Care Home: Alison House

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What the care home does well The people living in the home benefit from a family run business, which means the same people have cared for them over a number of years. The one resident we spoke to was very happy in the service and clearly felt it was their home. They said, "I am very happy here and they look after me very well". The three residents have lived together a number of years and clearly are very fond of each other. The home has good working links with health care professionals including the mental health service that enables the people living in the home to be supported with their health care issues. The people living in the home are able to follow lifestyles of their choice, seeing friends and relatives. The home is well located to enable the people living in the service to access local shops and other amenities. What has improved since the last inspection? The quality rating of the home has improved and all nine requirements made during the previous key inspection have been met. Risk assessments have been updated and risk management plans to reduce the risk are now in place. People using the service are encouraged to take part in community based activities and take part in designing their individual activity plans. Food is varied and people using the service are satisfied with the food provided by the home. People using the service are supported to get dressed appropriately and maintain the personal hygiene. 50% of staff working in the home hold National Vocational Qualifications in Care or equivalent qualifications in care. Over the past year the staff team have taken part in a number of training courses to ensure they are able to meet the needs of people using the service. The registered manager provided evidence that her qualifications in care are satisfactory and comparable to National Vocational Qualifications in Care. What the care home could do better: We have made three requirements during this unannounced key inspection. All people using the service must have an individual care plan folder, this maintains their confidentiality and individuality. The complaints procedure must include the Care Quality Commission`s (CQC) up to date contact details, which ensures people using the know how to contact the CQC. An ongoing maintenance plan will ensure that repairs are and renewals are pro-active and people using the service can be confident that equipement and furnishing are replaced if they become old and unusable. Key inspection report Care homes for adults (18-65 years) Name: Address: Alison House 4 Hadleigh Road London N9 7BX     The quality rating for this care home is:   two star good 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: Andreas Schwarz     Date: 1 9 0 4 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 Adults (18-65 years) Page 2 of 27 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 Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © 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 Adults (18-65 years) Page 3 of 27 Information about the care home Name of care home: Address: Alison House 4 Hadleigh Road London N9 7BX 02088053200 02082118098 alison-house@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Angelina Linga Espino,Mr Jessie Busenpeso Espino Name of registered manager (if applicable) Mrs Angelina Linga Espino Type of registration: Number of places registered: care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The registered person may provide the following category of service only: Care Home only Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia Code MD The maximum number of service users who can be accommodated is: 3 Date of last inspection Brief description of the care home Alison House is a family run business with the care staff coming exclusively from family members. The home stated aims are to provide high quality 24 hour residential care for you whilst supporting and maintaining your independence and supporting you so make your choices . The home is situated in Edmonton, just off the main Hertford Road. A range of shops and amenities is nearby and there are good public transport links. The lounge-diner, one bedroom and a toilet, are located on the ground floor. There are two other bedrooms on the first floor, and a staff bedroom, which is also the Care Homes for Adults (18-65 years) Page 4 of 27 Over 65 0 3 Brief description of the care home office. There is another toilet and bathroom upstairs. There is a lean-to conservatory and a garden at the rear of the building. The fees for the service range from £350.00 to £400.00 per week. A copy of this report can be obtained direct from the provider or via the Care Quality Commissions website. Care Homes for Adults (18-65 years) Page 5 of 27 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: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection toll place in April 2010 and lasted three hours. The registered manager was available throughout this key inspection. We spoke to one resident during this inspection. We requested to speak to more people using the service, but one person was was out for activities and the other person did not want to talk to us. During the day of this inspection no other staff apart from the registered manager were on th premises. The home returned a completed Annual Quality Assurance Assessment (AQAA) within the given timescale. We would like to thank the registered manager and people using the service for making us welcome during this key inspection. Care Homes for Adults (18-65 years) Page 6 of 27 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 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 Adults (18-65 years) Page 7 of 27 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can be assured that their individual needs will be recognised and that the staff have the skills and ability to meet these needs. Evidence: The home has a combined statement of purpose and service users guide, training information regarding staff working at the home has been updated in March 2010. We judged both documents as detailed, providing information about the care and support offered. All people using the service are able to read and write and can access the service users guide and statement of purpose. Information relevant in how the home plans to meet peoples cultural needs is demonstrated. We were able to speak to one person using the service, the person was unable to tell us if he/she has seen the documents. Since the last inspection there have been no changes in the residents living in the home. The service user guide includes details of how admissions would be handled in the home and says that potential residents would be offered visits as part of this process. During our previous key inspection the inspectors viewed assessments and Care Homes for Adults (18-65 years) Page 9 of 27 Evidence: made the following comments: We looked at the assessments for the three current residents. These have all been updated since the last inspection and provide a useful summary of each persons needs. The assessments include details of each persons race, culture and religion. Care Homes for Adults (18-65 years) Page 10 of 27 