Care Home: Ancholme Lodge Care Home

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What the care home does well The needs of people using the service continue to be appropriately assessed to ensure the service is able to meet them and their health and personal care needs are monitored closely by a staff team who are caring and who know them well. The concerns of people living in the home are taken seriously by staff who have received training to make sure they know how to safeguard them from potential harm. A comfortable and homely environment is provided that is generally well maintained and people using the service are supported by a staff team who are appropriately trained to ensure they can do their jobs. The home has appropriate administrative systems to ensure the smooth running of the service. What has improved since the last inspection? Care plans for people using the service have continued to be developed to ensure staff have information about how to support them appropriately. Assessments of people living in the home have been developed to ensure their rights are protected under the Mental Capacity Act. A Nintendo WII game has been introduced to help people enjoy taking part in gentle exercises and more activities have been developed although more of these are still needed. A plan has been developed to upgrade the building and ensure it is well maintained and areas of the home continue to be decorated in accordance with the choices of people using the service and flat screen televisions installed in the communal areas of the building. Security of the outer building has been improved allowing people to use the area when they wish, whilst maintaining their safety. Staff training has continued to be developed to ensure they have the skills needed to do their jobs. What the care home could do better: A report by the people that own the home must be submitted to the Care Quality Commission to ensure the home is properly run and the health and welfare of people using the service are promoted and protected. Dementia care plans should be further developed to enable staff to support the strengths and weakness of people using the service and enable care to be provided in individual way and enhance the potential for the promotion of their personal dignity. Personal information about people using the service should not stored collectively to ensure the confidentiality of people using the service. Specialist training on dementia related social activities should be provided and staffing levels should continue to be reviewed to ensure the dignity of people with dementia can be further promoted. Staff should receive professional supervision six times a year to ensure their career development and enable them to do their jobs. The bathing facilities in the upstairs bathroom should be upgraded to ensure the comfort of people living in the home. Key inspection report Care homes for older people Name: Address: Ancholme Lodge Care Home Scawby Road Broughton Brigg North Lincolnshire DN20 0AF     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: Rob Padwick     Date: 0 9 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 26 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Ancholme Lodge Care Home Scawby Road Broughton Brigg North Lincolnshire DN20 0AF 01652657349 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: ancholme.lodge@hotmail.co.uk Mr Balbir Singh Lally care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be admitted is : 24 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 need on admission to the home are within the following categories: Old age not falling within any other category - Code OP, maximum number of places 24, Dementia - Code DE, maximum number of places 13 Date of last inspection Brief description of the care home Ancholme Lodge is registered for the care of 24 service users with residential care needs; thirteen of these places are for service users with needs associated with dementia. The home is set on the outskirts of the village of Broughton, near the main town of Scunthorpe. It is a large older style Victorian building that has maintained a number of existing features. Care Homes for Older People Page 4 of 26 Over 65 0 24 13 0 0 8 0 1 2 0 0 9 Brief description of the care home The accommodation is provided on two floors accessed by a passenger lift, stairs and a platform lift. All bedrooms are for single occupancy and the majority have en-suite facilities; all the rooms are individually furnished. There are a variety of communal sitting areas and a large dining area. The gardens are mainly paved and are accessible to service users. There is ample parking provided at the front of the building. The fees for the home range between 360.50 to 395, which are reviewed annually. Additional charges include hairdressing and chiropody. The Service Users Guide and Statement of Purpose are on display in the main reception area and given to each prospective person seeking accommodation. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection report is based on information received by us since its last key inspection, which took place on 8/1/09 and includes information gathered during a site visit to the home. As part of the inspection process, we send out a self assessment document that the Registered Person must complete and return to us. This helps us know how well the home is meeting regulations and National Minimum Standards and what has been done to improve it and what still needs to be done. The self assessment was completed by the manager and information from this used as part of the inspection process. Other information used included feedback from people living in the home their relatives and Professional people who know the service well as well as official notifications sent to us by the home. This information helps us to reach judgments about the service provided. The site visit took place on 9/12/2009 and lasted for 7 hours. The provider was not told in advance when it would take place. The manager was available throughout the period Care Homes for Older People Page 6 of 26 of our site visit and as well as speaking to her, we talked staff who were on duty and people living in the home. We looked round the building, including the bedrooms and shared areas of the home and we inspected the records of peoples care, staff files, health and safety documents and other records kept by the service. 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 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 26 What the care home does well: What has improved since the last inspection? What they could do better: A report by the people that own the home must be submitted to the Care Quality Commission to ensure the home is properly run and the health and welfare of people using the service are promoted and protected. Dementia care plans should be further developed to enable staff to support the strengths and weakness of people using the service and enable care to be provided in individual way and enhance the potential for the promotion of their personal dignity. Personal information about people using the service should not stored collectively to ensure the confidentiality of people using the service. Specialist training on dementia related social activities should be provided and staffing levels should continue to be reviewed to ensure the dignity of people with dementia can be further promoted. Staff should receive professional supervision six times a year to ensure their career development and enable them to do their jobs. The bathing facilities in the upstairs bathroom should be upgraded to ensure the Care Homes for Older People Page 8 of 26 comfort of people living in the home. 