Inspection on 23/02/10 for Summer Court Hall Residential Home

This inspection was carried out on 23rd February 2010.

CQC found this care home to be providing an Poor 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Summer Court Hall Residential... 24/11/09

Summer Court Hall Residential... 16/06/09

Summer Court Hall Residential... 27/02/07

Summer Court Hall Residential... 06/02/06

Summer Court Hall Residential... 30/08/05

Summer Court Hall Residential... 05/01/05

Summer Court Hall Residential... 11/08/04

Summer Court Hall Residential... 13/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/05/2010.

Key inspection report Care homes for older people Name: Address: Summer Court Hall Residential Home Football Green Hornsea East Yorkshire HU18 1RA     The quality rating for this care home is:   zero star poor 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: Sarah Rodmell     Date: 2 3 0 2 2 0 1 0 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 43 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 43 Information about the care home Name of care home: Address: Summer Court Hall Residential Home Football Green Hornsea East Yorkshire HU18 1RA 01964532042 01964532042 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Hexon Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 37 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The Home may admit up to 37 service users when the building works are completed and a Certificate of Completion issued under the Building Act 1984 Building Regulations Date of last inspection Brief description of the care home Summer Court Hall is located in the seaside town of Hornsea on the coast of the East Riding of Yorkshire, close to all local amenities. It has parking facilities for several vehicles. The home is registered for thirty-seven older people, a maximum of twelve may have dementia and are cared for in a separate area of the home. The home does not provide nursing care. Currently the service is without a manager. Care Homes for Older People Page 4 of 43 Over 65 12 25 0 0 2 4 1 1 2 0 0 9 Brief description of the care home The bedrooms are arranged on both the ground and first floor, with a lift and stairs providing access for residents. The home has a lounge with a conservatory, and a separate dining room in the main part, and a connecting lounge and conservatory in the dementia care unit. There are bathrooms and toilets on each of the floors. The current fees for residents range from £374 to £420 a week and are primarily based on their assessed needs. This was correct on 23rd February 2010. Information is available in the statement of purpose and service users guide. Care Homes for Older People Page 5 of 43 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: zero star poor 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: The quality rating for this service is 0 star. This means that the people who use the service experience poor quality outcomes. This inspection report is based on information received by the Care Quality Commission (CQC)since the last key inspection on 24 November 2009, including information gathered during a site visit to the home. The unannounced visit was undertaken over one day by one inspector. It began at 9.00 am and finished at 7.20 pm. On the day of the visit the inspector spoke with people who live in the home, staff, the managers, a visiting professional and a relative. Inspection of the premises and close examination of a range of documentation, including three care plans were also undertaken. At the end of this visit, feedback was given to the managers on our findings, including Care Homes for Older People Page 6 of 43 any requirements and recommendations that may be in the key inspection report. At the last inspection of this service a quality rating of 0 stars was awarded which meant that people receive a poor service. Subsequently a Statutory Requirement Notice (SRN) was issued, informing the provider that they were in breach of Care Homes Regulations 2001. Although this inspection was a key inspection, inspecting all of the key standards, it also included assessment against compliance with the requirements of the Statutory Requirement Notice. We explained to the managers at the time that the visit would entail collecting evidence under the police and criminal evidence act, (PACE) that could be used for enforcement against the home if the regulations had been breached. We ensured that they were fully aware of the procedure and gave them a list of any documents that we photocopied. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations , but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 43 What the care home does well: What has improved since the last inspection? What they could do better: There are a large number of outstanding requirements in this home. One of the requirements was identified in a Statutory requirement notice of breach of regulations following the last visit to the home and this still has not been met. Further action may now be taken. Due to the large number of outstanding requirements, it is clear that the home continues to not be well managed, further action may be taken by the CQC. Peoples assessments and care plans could be developed further to include more detail of their needs so that staff are fully aware of these and can work to meet them. Peoples records should be kept up to date so that staff are aware of the latest needs of people and peoples medication needs must be met, medication must be administered as prescribed. There is a lack of social and leisure activities, meaning that peoples needs for social stimulation and activity are not being met, people may be bored. Staffing levels and peoples needs at meal times could be assessed to ensure that there Care Homes for Older People Page 8 of 43 are enough staff to support people and that their needs are being met, additionally staff should always have rest breaks between working shifts to make sure that the risk of accidents and errors is reduced and peoples needs are met. Furthermore people should be supported by a staff team that receive training so that they can fully meet peoples needs. The home should be maintained and managed to a good standard so that it does not pose a risk to peoples safety. Risk assessments and daily maintenance should take place. The home should be clean throughout, so that is relaxing and comfortable for people. Sufficient quantities of all medicines must always be made available. Medicines must be given strictly according to the directions of the prescriber. Medication records must be accurate and detailed in describing exactly what medicines are received, given, and disposed of. All medicines must be stored securely at temperatures and conditions recommended by the manufacturer. All staff must be fully trained in safe medication handling and shown to be competent to give and record the use of medicines. The homes medication policy and procedure documents should be updated to reflect current best practice. Information should be gathered about peoples medication taking preferences. Guidance should be kept for those medicines prescribed to be given as and when needed. The home should be well managed, peoples needs should be met and their safety ensured. 