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home have a care plan that they have discussed with their key worker. People using the service are able to express their wishes and choices and are protected from risks. Evidence: We viewed care plans of three people using the service. All care plans were found to be of good standard and have been reviewed within the last six months. All three care plans were put together in one folder, this does not promote the individuality of each person and is not good practice. The manager told us that he was instructed during previous inspections to do this. We noted that People using the service have been involved in this review process and indicated their participation by signing the care plan. One person we have spoken to during this inspection confirmed of having seen the document. Previous inspections raised the need for staff to do person centred training, currently only the manager is dealing with the care plans. The manager demonstrated some understanding of person centred planning principles, but would benefit from a more in depth training. The manager told us that a review with the Care Homes for Adults (18-65 years) Page 11 of 27 Evidence: social worker was undertaken in October 2009, but minutes have not made available to the home. We observed people using the service accessing all areas in the home. One person told us, It couldnt be better here.People using the service are responsible for their own finances, but the manager explained to us that she would accompany people using the service to the bank and help them to withdraw money. People using the service are verbal and able to advocate for themselves, or with support from their family which is involved with all service users. Previous inspections raised the need to support one person to access the correct benefit, the manager told us that she has discussed this with the person following the last inspection, but the person refused to apply for the benefit. This was clearly recorded in the person care plan. We read the risk assessments for the same three people who live in the service. These were completed using a standard format. Risk assessments have been updated and reviewed during review meetings. Risk assessments are judged of good standard and provide relevant information to minimise areas of risk and ensure people using the service are protected. From talking to the people using the service and the manager it was evident that as the home is very small the residents are able to express their wishes. Care Homes for Adults (18-65 years) Page 12 of 27 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience 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 are supported to develop their daily living skills and are also enabled to follow their own routine. The residents go out in the local community. People using the service voiced satisfaction of the meals provided. Evidence: The manager informed us that two people using the service go out independently and one person needs to have support. We spoke to this person who told us that she is happy with the manager helping her to go out. The person told us, that she would go out using a car, but also likes to go out for walks. One person noted in her care plan that she is not interested in accessing day centres or college. The manager explained to us that Haringey Council has closed the day centre which has been accessed by two people using the service and an alternative has not been offered by the council. None of the people living at the home are in paid employemnet. Care Homes for Adults (18-65 years) Page 13 of 27 Evidence: Care plans viewed showed that people using the service go swimming, access the library, go for walks, etc. One person is arrnaging her own day time activities and visits families and friends. During the day of this inspection two service users stayed in and planned to go out for a late lunch to a local restaurant. The AQAA showed us that two people using the service are Christian and on person is Jewish. The home has explored and encouraged the Jewish person to take part in religious activities, but she showed no interest in taking part, she however occasionally accompanies the other people using the service to the Catholic church on Sundays. One of the current residents has regular contact with her relatives and goes to visit them. Another resident sees her boyfriend regularly, which is very important to her. Another resident has good links with her family which she visits regularly and goes for medical appointments. It was observed and by talking to residents that routines in the home are flexible, people using the service can get up and go to bed when they choose to. We observed people using the service relaxing in their rooms and watch their favourite TV programmes, while another person had a lay in. We viewed the homes menu, meals eaten by people using the service are recorded. The manager is cooking the majority of meals, but people using the service help to set the table and do the washing up. We spoke to one person who told us, I like the meals very much, food is very tasty. There were fresh vegetable in the fridge and drinks and snacks can be accessed by the people using the service. Care Homes for Adults (18-65 years) Page 14 of 27 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical and emotional health care needs of people using the service are generally well met with the support of the local G.P and community mental health teams. The residents are supported by the staff to provide their own personal care. There is no evidence that self-medication is being carried out safely, which could put a person at risk. Evidence: Residents attend to their own personal care, but where some prompting is needed this takes place in a sensitive and encouraging manner. We observed that the residents were all dressed in an appropriate manner. We discussed with manager that one person needs more prompting around personal care, but records show she has found a good system which ensures that the persons personal hygiene is acceptable. We looked at the health care records for the people living in the home. Everyone was registered with the GP and had regular health checks. Everyone had been encouraged to visit the dentist and optician. All the residents had input from the local mental Care Homes for Adults (18-65 years) Page 15 of 27 Evidence: health care professionals. The staff understand the importance of monitoring each persons mental health and contacting the care professionals if there are any issues to address. The records show that the residents have been supported to check their weight since August 2007. This was a matter of concern as one resident has issues with her weight. We looked at the medication procedure and staff training records. Two of the residents only have a prescribed depot injection and the home keeps a record of when they have attended an appointment for this. The third resident self-administers her medication and this is approved in writing by her GP. The manager has discussed the use of homely remedies with the GP. The training records were inspected and the staff team had last received medication training in December 2009. Care Homes for Adults (18-65 