Care Home: Bracknell House Residential Care Home

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Key inspection report CARE HOMES FOR OLDER PEOPLE Bracknell House Residential Care Home 34 Helena Road Capel-le-Ferne Folkestone Kent CT18 7LQ Lead Inspector Christine Lawrence Unannounced Inspection 27 April 2009 09:30 DS0000069647.V375097.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. 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. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 2 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 Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bracknell House Residential Care Home Address 34 Helena Road Capel-le-Ferne Folkestone Kent CT18 7LQ 01303 254496 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Bidianund Jaunky Mrs Vindoo Jaunky Mrs Vindoo Jaunky Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Key Inspection July 2008 Random Inspection 18 February 2009 Brief Description of the Service: Bracknell House is a large detached property, located in a quiet residential street of Capel-le-Ferne, near Dover. Whilst retaining some of its original features, the home has benefited from considerable upgrading and modernisation whilst still maintaining an appearance in keeping with surrounding properties. Communal areas and some bedrooms are located on the ground floor with the remaining bedrooms and bathrooms on the first floor, which may be accessed by either one of two staircases (one of which also has a stair lift installed). The home currently has fourteen single rooms and three shared rooms. Ten of the single bedrooms have en suite facilities. The home has several small lounges, and a conservatory to the front of the property; a second and larger conservatory has now been installed to the rear of the home overlooking the garden, with a ramped access into the garden. There is limited parking at the front of the property but unrestricted parking is available in the road. The current fees range from between £328.00 and £390.00 per week. Further information about Bracknell House can be provided by the manager on request. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We, that is the Care Quality Commission (CQC), visited Bracknell House without notice. We had previously sent out surveys for residents, their representatives or relatives and staff to complete. We received six from residents and their relatives and four surveys from staff members. Prior to this visit the providers had completed an annual quality assurance assessment (AQAA) for the last inspection and this information was still current. Information from the surveys and the AQAA is used in this report. We also used information from the previous inspection report () and the random inspection carried out in February 2009. As well as the lead inspector a pharmacist inspector carried out a specific inspection relation to medications. During our visit to Bracknell House we spoke to various members of staff and to Mr and Mrs Jaunky. The senior carer on duty took us for a tour of the building and introduced us to residents. She gave us opportunities to talk to people who live at Bracknell House. Comments from surveys, as well as talking to people on the day are included in this report. The random inspection was carried out in February 2009 because we had received some information subsequent to a safeguarding alert and there had also been a further safeguarding alert. Both of these alerts have now been dealt with to the satisfaction of the social services. At the random inspection we identified that some care plans and assessments were not completely up to date and some criminal record bureau checks had not been carried out for staff working at the home. We sent a formal warning letter to the providers and decided that we would carry out a key inspection to make sure everything had been done. What the service does well: The comments in surveys and those made on the day reflect that people are satisfied with the service they receive at Bracknell House. Lots of comments were made about the staff and how they treated people as individuals. The quotes can be found in this report within the section about staff but they are noted here also:- “I have seen on every occasion the staff there for everyone. I visit 2 or 3 times a week so I feel that is general practice” “They are cheerful, courteous and professional” “The staff are very good in supporting and caring for my mother’s needs” “The staff are brilliant and look after … really well” “Everyone treats xxx as a person, not just a number and she has always been clean and well dressed and comfortable every time I see her, which is often” All staff are very good and are always willing to help in every way” “I never have any problems with availability, there are always members of staff on the floor at all times”. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 6 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. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that the home judges that it can meet their needs because it assesses their needs before they move in. EVIDENCE: We looked at three individual records for this inspection, including a recently admitted resident. They showed that information is gathered before admission about what someone’s needs are. This assessment is carried out by the manager/owner. The assessment covers a range of aspects of daily living and care needs. There was an example of information being provided by the placing authority, including one ‘joint assessment’ involving health care professionals also. The information is used to compile a care plan. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 9 These quotes were taken from the surveys completed by residents and their relatives, indicating that Mrs Jaunky ensures she knows what people’s needs are before agreeing to admission:- “The owners also visited our home to make their own assessment of my mother” “Proprietor called on xxx in temporary care home to chat and see how xxx would fit in and if they would be able to manage the sometimes challenging behaviour”. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from having an individual plan of care which identifies how their health and care needs are to be met. They can be confident that they will be treated with respect. Quality in medicine management area is good. The Pharmacist Inspector assessed this area. The residents receive their medicines as prescribed. However the records around medicine management and care plan details could be improved. Systems are in place for good management of medicines. EVIDENCE: Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 11 Three care plans were looked at for this inspection. Care plans generally contained guidance to staff about care needs and contained information about a range of things such as personal care and physical well-being; diet and weight including dietary preferences; sleeping routines; oral health; mobility and dexterity; foot care; continence; medication usage; physical/mental state and cognition; personal safety and risk; social interests, hobbies and activities and carer and family involvement and other social contact/relationships. Risk assessments were also seen and they included falls, taking medications, mobility and diabetes. There is a format for reviewing the care plan on a monthly basis. The care plan contains goals and objectives, based on assessed needs, and actions to be taken. The manager has identified (within the AQAA) that she would like to encourage more family involvement where this is appropriate. We discussed with Mr and Mrs Jaunky the value of having pen pictures for all residents (some did have this) and they agreed to consider this. The care plans, assessments and risk assessments have been sorted out subsequent to the random inspection in February, making sure that out of date information is not included. One relative said in their completed survey “I think xxx is well looked after, she is kept clean and tidy and her personal hygiene is much improved”. Other comments confirmed that people felt their needs were met. The care plan contains information relating to individual’s health care needs and records the involvement of health care professionals such as GPs, consultant’s appointments, chiropody, optical tests and dental appointments. There is a section within the record which is used to keep all correspondence relating to health together. An assessment tool is used when there are concerns about skin integrity and residents’ weight is monitored monthly. There is a chair exercise session each week. Morning medicines are done at different times according to when the resident is up. The procedure was observed and followed good practice. One medicine prescribed for 4 residents (to be taken on an empty stomach) was managed well for one resident but not for the other three. The medicines management records were viewed. The records on the medicine administration record (MAR) chart were good. There was one instance when for 28 doses received there were 31 signatures on the chart. There were no guidelines in the care plan on criteria to use for medicines prescribed only when needed (for six residents) or a risk assessment for medicines that were being self-administered for one resident. Controlled drugs register records corresponded with the stock levels. There was training on medicine management systems the previous week from the local pharmacist. Medicines are stored in locked cupboards. There is a window to the room where medicines are stored which if opened has access to the street. Controlled drugs are not stored according to the requirements of the law. Medicines keys were in a drawer at stages during our visit and the Security of Controlled Drugs cupboard key storage is not safe. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 12 We observed staff to be polite when talking to residents. They were patient when helping them and we noted staff taking time to explain what was going to happen with regards to the support being offered. We saw staff knock on doors before entering rooms and being discreet when assisting with personal support. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that their preferences will be identified and responded to and that they will be enabled to maintain contact with friends and family. Residents will be enabled and encouraged to make choices and they will benefit from healthy, well-presented food at a time and place to suit them. EVIDENCE: The daily records and care plans seen show that residents make choices about daily routines such as what time to get up and whether or not to join in activities. A local church provides a monthly service in house which many residents enjoy. People who live at Bracknell House pursue their own interests such as reading (books and newspapers etc), watching television, listening to the radio or music tapes and they also choose to be on their own at times or join others in the communal areas. A notice on display had the following as planned activities within the home:- doing puzzles, board games, book reading, bingo, colouring/art and chair exercises. The care plan contains Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 14 information about individuals’ social interests, hobbies and family/friends involvement. Several people went out during the afternoon of the inspection to a local over 60s club. Residents and staff confirmed that there are no restrictions on visiting. There are lots of pictures on display of past social occasions such as birthday celebrations or Christmas/Easter parties etc. Residents told us that their relatives were made welcome when they visited. The residents we spoke to during this visit, and responses made through the surveys completed by people who live at Bracknell House were positive about the food. Mrs Jaunky confirmed that special diets can be catered for and residents’ likes and dislikes are known. Residents can choose to have their meals in their rooms or in the dining room. The following quotes were noted on surveys completed by residents and their relatives or made on the day of the visit:- “…has the company of other clients in communal areas and staff often chat too” “…has newspaper to keep her brain active and nice touches like nails polished” “…chooses not to take part in activities” “Meals are very good, and varied, there is always a choice”. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints would be handled objectively and in keeping with the homes appropriate procedures and residents and their representatives can be confident that any concerns will be listened to, taken seriously and responded to. Staff are aware of adult protection issues and there are systems in place which create an atmosphere for protecting residents from abuse. EVIDENCE: Residents and their relatives confirmed through the surveys completed or by talking to us on the day, that they know how to make a complaint if they needed to. The following comments were made:- “The owners and staff listen to any concerns and always do their best to rectify any problems or misunderstandings” “The owners listen and pass on to their staff the relevant information” “The owners are always there and amenable to any concern”. All of the staff who completed surveys ticked ‘yes’ when asked if they knew what to do if a resident or relative had concerns. Staff spoken to were aware of their responsibilities with regard to protecting the people who live in the home and they were aware of the policies in place such as disclosure of bad practice and abuse (whistle blowing) and safeguarding adults, as well as those relating to residents’ money and valuables. Mr and Mrs Jaunky have demonstrated their willingness to cooperate with social services when any concerns have Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 16 been raised. Adult protection training is part of the ongoing programme of training in the home. Almost all of the staff have recently completed portfolios for assessment under the common induction standards through a local college and nine people have national vocational qualifications, both of which cover adult protection. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a safe, well-maintained home which is homely, clean, comfortable, pleasant and hygienic. EVIDENCE: We toured the building with the senior carer. The house is well maintained and decorated and the furnishings are domestic in style although in the AQAA Mrs Jaunky has noted that that there are plans to continue to improve the décor. The garden is attractive and welcoming, providing space and furniture for residents to enjoy sunshine and fresh air. The bedrooms seen during this inspection were personalised and residents spoken to confirmed they were satisfied with their surroundings. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 18 The home was clean and fresh at the time of this inspection and residents spoken to and who completed surveys confirmed that this was usual. The laundry is satisfactory and many of the staff have received training in infection control and food safety Relatives comments included the following when asked the question about the home being clean and fresh:- “This is the very first thing I noticed about Bracknell House” “I have been in a few homes in and around Folkestone and I have to say visiting Bracknell House is a pleasure. There is never a smell of urine or anything else, and I think the hygiene is very good”. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are met by sufficient staff who are competent and trained. Residents are supported and protected by the homes improved recruitment procedures. EVIDENCE: Subsequent to the random inspection in February Mr Jaunky has sought criminal record bureau checks for the staff who did not have them. The records of newly appointed person contained all the information needed which included an application form, a record of the interview, terms and conditions of employment, references and relevant documentation relating to permission to work in the UK. The AQAA stated that nine people have NVQ level 2 and two people are currently undertaking this. As previously mentioned, staff are completing the common induction standards through a local college. Mrs Jaunky has started a ‘mentoring’ system so any less experienced member of staff has a more experienced person they can discuss things with. The following are quotes from surveys or comments made on the day of the visit:- “I have seen on every occasion the staff there for everyone. I visit 2 or Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 20 3 times a week so I feel that is general practice” “They are cheerful, courteous and professional” “The staff are very good in supporting and caring for my mother’s needs” “The staff are brilliant and look after … really well” “Everyone treats xxx as a person, not just a number and she has always been clean and well dressed and comfortable every time I see her, which is often” All staff are very good and are always willing to help in every way” “I never have any problems with availability, there are always members of staff on the floor at all times”. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from the home being managed by someone who is competent, experienced and knowledgeable. Residents financial interests are safeguarded and their views are sought. Staff and residents have their health and safety promoted and protected. EVIDENCE: Mrs Jaunky is the registered manager. Mr and Mrs Jaunky are registered nurses. Mrs Jaunky has the registered manager’s award. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 22 The home has an Investors in People award and the quality assurance system in the home now includes sending out questionnaires to residents and their representatives. The AQAA was completed when requested but was rather brief and there was not information relating to each of the core standards. Mr and Mrs Jaunky agreed to ensure this was more fully completed next time, reflecting residents’ and others’ views. The home does not manage any aspect of residents’ finances. We looked at some of the maintenance and service contracts including gas safety, electrical installation and hoists, and these were all satisfactory. There are policies and procedures in place relating to various aspects of health and safety and staff have either received relevant training or it is planned. Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Medicines prescribed to be taken only when needed, to have care plan information which is person centred and gives guidelines to staff for consistency To provide a Controlled drugs cupboard which complies with the Misuse of Drug regulations 1973 To have secure management for medicine storage keys To have a detailed person centred risk assessment around any medicine self administration To have clear, accurate and complete record of medicines use so that all medicines can be accounted for. Timescale for action 31/05/09 2. OP9 13(2) 31/07/09 3. 4 5 OP9 OP9 OP9 13(2) 13(2) 13(2) 15/05/09 31/05/09 31/05/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bracknell House Residential Care Home DS0000069647.V375097.R01.S.doc Version 5.2 Page 25 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 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. 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