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. Care Homes for Older People Page 9 of 43 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 10 of 43 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at standards 3 & 6. Peoples needs are not fully assessed prior to entering the home, this could mean that their needs are not all known and met. Evidence: We looked at the care files for four of the people who live in the home. There had not been any new admissions to the home since the last visit. We saw that the assessments in these files had not been amended since the last visit to the home. They continue to include only basic information, with some gaps and were not person centred. One persons assessment included the following information, What is health usually like?, with the response, 1 carer possibly 2. This does not describe the persons health, needs or what support they require and will not assist the person in having their needs met. Care Homes for Older People Page 11 of 43 Evidence: The managers told us that they have not undertaken any work regarding peoples existing care plans but that they have developed a new care file that is to be introduced for each person in the home. We looked at this new file and it included a large variety of forms and review documents. It also included a template letter that would be used by the home, following an individual assessment to formally state that their needs can be met by the home. We saw that people continue to have copies of the assessments undertaken by the Local Authority. When asked, the managers confirmed to us that the home continues not to provide intermediate care and so standard 6 does not apply. Care Homes for Older People Page 12 of 43 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at standards 7,8,9 & 10. Peoples plans of care continue to require more detail and supporting documents are not always completed. This means that peoples needs may not be met fully. Poor practice in medication issues means that people do not always have their medication needs met. Evidence: We examined four of the plans of care for the people who live in the home. At the last inspection of the home it was found that the care plans lacked detail and were basic. The managers told us that no amendments have been made to the care plans since the last visit to the home. However, when we looked at care plans it was clear that the previous manager had amended some of these and they do contain more detail. However, this is not the case for all of the care plans; it is concerning that the current managers are not aware of the content of peoples care plans and when Care Homes for Older People Page 13 of 43 Evidence: they were last reviewed. We looked at the care records and found that they were not always comprehensive. One persons care file included a section for personal care, it recorded that they required cream to their skin each day but the cream was not identified and was described as ? cream. Without these details staff may be unsure of the task and peoples needs may not be met. Another persons care plan included how they were to be supported when they became upset and agitated, the instructions to staff were, staff to resolve any issues immediately. This is not detailed enough and does not offer enough instruction to staff for them to be able to support this person fully, consequently this persons anxiety may remain and increase. When we spoke to staff and asked them how they knew what peoples needs were they told us that they would read the care plans and files. If these records are not up to date or not detailed enough then staff will not be working to meet peoples latest needs. At the last visit to the home we had concerns about peoples personal care and appearances as these were not to an acceptable standard. At this visit we noted that overall people in the main area of the home have had their personal care needs met. However the people who live in the dementia care unit did appear to have less personal care than other residents in the home, with people looking untidy and disheveled. We looked at the record keeping undertaken by the staff regarding peoples personal care. Daily records would include that people had been assisted with their personal care and there were monthly and daily record sheets for personal care or bathing. We saw that these records had not been completed regularly and that some of the records for the month of February were blank. We spoke to a relative of one of the people who live in the home, they felt that the staff addressed this persons personal care needs and supported them well. However, our observations did not qualify this. There were separate records of bathing, kept in the bathrooms of the home. These were fastened to the wall and included the date, water temperature and name of the resident. This method of recording is not appropriate, does not account for a persons dignity and is not good practice. One of the managers removed these records at the visit and developed a new recording sheet for the bath temperatures that does not include peoples names. We saw that there was some improvement in the meeting of peoples health needs and in seeing their GP or a district nurse. Records are kept of professional visits to the home and these included the GP and district nurse. We saw the district nurse on the day of the visit and she confirmed that there had been some small improvements to Care Homes for Older People Page 14 of 43 Evidence: the home, this included peoples personal appearances and the cleanliness of the home. However she felt that systems in the home could be improved upon so that staff were more organised, particularly in relation to the storing of notes and medical aids, for example, dressings. We looked at the records of peoples health needs, these reflected that the GP and district nurses are seen by people. One relative told us that the home always see to their relatives health needs and call the GP if needed. At the last visit to the home it was found that staff were not proactive in obtaining medical attention quickly for people. Overall we saw that people had received medical attention , although one persons records noted that a potential medical problem had re-occurred, and it was two days before the staff arranged medical attention for this. This does not ensure that peoples health needs are met. People continue to have a nutritional screening tool included in their care file. These tools do not always contain the persons name, are not individual and have no review dates on them. We saw individual record sheets to monitor peoples weights, these were not up to date but the manager showed us a separate record book, were people weights were recorded. These were on the whole up to date. It is recommended that there is only one record kept for each persons weight monitoring. At