years) Page 16 of 27 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are happy with the service provided and know how to complain if necessary. The staff have attended training in the protection of residents from possible harm or abuse. Evidence: The home told us in their AQAA that they have nor received any complaints since the last inspection. A complaints procedure is available and displayed in a cabinet in the lounge. The complaints procedure is also available in the service users guide. We noted that the Care Quality Commissions contact details have not been updated and discussed this with the registered manager. One person told us, I have no complaints and I am very happy here, but I would talk to the manager if I have a problem. Staff have attended safeguarding training in November 2009. No safeguarding referrals have been made since the last key inspection. Copies of the organisations procedures and social service procedures are available in the home. Care Homes for Adults (18-65 years) Page 17 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home benefit from a comfortable and homely environment, although this would benefit from a programme of modernisation. Evidence: The manager informed us that the communal areas of the home have been repainted since the last key inspection. We were shown around the premises by the registered manager. Accommodation is on the ground floor and on the first floor of the home. The ground floor has a shower room and toilet, a lounge and dining area and a conservatory. A decent sized garden can be accessed through the conservatory. The communal area is spacious, but carpets are very worn and dark, and it should be considered to replace the carpet to give the lounge and communal areas a fresher and lighter look. Fixtures are very used and the registered person should consider to replace them. The manager told us that the home does not have an ongoing maintenance programme, which is required to ensure regular updates of the premises are undertaken. One of the people using the service invited us to see her room, the room was spacious and the person told us that she has chosen the wall colour. She commented on her room, I really like my room, it is very comfortable. Care Homes for Adults (18-65 years) Page 18 of 27 Evidence: The home does not have a separate utility room, the washing machine and electric dryer is located in the conservatory. The home was clean and free of any offensive odours during the day of this inspection.. Care Homes for Adults (18-65 years) Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are supported by a small team of staff who have all worked in the service for a number of years. Training and supervision has been provided to enable them to work to a high standard. Evidence: There have been no changes in staffing since the last key inspection. The home continues to employ five staff members. Staff employed by the home are all related to the registered manager. The registered manager is hands on and spends a considerable amount of time in the home working with people using the service. Three other members of their family assist on a part-time basis. Two other relatives come to the home occasionally when Mrs Espino needs to pop out. There is one person on duty during the day and at night one-person sleeps in the home. There have been no staff changes for a number of years. The home informed us in their Annual Quality Assurance Assessment (AQAA), that one of the staff had completed an NVQ in care level 2 and one is a qualified nurse. Another one of the care staff needs to complete the NVQ and the manager said that none were registered to start the training at present. Staffing records have been assessed during our previous inspection and it was found Care Homes for Adults (18-65 years) Page 20 of 27 Evidence: that all the staff had all the necessary recruitment checks including references and ID, a POVA check and a CRB disclosure. Since our last inspection staff have taken part in adult protection training, medication training and training is basic nutrition. The manager confirmed that she is aware of training provided by Haringay council, which can be accessed for free or for a small fee. The manager informed us that staff have received regular two-monthly individual supervision. The format used for supervision is appropriate. Care Homes for Adults (18-65 years) Page 21 of 27 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All residents benefit from a permanent manager. The residents are protected by appropriate health and safety measures being available in the home. Evidence: The service has a registered manager. The manager is a qualified nurse who has many years experience of caring for people with mental health needs. The manager has not completed an NVQ level 4 in management and care, although she does have a City and Guilds qualification. The manager said that she had spoken to an NVQ assessor to see if her existing qualification is equivalent to an NVQ. An official letter from City and Guilds stating that the managers qualification was equivalent to an NVQ was shown to us. The company has questionnaires to seek the views of people using the service, relatives and other care professionals as part of a quality improvement exercise. The manager had obtained the views of the residents and one relative. She said that no care professionals had responded. The responses were all positive. Care Homes for Adults (18-65 years) Page 22 of 27 Evidence: The home informed us in the AQAA that equipement is regularly maintained and all certificates such as Landlords Gas Certificate and Portable Appliance Test is up to date. The fire equipement has been serviced in February 2010 and fire safety checks such fire drills, fire point test were found to be up to date. Care Homes for Adults (18-65 years) Page 23 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R 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 Care Homes for Adults (18-65 years) Page 24 of 27 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 6 17 The responsible person must 31/05/2010 ensure all care plans are put into individual folders. This ensures peoples individuality is maintained. 2 22 22 The responsible person must 01/06/2010 up date the Care Quality Commissions contact details i n their complaints procedure. This ensures people using the service have up to date information available. 3 24 23 The responsible person must 01/06/2010 put an ongoing maintenance programme in place. This ensures people using the service can be confident that the environment is well maintained and regularly updated. Care Homes for Adults (18-65 years) Page 25 of 27 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 6 We recommend for the registered manager or person responsible for the care planning to take part in person centred planning (PCP) training. The home should get in touch with the social workers to obtain review minutes for meetings held in October 2009. We recommend to replace the worn and dark carpets to improve the overall appearance of the home. 2 3 6 24 Care Homes for Adults (18-65 years) Page 26 of 27 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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