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 26 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs of people using the service are assessed before they move in to the home to make sure it can meet these appropriately and information is available to help those thinking about using the service to reach an informed decision about it. Evidence: Information about the home in its statement of purpose and service users guide has been developed since the last time we visited, to ensure people who are thinking about using the service can make a more informed decision based on information that is up to date. Case files of people who had moved into the home contained assessments about them carried out by both the home manager and their funding authorities to ensure the service could meet their needs. Relatives told us they had made a positive choice about using the service after hearing good reports about the home and confirmed they were very happy with the service received. The manager told us questionnaires continue to be issued to people using the service and their relatives following their admission, to enable the service to gain feedback how well Care Homes for Older People Page 11 of 26 Evidence: this had been managed and to help the service to further improve. Care Homes for Older People Page 12 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the health and personal care needs of people living in the home are generally well met, further development of specialist support for those with dementia would enable their well being to be better promoted. Evidence: People living in the home told us they were happy with the way their health and personal care needs were met and their case files contained care plans covering a wide range of their needs that were generally of good quality and clear to follow. There was evidence of regular monitoring of needs and evaluations of support to ensure care plans remain up to date and people using the service and their relatives confirmed they were consulted about these and that care staff were Very Caring. Relatives told us communication with them was Good and a visiting relative told us that staff respected her wishes and that care provided was sensitively given to those who were frail and unwell. A local doctor confirmed this stating Staff contact me when concerned and work hard to help patients be as comfortable and well looked after as they can during illness. Care plans recorded regular visits from health professionals as appropriate, together with assessments concerning the management of known risks to Care Homes for Older People Page 13 of 26 Evidence: people using the service and evidence these were being regularly reviewed. A number of people living in the home have memory problems or are living with dementia and whilst there was information in their care plans about their personal life histories to help staff gain a better understanding of them, a recommendation is made that these continue to be further developed to ensure support is provided in a person centred and individual way that enhances the promotion of their personal dignity, whilst empowering them to maximise and encourage self control. Appropriate medication policies and procedures continue to be held to make sure people living in the home are safeguarded from harm, and the service had notified us following an error about medication for which a prescription had not been correctly supplied. Staff responsible for administering medication have received training on this and the manager told us a number were in the process of doing a further long distance course, following competency checks by her of their ability to do this safely. Medication records checked by us were up to date and discussion with staff indicated they were confident and knowledgeable about this element of practice. People living in the home told us they were able to make individual choices about times of getting up and going to bed and we observed some choosing to enjoy the privacy of their own rooms. There was evidence of recent assessments to ensure their ability to make decisions were safeguarded under the Mental Capacity Act 2005, but whist case files belonging to them were being securely stored, we observed these be currently collectively held, which posed a potential beach of confidentiality and data protection. A recommendation is made about this. Care Homes for Older People Page 14 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the health and personal care needs of people living in the home are generally well met, further development of specialist support for those with dementia would enable their well being to be enhanced. Evidence: People living in the home told us they could take part in a variety of activities and make active choices about things like times of getting up and going to bed. We observed a group of people joining in a game of bingo and were told about a recent Halloween party that children from the local village had attended and another planned to celebrate Christmas festivities. Since the last time we visited a Nintendo WII activity game had been obtained to enable people to take part gentle exercise games in addition to regular visits from a local specialist Motivation group that assist with this aspect of the home. We recommended specialist activities be further developed for people with dementia related difficulties the last time we visited and whilst the manager told us she was hoping improve the amount of one to one time spent with people using the service and for more activities and outings to be arranged, a recommendation is made that specialist training is provided to staff about this. The service has a minibus to enable people living in the home to get out in the community and we were told about trips planned to a Christmas pantomime and carol service in Care Homes for Older People Page 15 of 26 Evidence: the near future. Policies are in place to encourage the involvement of friends and relatives and a number who were visiting confirmed they were generally happy with the service provided and that action is taken to follow up any concerns they might have. People living in the home told us they enjoyed the food served and looked forward to mealtimes and could make choices about these. Case files belonging to people living in the home contained nutritional assessments and monitoring of aspects of these and menus inspected contained evidence of a range of healthy home cooked and nutritious meals. A four star rating had recently been awarded by the local Environmental Health Department for the standard of cleanliness maintained in the kitchen. Care Homes for Older People Page 16 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The concerns of people living in the home continue to be taken seriously and staff training has been provided to make sure they know how to safeguard them from potential harm. Evidence: Policies and procedures are in place to ensure the concerns of people living in the home are taken seriously and they are safeguarded from harm. Feedback received from those using the service was generally positive and a relative told us I think the service and staff at Ancholme lodge are excellent. We saw evidence of consultation with people living in the home and their relatives to make sure their views can be heard and no complaints had been received by us or the home since the last time we visited. Training had been provided to ensure staff know how protect people using the service from potential abuse and the records of finances held on their behalf were appropriately kept and accurately maintained. Records of accidents that had occurred in the home indicated appropriate action had been taken about these and as previously noted we saw evidence of assessments carried out under the Mental Capacity Act 2005 to make sure the rights and best interests of people living in the home are properly protected. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience 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 provided with an environment that is generally comfortable and homely to ensure their needs can be appropriately met. Evidence: The home is comfortably furnished and has a warm friendly atmosphere. Since the last time we visited new carpeting had been laid and the lounge and dining room areas redecorated, with new windows installed and new curtains and bedding replaced. Whilst further work to upgrade the large Victorian period building would improve the environment provided, we saw evidence of plans for these. Appropriate checks were being carried out to ensure the building and equipment are safe to use and there was evidence staff had been provided with infection control training and antiseptic hand washing facilities were in place throughout the home. Bedrooms belonging to people living in the home were individually furnished and reflected their personalities and the home smelt fresh and clean and was generally neat and tidy. A relative commented positively on this stating My mother is always clean and happy. Her room is always clean. One of the bathrooms was out of use at the time of our visit and whilst we were told about plans to upgrade this in the near future a requirement is made about this to ensure the needs of people using the service can be more comfortably met. Care Homes for Older People Page 18 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are supported by a friendly and caring staff team who are appropriately trained to ensure they can do their jobs. Evidence: Comments received from people living in the home continue to be very positive about the staff team and relatives told us they are Very caring and that they Couldnt ask for more. Since the last time we visited staff levels in the home had been reviewed and whilst comments received indicated they were generally satisfactory, some stated there were still times these could be further improved. Staff interactions with people living in the home were observed to be friendly and sensitive and it was clear that they knew them well, however as previously noted, a number those using the service have dementia or memory problems and it is recommended staff levels continue to be reviewed. This is to ensure the dignity of people with dementia can be further promoted and enable staff to engage with them better about their individual wishes and feelings. There continues to be a strong commitment to developing staff skills and we saw evidence of appropriate induction training and a range of mandatory and specialist courses to ensure staff are able to do their jobs. Staff files documented NVQ training and annual appraisals to enable career development and a training matrix was in place to enable refresher courses to be booked when these are needed. Recruitment policies are in place to ensure staff are safe to work with people living in Care Homes for Older People Page 19 of 26 Evidence: the home. Staff files contained evidence of checks of identity, criminal records and references taken up. However the manager was reminded new staff should only be started in exceptional circumstances with only a preliminary Protection of Vulnerable Adults check, as one of those inspected indicated the member of care staff had started work before a full Criminal Records Bureau check had been received for them. Care Homes for Older People Page 20 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate administrative systems are in place to enable the smooth running of the service, however regular reports by the owner were needed to enable the service to be better monitored and ensure the best interests of people living in the home are promoted and protected. Evidence: The manager has been registered for approximately 18 months and there was evidence she has settled in to her role well and continues to be committed to doing her job well. Staff comments about her were positive and indicated she takes an open and supportive approach and confirmed the service has a Management that listens and deal (s) with changes that are needed. There was evidence of meetings with staff and relatives of people living in the home to ensure good communication is provided and staff records indicated supervision sessions were taking place, although the frequency of these could be further improved and a recommendation is made about this. There was evidence of regular audits of various aspects of the home to ensure it was performing appropriately and Quality Assurance records included twice yearly Care Homes for Older People Page 21 of 26 Evidence: surveys and analysis of these to enable feedback about the service to be obtained. Records of money belonging to people living in the home were being accurately maintained with invoices available to confirm transactions made and maintenance records contained evidence of regular checks of the building and up to date certificates for the servicing of equipment. We were told however that due to sickness regular monthly reports of visits carried out by the provider had not been carried out as needed and a requirement is made about this. Care Homes for Older People Page 22 of 26 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 Older People Page 23 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 23 The Registered Person must ensure there are adequate bathing facilities and that the upstairs bathroom is upgraded. This is to ensure the comfort of people living in the home. 01/03/2010 2 37 26 The Registered Person must submit a report following monthly visits to the home to the Commission. This is to ensure the home is properly run and the health and welare of people using the service are promoted and protected. 27/02/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 The Registered Person should ensure dementia care plans are further developed to enable staff to support the Care Homes for Older People Page 24 of 26 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 strengths and weakness of people using the service and enable care to be provided in a more person centered and individual way and enhance the potential for the promotion of personal dignity. 2 7 The Registered Person should ensure personal information about people using the service is not stored collectively, in order to protect their privacy and prevent potential breaches of confidentiality. The Registered Person should ensure specialist staff training is provided on dementia related social activities. The Registered Provider should continue to ensure staffing levels continue to be reviewed. This is to ensure the dignity of people with dementia can be further promoted and to enable staff to engage with them further about their individual wishes and feelings. The Registered Person should ensure staff receive professional supervision six times a year to ensure their career development and enable them to do their jobs. 3 4 12 27 5 36 Care Homes for Older People Page 25 of 26 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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