the last visit it was noted that one person had needs associated with nutritional intake and that the care plan stated, carers aware that dietary supplements have been prescribed, but did not include what these were, when the person was to have them and if they were to be provided only when the person declined to eat all of their meal. Another care plan was seen at this visit and it also included, has prescribed dietary supplements, again it did not include what these were, or when these were to be offered. There was some evidence that the home has liaised with specialist nurses to help people with managing their behaviour. However, one example seen was a record that a service user had dragged a member of staff to their bedroom and that it had taken the assistance of a second member of staff to free the first person. There was no evidence that any support work had been completed regarding this to protect both the person concerned and the staff supporting them. This persons care plan included a section for mental health challenging behaviour. Although it described that this person did demonstrate challenging behaviour, one of the methods for managing this by staff was to use distraction methods and to observe interactions. This does not include enough detail to support the individual and the staff in managing these behaviours.Another person had identified in their care plan that they required support Care Homes for Older People Page 15 of 43 Evidence: as they could become agitated and frustrated. Yet one of their prescribed medications had not been administered for 7 days. The lack of this could be uncomfortable for the person and increase their agitation and frustration. This practice does not meet this persons needs. We saw for one person that they had a behaviour record chart, this recorded how they managed going to the toilet and any associated behaviours. This persons care plan provided by the Local Authority stated Carers to be particularly supportive and understanding. regarding this need. However, staff comments included, bad behaviour, he lied and denied it, and told to calm down. This is judgemental and does not respect the dignity of the service user. We noted that when the dementia unit has been added to the main part of the home one of the connecting doors had been left in place, but is not used and does not open. During the visit we observed that one person in the dementia unit repeatedly attempted to open this door through to the main lounge. It was clear that the person found it distressing and frustrating that they could not open the door, this does not protect peoples dignity and must be addressed. Peoples files included a document called advanced life of care plan, which included sections, for what is important to me at the end of my life, who I should be with when I die, my religious beliefs are, and I have a specific request, none of these were completed. consequently peoples choices and control are not respected. We looked at the risk assessments in peoples files, again there was no evidence that these had been updated since the last visit to the home. It was found that risk assessments did not always link to care plans and were not always reviewed. People had a form, entitled, care plan risk assessment/need, but these did not contain the persons name and were not individualised, with no date for review. One person had a risk assessment for the risk of smoking. It identified that smoking carried a risk of burns to clothing and skin, but the only actions to be taken were that all smoking is supervised by either care staff or the service users wife. On a separate document for the same service user, smoking is identified as a risk alongside two other areas of risk. In this document the actions required to reduce the risk is, supervised smoking outside in the garden. The managers told us that four people in the home use bed side rails. We looked at two of these and found that they fitted loosely under the mattresses. One of these had Care Homes for Older People Page 16 of 43 Evidence: a specialist mattress in place, however the straps to hold the mattress in place were not fastened. Not fitting correctly increases the risks when they are being used, for example there is a larger gap were people may become entrapped. The manager fastened these at the time when attention was drawn to them. We looked at one persons risk assessment for the use of bed side rails. This assessment was basic and had been reviewed once in Dec 2009, since its completion in December 2008. It is very basic and does not cover all of the areas listed in the Health and Safety Executives guidance on bed rail risk management. This document coves 23 separate risk assessments areas, including, for example, if the occupant has been assessed and if the manufacturer has provided advice on any contra-indications for its use/foreseeable mis use. The risk assessment in the home does not contain this detail. Following the last visit to the home a Health and Safety officer from the Local Authority visited the home. They addressed the concerns relating to safety issues including bed side rails. At the time the manager of the service stated that they had accessed HSE information regarding bed side rails and was completing new risk assessments and staff training. Following this inspection of the service the Health and Safety officer has re-visited the service. Their response is included later in this report. The pharmacist inspector spent 5 hours in the home looking at the medication ordering, storage, handling and disposal arrangements, examining medication administration record charts (MARs) and speaking to staff. The outcome is as follows. We found evidence that some people had not received their prescribed medicines for some days at a time as none were available in the home to give. The lack of clear medication receipt, transfer and administration records means it is not possible to be certain that everyone living in the home always receive their prescribed medicines exactly as directed. Medication management processes in the home still do not follow best practice and we found a lack of awareness of current professional guidance. When we examined the 19 current MARs for accuracy and completeness we found difficulties in being sure everyone had received all their prescribed medicines correctly. For example, four MARs showed that five prescribed items were not available to give at times when they were needed, four MARs contained a total of nine administration gaps without any explanation given, and five MARs contained inadequate records of the use of six prescribed skin care products. Where administration gaps or omission codes were seen on the MARs, insufficient additional information was found explaining why these doses hadnt been given. We found little additional information about when and how people living in the home prefer to receive their medicines or about how to give medicines prescribed when required. Such information helps staff to give medicines consistently and correctly and also helps