discussed with the staff at supervision sessions. Care Homes for Older People Page 13 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A variety of activities are offered and enjoyed both inside and outside the home. Each meal is chosen by the resident and is provided in a relaxed and friendly atmosphere. Evidence: While care plans do not contain details of how a person has spent their day, the activities person does keep detailed records on all activities undertaken. The room that is used for activities is a relaxed, comfortable area that offers time to sit and chat as well as undertake various activities. One to one chats are also undertaken either in the activities room or in individual rooms. While touring the building, the activities person was visiting people in their rooms to discuss activities and any other subjects on an individual basis. Outings continue to be undertaken along with activities and these include a visit from the local school for pupils to talk to people and also to play some music. The manager hopes this will continue to be a regular activity as the residents had enjoyed these visits. There is a monthly organ recital and harvest festival is being planned with a special service in the home. Religious services are supported and communion is carried out in the home on a monthly basis. A tea party has also been enjoyed by residents, families and visitors with stalls and activities. The manager told us that the Care Homes for Older People Page 14 of 26 Evidence: home is well supported by families and visitors who are invited to events and special celebrations such as birthdays. Previous discussions with visitors have also confirmed this is the case. Many of the residents are over 90 years of age and we spoke to six people in the home who were happy and enjoying their day, except for the disruption that the lift was unfortunately causing. People were smiling and chatting to staff and each other during this inspection. One person had just finished a walk around the grounds with a walking frame. The resident told us that they enjoyed the large grounds and that regular walks are undertaken with staff support. Another resident was sitting on a bench and enjoying some late sunshine. Previous discussions and observations at this time confirm that residents are offered meals of their choice. During the lunch period meals looked and smelt appetizing and a variety of meals and portion sizes were provided. The atmosphere was relaxed and staff and residents were enjoying talking together and people were not hurried in any way. Care Homes for Older People Page 15 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems and procedures in place to protect people and staff undertake appropriate training to be aware of protection issues. Evidence: Discussions with residents at this and the previous inspection show that people are confident to discuss any matters of concern with the staff team. One resident expressed concerns about the lift breaking down on a number of occasions during the previous week. The deputy manager explained that a team were due in the home to try to find exactly why this keeps happening and to carry out repairs. The home operates in an open manner and residents have the opportunity to talk to staff on a one to one basis as necessary. Information about how to make a complaint is provided for residents and details and information was up to date and current at this time. Staff undertake training regarding recognising abuse and staff have expressed their confidence in speaking out if necessary about any inappropriate behaviour or matters of concern. Care Homes for Older People Page 16 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience 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 welcoming and has a relaxed atmosphere, when the planned refurbishment and decoration is completed, it will also offer a comfortable and homely environment. Evidence: The home is welcoming and staff were seen to be laughing and talking with residents in a considerate and appropriate manner. The environment continues to need upgrading and we were told that new carpet has been ordered for the corridors and then each room is to be decorated and new carpet installed. Each room will also have new furniture that has been ordered and soft furnishings, such as curtains and armchairs, will match. New bedding has been ordered as well as some new beds, however, where specific beds are needed for the individual these will be retained. We spoke to people in their rooms and observed many curtains that were loose on their rails. It was explained that discussions have been undertaken about the new curtains as windows are very high around the home and often come loose when pulled closed or open. The new curtains have been chosen with this in mind to ensure they will be suitable for such use. Care Homes for Older People Page 17 of 26 Evidence: Residents were enjoying the view from their rooms and some were outside walking or just sitting on a bench. The grounds are quite extensive and offer a safe environment in which to sit or walk. Care Homes for Older People Page 18 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home have their needs met by a consistent staff team who are trained and supervised, providing stability and continuity of care. Evidence: Staffing consisted of one senior carer and six additional care staff, one cook, a kitchen assistant, three domestic staff with one person working in the laundry, a maintenance man plus the manager and deputy manager. There are five care staff on duty during the afternoon shift, one or two being senior carers. There is also an activity person on duty from nine to five during Monday to Friday. There is one senior carer and two care staff on duty during the night period. Staff files have previously been reviewed and these contained all appropriate information required under the term of registration and to safeguard residents. The manager told us that while supervision has been undertaken regularly in the past, recently this has not been as frequent as it should be. Discussions were undertaken regarding this and we were told this would be improved and be more frequent. The manager stated that staff can discuss any matters they wish at any time with herself or with the deputy manager. The last inspection identified that staff had not had formal training regarding dementia Care Homes for Older People Page 19 of 26 Evidence: care. The manager told us that distance learning through the local collage had been undertaken and the manager is also doing this course. Fire awareness and moving and handling have been booked for refresher training and all core areas of care are refreshed yearly. The home is also in touch with a local pharmacy regarding a review of medication and the practices for the administration of medication. Discussions were undertaken regarding the need for care planning training to support staff in their recording and developing of new care plans. Care Homes for Older People Page 20 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager operates an open door policy that means residents or staff are able to discuss any matters with her. Evidence: The registered manager informed us at this time that she is to retire and a date for her completion of service is yet to be agreed. A new manager has been identified but has not yet been recruited. Lengthy discussions were undertaken regarding the previous requirement for regular monthly reports that are required to be carried out by the provider. The manager explained that while these have been undertaken, the proprietor does regularly visit the home but has not completed a formal report of this. The visitor from the local authority quality monitoring department is also going to assist the proprietor with the completion of a report for these monthly visits. The manager was informed that the Commission require a copy of this monthly report to be sent or emailed for the next three months. A copy of all monthly reports are to be stored in the home for Care Homes for Older People Page 21 of 26 Evidence: inspection. While the home usually keep us informed of incidents that occur in the home, we were not informed that the lift was continually out of order throughout the previous week. During this inspection, a team of engineers from the company who service the lift were trying to identify the fault that keeps rendering the lift out of order after about five or six hours of use. The proprietor has spent some considerable money on the lift during the last few months to ensure the comfort and safety of the residents, however, the current fault is proving difficult to identify. A check of maintenance and servicing certificates was carried out and these were found to be up to date and the manager is aware when these require renewal. Hoists are curretnly being serviced every six months in the home. Care Homes for Older People Page 22 of 26 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 19 13 The registered person shall 28/11/2008 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. An environmental risk assessment to be completed to support the health and safety of all persons in the home. 2 37 26 The registered provider must 13/02/2008 ensure that visits to the home are made monthly and that a copy of the visit report is sent to the Commission. Care Homes for Older People Page 23 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 13 The safety and welfare of 30/11/2009 people must be safeguarded by full risk assessments being developed. These must contain clear directions as to how any risk can be minimised. Particularly with regard to the use of bed rails. 2 38 26 Where the registered 06/11/2009 provider is an individual, but not in day to day charge of the care home, the person shall inspect the premises, records and complaints and prepare a written report on the conduct of the home. The completed report for these monthly visits are to be sent/emailed to the Commission for the next three months. 3 38 13 The registered manager 30/11/2009 provides a written statement of the policy, organisation Page 24 of 26 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action and arrangements for maintaining safe working practices. That an environmental risk assessment is completed. (Particularly with regard to worn/frayed carpet that may pose a risk to people) 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 7 It is recommended that staff are supported and monitored during the implementation of the new care plans. This will ensure appropriate recording systems are developed and understood plus provide staff with the opportunity to discuss and feedback about this development. Care Homes for Older People Page 25 of 26 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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