Care Home: Brendoncare Woodhayes

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What the care home does well The service is manged well. The manager is committed to driving through improvements to the experiences of people who live at the home. In particular this is in providing a service that is more tailored to individual needs and preferences rather than whole home approaches to care delivery. Internal quality assurance processes are well developed and helpful in informing what improvements need to be actioned in the home. There is a stable staff team who have received suitable training specific to their roles. The environment is clean and homely and people told us that the quality of meal provision was high. What has improved since the last inspection? We made 7 requirements and 4 recommendations to the home at the last inspection in 2007. The home has taken the necessary steps to address the requirements to make people safer and to act on recommendations for best practice. Issues we had highlighted in our last key inspection report were referred to, with current progress reports, in the AQAA submitted to us from the home prior to the inspection. What the care home could do better: As a result of this inspection we have made two recommendations to the home. Nurses administering people`s medication need to consistently record a variable dose. This will enable them to assess a therapeutic dose of the prescribed medication. Secondly, where a person is assessed under the Mental Capacity Act, the assessment should make clear reference to what decision is being considered as part of the mental capacity assessment. This makes the assessment meaningful. Key inspection report Care homes for older people Name: Address: Brendoncare Woodhayes 36-40 St Leonards Road St Leonards Exeter Devon EX2 4LR     The quality rating for this care home is:   three star excellent 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: Judith McGregor-Harper     Date: 0 7 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 Older People Page 2 of 25 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 25 Information about the care home Name of care home: Address: Brendoncare Woodhayes 36-40 St Leonards Road St Leonards Exeter Devon EX2 4LR 01392667290 01392667292 csampford@brendoncare.org.uk www.brendoncare.org.uk The Brendoncare Foundation Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Elizabeth Caroline Mary Sampford Type of registration: Number of places registered: care home 27 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Approved Person in Charge is Mrs Wendy Rendal-Jones RGN Notice of Proposal to Grant Registration for staffing/environmental conditions of registration was issued 15/3/1994 Registered for 27 - Elderly General Nursing Care Registered for 8 Elderly Residents Date of last inspection Brief description of the care home Woodhayes Nursing Home is in a quiet residential area close to the centre of Exeter. It is also within level walking distance of local shops and bus routes. The Home is a listed building, converted from two dwellings, occupying a large corner site, with gardens to the front and parking to the rear. A few steps lead up to the main Care Homes for Older People Page 4 of 25 Over 65 27 0 Brief description of the care home entrance of the Home, although there is an alternative entrance for those who use wheelchairs or who cannot climb steps There is level access throughout the ground and first floors of the home and a staircase and a passenger lift join these. There is a stair lift leading to the first floor flat that is occupied by residents who have a larger degree of independence and who do not require nursing care. All bedrooms have hand basin facilities. Full laundry and catering services are provided on site. The fees charged range from 511.00 - 840.00 pounds per week. These charges do not include the cost of items such as chiropody, newspapers and magazines, hairdressing or personal toiletries. Further information about his home is available direct from the home or from the Brendoncare Foundation. Care Homes for Older People Page 5 of 25 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: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 3 stars. This means that people who use this service experience EXCELLENT quality outcomes. This key inspection was unannounced and was a scheduled visit as part of our routine inspection programme. The homes last key inspection was carried out on the 20th April 2007 and the home received a rating of excellent at that inspection visit. We have carried out two Annual Service Reviews since the 2007 key inspection. Annual service reviews were completed using information supplied to us by the home and surveys from people with an interest in the home. In these reviews the information we received gave us no reasons for concern or to bring our planned inspection schedule forward. For our inspection on the 7th April 2010 we (the Commission) spent one day at the home. We looked at key standards covering choice of home, health and personal care, daily life and social activities, complaints and protection, environment, staffing, and management and administration. Care Homes for Older People Page 6 of 25 During the visit we met or observed the majority of people who live at the home. We looked closely at the care, services and accommodation offered to 3 of the 24 people who were living at the home. This is called case tracking and helps us to make judgements about the standard of care and helps us to understand the experiences of people who live at the home. We looked at care and