to Care Homes for Older People Page 17 of 43 Evidence: reduce the risk of refusals or omissions. One MAR contained an extra hand written dose instruction which had not been signed, dated or witnessed. Hand written entries and changes to MARs must be clear, detailed and complete and safe arrangements must be made to ensure staff know the reasons for the changes. A second person should always check these entries for accuracy so that all staff follow the changes on the MARs correctly. We found that whilst the medication store room was secure it was a very cramped working environment as care files and office equipment were also kept in this room. One medication cupboard was unable to be locked and there were no room temperature records for the room. All medicines must be stored securely at temperatures recommended by the manufacturer as this will help staff to know medicines are safe to use when needed. The arrangements for storing and recording the use of controlled drugs meet current standards. So that all staff know exactly what is expected of them, the homes medication policy and procedures should be updated in line with professional best practice guidance published by the Royal Pharmaceutical Society and the Care Quality Commission. We were told that a new pharmacy supplier was now working with the home and that a programme of medication safety and systems update training had commenced. Having well trained up to date staff all of whom follow best practice guidance helps to reduce the risk of medication errors. Care Homes for Older People Page 18 of 43 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at standards 12,13,14 & 15. People are not offered opportunities for activities or stimulation. Their social and leisure needs are not met. People receive limited choices with their dietary needs. Evidence: At the last visit to the home it was noted that there was only minimal social stimulation for the people who live in the home. This was seen again at this visit. There is a large screen television in both of the lounges in the home. The television in the dementia unit of the home was on a music channel. One of the staff told us that in their opinion the introduction of the wide screen televisions had actually reduced the opportunity for interaction with the people who live in the home. Apart from the short conversations that staff were able to hold with service users, the majority of people received no other opportunities for stimulation or social activities. One person was visited by a relative and went out with them. A second person went out for lunch with Care Homes for Older People Page 19 of 43 Evidence: a member of staff and later told us that they had enjoyed this experience and had ate their lunch at the home of the member of staff. We did not see any risk assessments for this or evidence that this practice follows the polices within the home. We looked at the records of activities people had been offered, the only records of activities included that there is a motivational person who visits twice a month and that people are visited by their relatives. There are no other activities recorded, we did not observe any additional activities either in the main area of the home or in the dementia care unit. The dementia care unit remains sparse and people were sat with no activity and with the television to listen to. At the last visit an activities board had been available, this was not observed at this visit. When we spoke to staff they told us that people can play dominoes, read and listen to music. A relative told us that there are not a lot of activities in the home. Subsequent to this visit the manager told us that the chiropodist now undertakes hand care and that an activities person is being employed in the home for 5 days each week. There was limited evidence that people have choices in their daily lives. The menus have been adapted to offer two choices of the main meal. We observed on the day of the visit that this included either sausages or fish, with potatoes and vegetables. The records included that one person had chosen sausages but the staff member said this was incorrect and gave them fish. When we spoke with the staff member they told us this was because the person required a softer diet and would not be able to eat sausages. We saw that no-one had attempted to provide a choice for people who require a soft diet. When we spoke to staff individually and asked them about the choices that people can make each day they told us that they can choose whether to have the television on or not, whether to go out for a walk,, what to eat, what to wear and who to sit with. We observed that staff continue to serve the main meal from a bain-marie, which enabled them to provide people with the right amount of food of their choice. However, we observed that there were 4 staff on duty, one person served lunch, and two supported people in the main part of the home, leaving only one person to support the people in the dementia care unit. This staff member worked hard to Care Homes for Older People Page 20 of 43 Evidence: support several people at once, this does not encourage a relaxing meal time. Neither does it ensure that people have enough support to eat their meals. We spoke to the managers and staff about this. The managers told us that they would normally assist the staff in supporting people over a lunchtime. However, the managers do not work at the weekends and staffing levels do not increase, meaning that people do not always receive enough support with their diets. A relative told us that they felt the food offered had improved and that people now get two choices of their main meal of the day. Care Homes for Older People Page 21 of 43 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at standards 16 & 18. People are at risk of not having their health, and social care needs met due to poor quality of care plans, risk assessments and medication practices. Evidence: There continues to be a complaints policy available within the home. The managers told us that there have not been any complaints received to the home since they have worked there. The CQC has not received any complaints regarding the home since the last visit. There is a copy of the multi-agency policy and procedure for safeguarding vulnerable people from abuse. Records of staff training reflected that since the last visit to the home, staff have received training on this area and when we spoke to staff they were positive in the actions that they would take and that they would support people with this. We examined records of incidents that had occurred in the home, including those of incidents between the people who live there. At the last visit to the home incidents were not being reported to the CQC or the local authority. We saw that one incident had been reported to the local authority and the commission have received some notifications of incidents in the home. Care Homes for Older People Page 22 of 43 Evidence: We saw that there was one incident when someone had cut their head, that had been dealt with by the home, but that had not been reported to the CQC. There was another incident when a service user hit another service user on the head, that had not been reported to either the commission or the local authority. A further incident when a service user was admitted to hospital with a serious illness had also not been reported to the CQC. We looked at peoples finances and how these are handled in the home. There are systems in place and peoples monies are checked. Poor care planning, risk assessments and management of medication is placing people at risk of harm as it can not be ensured that their needs are being met. Care Homes for Older People Page 23 of 43 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. We looked at standards 19,20,24,25, & 26. Despite some decoration work being undertaken there continues to be a large amount of work required, including some health and safety work to ensure that people live in a clean, comfortable and safe home. Evidence: The home comprises of a large old property that is used as the main care areas and a newer extension that is the dementia care unit. The ground floor of the main home comprises of bedrooms, a bathroom, the main lounge, a conservatory and dining room, the managers offices and the kitchen. Upstairs there are further bedrooms and another bathroom. The dementia care unit is on the ground floor and includes a dining area/lounge, bedrooms, bathroom, the laundry room and a conservatory. Some painting has taken place in the home and this has improved the light in the home. The manager told us that they have received some new bedroom furniture and that a small amount is to be replaced each month. We completed a tour of the premises with either one or both of the managers present at different times. Care Homes for Older People Page 24 of 43 Evidence: The lounge in the main part of the home has been painted and a new carpet has been put in place. This carpet has not been well fitted and has marks on it. The manager told us that they are hoping to replace this. The conservatory is adjacent to the lounge and the manager told us about two of the service users who use this room. The radiator in here was not guarded. The lift is separate to the lounge at the side of the building. This area is dark and undecorated and has two different patterned old carpets fitted. Some of the bedrooms were being used as storage and the manager told us that people have moved rooms to accommodate refurbishment/redecoration. One bedroom had a bed that was unstable and the manager told us that this bed is not currently used and is to be replaced. When we tried to open the curtains in this room the pole and curtains fell down, additionally the window opening was not restricted to protect people from falling out of the window. Another bedroom included a radiator without any guard to protect people from the risk of burning and we saw that several radiator covers in other bedrooms were damaged. The manager told us that staff have had to make holes in these to be able to access the radiator temperature controls. The dementia care unit continues to be sparsely decorated and does not appear comfortable or relaxing. We looked at peoples rooms, again some of these were being used for the storage of furniture. One bedroom floor was very sticky with patches of flooring missing. Many of the bedroom doors throughout the home have star locks on them. These types of lock ensure that the door can be locked from the outside. However, they cannot be opened from the inside when this lock is operated. The manager stated that these locks were no longer in use. It is recommended that these are therefore removed, as if they were used they would compromise both peoples safety, dignity and choice. Many of the wardrobes in the dementia unit have hook and catch type locks added to them to prevent people from opening them. This does not maintain peoples dignity, and is a safety risk as one person has pulled at the wardrobe door until it has broken, there is also the potential for the wardrobe to fall over. This was discussed with one of the managers at the time of the visit who agreed this was not good practice. Care Homes for Older People Page 25 of 43 Evidence: All but one of the windows in the dementia unit were observed to have window opening restrictors, however one window did not have a restrictor in place. The dementia unit has key coded locks to assist people with their safety, however previously one service users had left the home and was later found in the grounds. At this time it was unclear how the person had left the home, fortunately they were not harmed from his incident. The home must make sure that peoples safety is not compromised through the lack of adequate maintenance and attention to the property. There were two people who required the use of a specialist mattress to help them with a medical condition. Neither of these mattresses were fastened correctly to the bed and one of the managers rectified this at the time of the visit. In another bedroom a stained mattress was stored against the wall , the manager was unsure as to the reason for the mattress being in the persons room. Several of the rooms require redecoration, and currently have old furniture. One of the managers told us that there is an ongoing programme of refurbishment and that 6 bedrooms have been redecorated, with another 2 sets of new bedroom furniture being supplied each month. As the home accommodates up to 37 people, with some double rooms, this programme of refurbishment could take up to another 17 months. We saw the bedrooms that have been decorated and have some of the new furniture in, these were comfortable and clean. The hot water outlets in these rooms all exceeded 43 degrees centigrade and may pose a risk to people who are frail, the managers agreed that this requires attention. This was reported to the Health and Safety officer who visited the service. They found that mixer valves had been fitted to wash hand basins and delivers temperatures of 37-44 degrees. At the last visit it was noted that several hot water outlets supplied water that was in excess of 43 degrees centigrade, the managers told us that thermostatic mixer valves are now in place. We found that the hot water in the bathroom was now being provided at 35 degrees centigrade, which is probably now too cold as once the bath is poured the temperature is likely to be much lower than 35 degrees. The home was generally clean throughout, but the upstairs bathroom toilet had faeces on the base of it, as did a light switch in one of the bedrooms and the covers for bed rails in another. This does not ensure that the polices for the control of infection are followed and may compromise peoples health and safety. A relative told us that they thought the home was a lot cleaner now than previously. Care Homes for Older People Page 26 of 43 Evidence: Bedrooms in the main part of the home and a couple in the dementia unit were personalised to differing degree, reflecting the personality of the individual. Some of the