attention given by staff to people we case tracked and we looked at their assessment and care planning records. We spoke with visitors to the home, with one volunteer at the home, with duty staff and with the Registered Manager. We conducted a tour of the home and we saw all communal areas of the home. Prior to the inspection the manager sent us the Annual Quality Assurance Assessment (AQAA). This is a service self-assessment document giving us information about the home, its management and information about the needs of people living there. The AQAA asks for evidence in relation to what the home does well and what they think they can improve upon. Care Homes for Older People Page 7 of 25 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 Older People Page 8 of 25 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 25 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. Peoples care and support needs are assessed prior to them moving in to the home. This means that the staff at the home will have the skills and knowledge to meet peoples assessed needs. Evidence: We looked at the admission records for one person who had been admitted to the home since the new manager came into post in August 2009. We could see that there were re-assessments of need for this person who had taken a spell of respite care at the service previously. We saw that the assessment of need included a moving and handling assessment. Such assessments were made a requirement at the previous key inspection visit by the Commission in 2007. Prior to the inspection we sent surveys to people who live at the home and we received five completed survey forms. All respondents told us that they received enough information about the home for them to make an informed choice about the Care Homes for Older People Page 10 of 25 Evidence: suitability of moving in to the home. All five respondents also told us that they had a contract issued with the home. We asked the home to provide us with a copy of the most recent Statement of Purpose. We were advised this would be provided and the document was forwarded to us on the day of the inspection. The home does not provide intermediate care. Care Homes for Older People Page 11 of 25 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. Peoples care is well planned and their health care needs are met. Management of medication has improved since the last inspection; the risk of error from nurse administration of medicines has been minimised. Evidence: We looked at the care plans of three people with different care needs. We saw that care plans had been kept up to date reflecting changing needs. We saw that care plans were sufficiently clear and detailed to direct staff toward provision of appropriate care. Where a person had fallen or was at risk of falls this had been risk assessed with a plan of action to minimise falls suffered. The surveys we received from people who live at the home told us that people feel that they always or usually receive the care and support they need and support from staff when required. Surveys we received from two visiting health care professionals indicated that they consider the home provides good care with helpful staff. Care Homes for Older People Page 12 of 25 Evidence: We observed staff interacting with people and we saw that staff were polite and addressed people respectfully. We had received two concerns since the last inspection regarding the harsh tone of voice used by a minority of staff. We have raised the issues directly with the home, with the previous manager, and we also made reference to staff needing to be aware of their tone of voice at the last inspection in 2007. We did not observe poor practices in addressing people at this return inspection visit. We inspected the management of medications in the home. A requirement was made at the last inspection in respect of medicines. We saw that the risk associated with poor medicines administration practices had been addressed and were much improved. We did observe, however, with medicines record keeping that the witnessing of hand transcribed entries on to medicines records was not consistently maintained, but this has improved since the last inspection. We saw that variable doses were not always recorded. This is an important and useful tool in assessing the therapeutic dose of prescribed medicines and therefore should be consistently recorded. The home administers homely medicines; those medicines that can be bought over the counter without a prescription. The home had taken a sensible precaution in consulting with GP practices on this matter, but this was some years ago. We suggested to the manager that this arrangement be reviewed. We saw staff caring for someone in the end stages of their life. It was evident that the home was in close consultation with grieving family members and was handling this time of life sensitively. The home is in the process of developing and introducing a resuscitation policy that will respect peoples wishes regarding advanced directives, but assumes that life saving emergency intervention will be given unless this has been fully discussed with the individual and those interested parties with a medical interest. This is good practice. Care Homes for Older People Page 13 of 25 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a full social programme available at the home, free and easy contact with families and friends and good wholesome, varied meals are on offer. Evidence: The home employs a full time activity coordinator and benefits from the time of several volunteer staff. This means that people have access to