bedrooms were clean and tidy. At the last visit to the home a strong smell of urine was notice in the entrance hall, this was not the case at this visit. Additionally the entrance hall has been painted. The kitchen area of the home has been divided so that it is not now used as a walk way. The kitchen and servery continue to be in need of decorating and cleaning. The main kitchen continues to be dated and some equipment remains close to the need for replacement. We saw items in the fridge that were uncovered and not labelled with the date of preparation and vacuum packed frozen raw meat had been left on a surface to defrost. It was identified at the last visit to the home that environmental checks need to take place regularly so that the managers pick up on these shortfalls. This continues to be the case at this visit. Previously a refurbishment and redecoration plan was required, it is clear that some work has commenced and that a plan is in place. Maintenance checks had been undertaken for the fire extinguishers, and the manager told us that staff have undertaken training in fire safety. The records to show that the fire alarm system had been maintained were not available at the visit but were subsequently provided to the CQC. As a result of our visit we asked the Health and Safety officer from the Local Authority to visit. This is their response: CQC requested that an Health and Safety Inspector from the Local Authority visit to consider concerns about trip hazards in the kitchen corridor, scalding risks, poor assessment of and poorly fitted bed rails.The Health and Safety Inspector identified: - trip hazards had been addressed. - poor monitoring of the homes safety management system to scalding from full body immersion with hot water delivery at 55-57 degrees in several communal outlets and bedrooms in the EMI area and other bathrooms. Certain bedrooms with residents without dementia were also delivering temperatures above 43 degrees but there were no risk assessments in place to account for these elected risks. - unclear procedures and assessments on use of and spacing of bed rails. The managers response to these immediate concerns was proactive and undertook an Care Homes for Older People Page 27 of 43 Evidence: immediate review of all hot water outlets and arranged for thermostatically controlled mixer valves to be fitted. A revisit identified that the manager had accessed HSE information on bed rials and was introducing a more robust policy on their use. Following the latest inspection by the Commission the H&S officer re-visited and are to undertake a further meeting with the home to consider progress on risk assessments and policy reviews. Care Homes for Older People Page 28 of 43 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at standards 27, 28, 29 & 30. People are supported by staff who have received some training, and who now have some supervision. However, the reduction in staffing numbers and poor practices in relation to covering staff sickness does not ensure the safety of the people living in the home or that their needs are fully met. Evidence: There have been changes to the staffing levels during the day. There are now only 2 carers throughout the day in both sections of the home , previously there were three in the main part of the home. There are three staff to support all service user throughout the night. The managers told us that this was due to a reduction by 3 of the amount of service users residing in the home. They told us that there were 21 people living in the home at the time of the visit. Due to the amount of requirements and concerns raised at the last visit it would be advisable that the home does not amend the staffing levels until there is clear improvement in the standards in the home. We looked at the duty rotas and at the actual staffing returns. There have been problems with staffing the home due to staff sickness. On two separate occasions staff have worked a 12 hour day shift and stayed on duty and completed a 12 hour waking Care Homes for Older People Page 29 of 43 Evidence: night shift. This has been organised by the managers of the home. They told us that they are not allowed by senior management to use agency staff to support the home when staff are absent. People working for 24 hours without a break from the home is poor practice, it increases the risks of accidents happening and peoples needs not being met. The manager told us that they have not employed any new staff this year, although they are planning to do so and are awaiting references and Criminal Record Bureau checks to be returned prior to people commencing employment. These checks help to make sure that only people suitable for the role and who do not hold a criminal conviction that may prevent them from working with vulnerable people are employed. We looked at the recruitment records for three of the people who work in the home. All of these files included an application form, 2 written references and a CRB check. Two of the references received were not clear and had not been verified to ensure that they were from the person that they had been requested from. Two of the three files included details of the staff induction, this was described as being designed in order to comply with TOPSS. We looked at the training records held in the home. The new managers have removed records of training that were provided by the previous organisation and told us that they are planning to retrain the staff. Since the last visit to the home staff have received training in Safeguarding Vulnerable People, Fire and medication administration.The managers of the home also told us about the National Vocational Training (NVQ), currently there are 2 staff who hold an NVQ level 3, 5 staff who hold an NVQ level 2 and 3 staff who hold the Registered managers award. At the last visit to the home large gaps in training were found, for example, moving and handling, health and safety, basic food hygiene, infection control, and first aid, these courses have yet to be undertaken. Additionally a training plan should be produced for the staff team as a whole. The managers have undertaken disciplinary meetings,with two staff members, although these have not been notified to the CQC. Care Homes for Older People Page 30 of 43 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at standards 31,33,35,36, 37 & 38. Although some improvements in the home have been made, the health and safety of the people in the home continues to be compromised and people are not fully protected from the risk of harm. Evidence: The previous manager is no longer working in the home and since January 2010 there have been 2 managers employed in the home. The managers told us that they have been addressing the requirements of the previous inspection but that as they address each problem another one appears. They told us that there are problems with the staff culture in the home and that the staff do not always assist in improving practice. The managers told us that they are addressing this. The home does not have a manager registered with the Commission. Care Homes for Older People Page 31 of 43 Evidence: At the last visit there was not a certificate of registration on display and it was noted that this is now in place. The management and quality of the home continues to require improvement. The new managers have undertaken some work, although there are a number of requirements that remain outstanding including the medication practices in the home and consequently the meeting of peoples health needs. Systems in the home for care support, care planning, risk management, staff training, and environmental checks all continue to require attention. As noted at the last visit to the home these areas require urgent attention to ensure the health, safety and welfare of the people living in the home. Additionally the managers have allowed staff to work excessive hours that may place people at risk. Of the previous recommendations only 2 have been met, some have been removed and are now requirements but the large majority remain, this demonstrates a lack of commitment from the management in improving the service. The owner of the home has undertaken regulation 26 visits to the home, as part of this he assessed the medication system in the home but did not see the discrepancies or address these found at this visit. This system is not adequate and must be improved upon to ensure that these visits are effective and assist the management and quality of the home. The new managers told us that there is a quality assurance system in the home and that they have started to work with this. They told us that there are not many relatives of whom they can consult or ask their opinion regarding the service and are addressing this. This system is not adequate as it does not address any of the areas for improvement. We looked at the supervision records for the staff. The new manager has recently developed a plan for supervising the staff. Some supervision has taken place and the new manager has also used these sessions for training. For example one person has received three separate sessions, one regarding medication, one regarding reporting incidents and one as a supervision session. The records for the other two staff showed that they have received one supervision each. The managers have identified that there are cultural concerns within the home and robust supervision practices would help to address this. As at the last visit not all of the required records were in place and up to date. This included assessment of individual need, care planning, risk assessment, staff training Care Homes for Older People Page 32 of 43 Evidence: and environmental checks. These records continue to require attention for them to be at an acceptable standard and this must now be addressed as a matter of urgency. At the last inspection there were a number of health and safety issues that required addressing. The health and safety officer for the Local Authority visited the home and advised them regarding these issues. However although some work has been completed to address the hot water issues, several hot water outlets in bedrooms were above the recommended 43 degrees centigrade, specialist mattresses were found unfastened with one being fitted to a bed with a bed rail that was also easy to move and not all of the windows in the home have opening restrictors.The health and safety officer for the Local Authority has been notified of these issues. We looked at the finance systems in the home. People have individual wallets and receipts are kept of expenditure. The managers showed us that the balances were correct in individual wallets, they also explained the receipts system in the home. We looked at some of the maintenance records in the home. This included that maintenance checks had been undertaken to ensure that systems were safe on the electrical appliances, the lift, electrical wiring and gas systems in the home, no concerns were raised in these checks. Care Homes for Older People Page 33 of 43 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 7 15 People must have their 22/01/2010 assessed needs detailed in care plans with clear task for staff in how to meet them. This will help to ensure that care is not missed. We will be considering issuing a Statutory Requirement Notice for the breach of this regulation. 2 7 15 Care plans must be produced 22/01/2010 in a timely manner and be updated when significant needs change. This will ensure that staff have information quickly about how to care for people. We will be considering issuing a Statutory Requirement Notice for the breach of this regulation. 3 8 13 Risk assessments must 22/01/2010 contain a full analysis of risk and the measures needed to reduce risk. This will help to ensure that staff are fully aware of any risk and what steps they need to take to minimise it and support people safely. Care Homes for Older People Page 34 of 43 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 We will be considering issuing a Statutory Requirement Notice for the breach of this regulation. 4 8 12 Prompt medical attention and 22/01/2010 advice must be obtained for issues affecting peoples health and welfare. This will ensure that people receive medical attention quickly and provide staff with information they need to care for people. We did issue a Statutory Requirement Notice for the breach of this regulation, this was not complied with. We will be taking further action. 5 9 12 Peoples medication must not 22/01/2010 be allowed to run out of stock. This will ensure that people receive the medication as prescribed for them. We will be considering issuing a Statutory Requirement Notice for this breach of regulation. 6 30 18 The staff team must be 22/01/2010 provided with training in order to gain the right skills, knowledge and experience to care for vulnerable people with a range of needs. Included in this is mandatory and service specific training. This will give staff confidence Care Homes for Older People Page 35 of 43 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 in how to care for people and help to ensure that care is not missed. Staff files to be audited and a training plan produced by the timescale for action date. We will be considering issuing a Statutory Requirement Notice for the breach of this regulation. 