a varied activity programme and one to one time for social activities in the community. A range of activities are displayed in the home and people told us in survey responses that this was a plus of staying at the home. People we spoke with said that the meals are good, this sentiment was echoed in survey returns. We observed lunch and visited the kitchen to talk to kitchen staff. The lunch was home cooked, nutritionally balanced and presented in an appealing and appetising manner. People ate communally at nicely presented dining room tables and some people chose to eat in their own rooms. Specialist diets are catered for at the home. Alcohol is available during meal times if people want to have a glass of wine. Care Homes for Older People Page 14 of 25 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. People living at the home have their complaints listened to as part of quality improvement processes. Staff know how to recognise sign of abuse and what they should do to report this so that abuse stops. Written assessments for mental capacity lack detail to what decision is being made. Evidence: We have received two concerns about the service since the last inspection in 2007. These were discussed with the home when they were raised to us and action was taken to resolve the complaints. The home has received one complaint to it in the last 12 months. The complaint was raised recently and we saw that this was in the process of being addressed. Survey returns from people who live at the home all indicated that people knew whom to raise concerns or complaints to. During the inspection we heard some people asking in an assured and assertive manner for assistance from staff. People also appeared confident in feeling able to direct staff to deliver assistance in an manner that the person requesting assistance felt was appropriate for their needs and comfort. Of the three care plans we looked at two had Mental Capacity assessments completed. We remarked to the manager that the assessments lacked detail to what decision on a significant event or topic was being assessed. We raised this as Mental Capacity assessments should not be used as a blanket catch all for capacity in decision making, but rather in assisting decision making on important life event topics and Care Homes for Older People Page 15 of 25 Evidence: understanding what additional support a person might need in order to reach specific important decisions. We saw that staff had been offered recent training in safeguarding adults. Staff we spoke to acknowledged recent training and were able to tell us what constituted abuse and how concerns of abuse should be raised to the home management or to outside statutory agencies. Care Homes for Older People Page 16 of 25 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. Woodhayes is a homely, clean and safe environment in which to live. Evidence: We conducted a tour of the environment and found it to be in a good state of repair, warm, comfortable and homely. The manager told us of plans for upgrades to decoration in the next 12 months. All survey responses we received from people who live at the home told us that they consider the home environment to be clean and fresh. The AQAA submitted to us told us the following information to what the home considers is good about the environment at Woodhayes; We are scrupulous in our attention to the decoration, hygiene and cleanliness of the Home. We have proficient, full-time in-house maintenance and contractor maintenance contracts in place for specialist equipment (evidence available in Admin Office). Breakdowns and repairs are reported and acted upon immediately. All staff receive Mandatory training in Health and Safety, Moving and Handling, Fire safety, COSHH and infection control and the necessity of the use for P.P.E. where appropriate (evidence available in Admin Office). The grounds are well maintained, safe, secure and accessible to residents who wish to use them. Adequate, well maintained and good quality garden furniture is available together with sun-protection in the form of parasols and gazebos. We have good communal areas available with separate dining room and lounge areas generously fitted with good quality furniture, fittings and Care Homes for Older People Page 17 of 25 Evidence: lighting of a domestic nature. Residents are encouraged to furnish their rooms with their own possessions where practicable and complying with fire regulations. Toilet, washing and bathing facilities meet NMS requirements, with each bedroom having its own washbasin and the principal bathrooms having baths with integral patient hoists, shower and spa facilities. In addition there is a wet-room on the ground floor for those preferring a shower. Specialist equipment including pressure relieving mattresses, profiling beds, hoists are provided according to the residents needs. They are serviced and maintained in accordance with legislation. All radiators are thermostatically controlled and covered or of the LST type, as is the water supply to all hot outlets. Temperatures are recorded monthly (evidence available in Nurse Station). The Home has a radio nurse-call system with ATX points in every room - both private and communal. The Home is well equipped with specialist moving and handling equipment to ensure optimum safety and comfort for residents and staff and grab rails are fitted in bathrooms, toilets and corridors. The Home complies with the local Fire and Rescue Services requirements and appropriate Risk Assessments are in place. Alarms and fire doors are checked weekly and the emergency lighting system