7 37 17 Records required for the 22/01/2010 effective running of the home must be in place and up to date. This will enable agencies to monitor how the home is managed and be sure that residents needs are being met. This refers to initial assessments of need, care plans, risk assessments, daily recording, medication charts, monitoring records, staff supervision and training and environmental checks. We will be considering issuing a Statutory Requirement Notice for the breach of this regulation. Care Homes for Older People Page 36 of 43 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 12 Detailed plans must be in place to guide staff on how to manage people whose behaviour may pose a risk to themselves or others. This will help to ensure that staff are fully aware of how to correctly support someone with their mental health needs and that these persons needs are met. 30/04/2010 2 8 18 Staff must be trained in and 30/04/2010 assessed as competent in understanding the causes of and how to correctly support someone when they present with behaviours that may pose a risk to themselves or others. This will help to ensure that people receive the correct support and their mental health needs are met. 3 9 13 Medication records must be accurately completed and 06/04/2010 Care Homes for Older People Page 37 of 43 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 maintained in a timely manner including those for all medicines received, administered and leaving the home. This will help to show that medicines are being used correctly as directed. 4 9 13 All medicines must be 06/04/2010 administered as directed and care plans must include relevant instructions for staff in this respect. This will help to make sure that staff administer all prescribed medicines correctly as and when needed. 5 10 12 All service users, including 07/04/2010 those who require additional support due to having dementia must be supported to maintain personal grooming, such as nail care, oral hygiene and general presentation. This will help people to maintain their dignity, health and standard of presentation. Care Homes for Older People Page 38 of 43 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 6 12 16 People must be assessed for 30/04/2010 and provided with social and leisure activities that offer them choices and meet their needs. This will help to ensure that people are not bored and that their social and leisure needs are met. 7 15 18 Individual assessments must 07/04/2010 be undertaken to review peoples lunchtime experiences to include the numbers of staff and levels of support required. This will help to ensure that peoples needs are safely and fully met. at the correct level and by the correct number of staff. 8 18 13 Systems must continue to 30/04/2010 be developed in the home to ensure that the multi -agency policy is continued to be used and incidents are reported to the safeguarding team. This will help to ensure that allegations of abuse and poor practice are reported to the correct agencies and investigated thoroughly and quickly. Care Homes for Older People Page 39 of 43 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 9 19 23 Windows must have opening 07/04/2010 restrictors. This helps prevent the risk of falls and injury for the people who live in the home. 10 22 13 Specialist equipment 06/04/2010 including bed side rails must be used only after thorough and comprehensive risk assessments that meet with the current legislation. This will help to ensure that people are protected from harm when using specialist equipment. 11 38 13 Radiators must have guards 07/04/2010 in place. These must be kept in a good state of repair and not damaged. This will help to reduce the risk of burns from radiators for the people who live in the home. 12 38 37 All notifications of incidents must continue to be notified to the CQC. This will enable us to monitor that the home is managing the incidents appropriately. 07/04/2010 Care Homes for Older People Page 40 of 43 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 3 Peoples needs should be assessed prior to admission and as their needs change. This will help to make sure that their up to date needs are known and met. Following assessment of their needs, people should receive formal, written confirmation that their needs can be met in the home. Care plans should be signed by the resident or their representatives to evidence they have seen them and agree the contents. Care plans should contain preferences and wishes about how people would like their care to be carried out. Monitoring charts, obviously put in place for a reason should be completed thoroughly. This will help to provide important information to staff and visiting professionals involved in their care. Staff should receive further training in how to maintain privacy and dignity. A weekly or monthly at a glance log would alert staff to those residents that had not participated in anything so that this could be addressed. Residents should have more choice regarding the activities and occupations that they are able to participate in. This will help them to remain mentally active. A plan for the refurbishment and maintenance of the home must be completed, kept up to date and be available to check against compliance. Doors to bedrooms should not have locks in place that would prevent someone from leaving their room as they chose. This will help to maintain peoples choices and dignity. Wardrobes must not have additional locks on them that at times cause confusion and do not preserve peoples dignity. Equipment in the home including beds,must be safe and must not pose a risk to the people who live in the home by being unstable. The redecoration of the home must continue, helping to ensure that people live in a safe and comfortable home. 2 3 3 7 4 5 7 8 6 7 10 12 8 14 9 19 10 19 11 12 19 19 13 19 Care Homes for Older People Page 41 of 43 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 14 15 16 17 19 19 20 26 Food must not be left uncovered, helping to prevent the risk of infection from contaminated foods. Carpets must be re- fitted and kept clean, helping to ensure that people live in a clean and comfortable home. The lounge in the dementia care unit should be made a more homely and stimulating environment for people. The manager should complete environmental checks to monitor cleanliness so that shortfalls can be addressed quickly. All areas of the home must be well lit. The home should be kept clean.This will help to make sure that people live in a comfortable home where their hygeine and the infection control policies are not compromised. Staff should have adequate rest breaks between shifts. This helps to ensure that staff are not over tired and that risk to peoples safety is minimised. A manager should apply for registration with the Commission to add stability to the home. It is recommended the home obtains the views of professional visitors as part of the quality monitoring. This will enable a wider view of how the home is managed. Action plans should be produced to address any shortfalls highlighted in surveys and audits, and in view of the number of issues found during the visit, the audits need to be completed more thoroughly. Care staff members should have a minimum of six formal and documented supervision sessions per year. This will enable managers to monitor practice and provide staff the opportunity to disucss issues of concern. The system of bed rail checks should be carried out consistently. This will prompt staff to check they are safe and in good working order. Risk assessments for steradent must be completed and kept up to date. 18 19 26 26 20 27 21 22 31 33 23 33 24 36 25 38 26 38 Care Homes for Older People Page 42 of 43 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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