monthly, and results recorded in fire log (available for inspection in Nurse Station). Equipment is well maintained and regularly replaced to ensure safety and efficacy. Bi monthly Health and Safety meetings are held with a representative from each department. Health and safety Audits are carried out both in house and independently HTS solutions to ensure a safe environment. We asked the home to tell us what improvements they had made to the environment in the last 12 months. The AQAA told us. Care staff are continuously reminded that they must seek assistance from maintenance if any heavy items, e.g. furniture, have to be moved. [This was recommended at the last key inspection by the Commission]. The ground floor bathroom is being completely refurbished and fitted with a new Arjo Malibu spa bath and hygiene system. We are continuing to get new patient handling equipment to further enhance both resident and staff safety. We asked what plans that service had for further environmental improvements in the next 12 months. The AQAA told us. Continue our planned maintenance programme of redecoration andrefurbishment of the Home. Acquire a small hoist that can be used in the smaller rooms. Upgrade bathing slings. Care Homes for Older People Page 18 of 25 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home benefit from being supported by a staff group who are well trained and employed in sufficient numbers to meet peoples needs. Evidence: On the day of the unannounced inspection staff interviews were taking place for bank staff, (those staff who are available to work to cover shifts of the regularly rostered staff). There were 24 people living at the home on the day of the inspection. The daily staffing compliment remains unchanged since the last inspection. There are usually 5 care staff and 1 Registered Nurse on duty in the morning, 3 care staff and 1 Registered Nurse in the afternoon and evening and 2 carers and 1 Registered Nurse at nighttime. Additional support is provided by the cook, housekeeper, kitchen assistant, administrator, manager, activities co-ordinator and maintenance man. Each shift is led by a designated team leader. Agency staff are not used as the home has its own bank staff. We spoke to staff about training they receive and training opportunities in the home. We could see that a range of training events for staff were advertised on staff notice boards. Staff told us that training is a priority within the home and that their training needs are met. Care staff who do not hold and NVQ award in care are offered this training. The organisation that owns Woodhayes holds the Investors In People Award. Care Homes for Older People Page 19 of 25 Evidence: Surveys we received from staff prior to the inspection told us that their recruitment had been conducted fairly and robustly in that pre-employment checks into the suitability of them working with vulnerable older people had been carried out. There have been no new staff recruited since the new manager came into post in the Autumn of 2009. Care Homes for Older People Page 20 of 25 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Woodhayes is a well managed home that utilises well developed quality assurance processes to drive improvements for people who live at the home. Evidence: Surveys we received from staff prior to the inspection told us that they receive good support from the manager to guide them when performing their roles. Surveys from visiting heath professionals told us the home was professionally manager. Surveys from people who live at the home told us that the home is a pleasant place in which to live. There are regular resident meetings held at the home, which are minuted and available in the home. The manager, Mrs. Sampford, has been in post since August 2009 and has previous experience of managing similar nursing establishments. She holds suitable qualifications to perform her role at the home. The home has established and helpful internal quality assurance processes. The AQAA Care Homes for Older People Page 21 of 25 Evidence: was completed well and provided us with clear evidence of where the service does things well and what issues need to be addresses to further drive improvements at the home. in addition, monthly visits by a representative on behalf of the provider are recorded and provide further scrutiny of quality issues affecting the home. On the day of the inspection there was a pleasing quality in the home of professional staff attitudes and friendly care delivery. We looked at records of how peoples money was managed by the office staff at the home. We were able to see robust accounting processes to ensure that peoples monies are handled safely. The homes AQAA provided us with detailed evidence of health and safety processes in the home and records of equipment servicing. We looked at accident records in the home and compared them with falls reporting and daily records in care plans. We found consistency of accident record reporting. Care Homes for Older People Page 22 of 25 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 25 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 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 9 Variable dose recording needs to be consistent to enable therapeutic dose of medicines to be established as part of the care planning processes. Mental Capacity Assessments should be completed with reference to decision making on a specific important issue. 2 17 Care Homes for Older People Page 24 of 25 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). 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