Care Home: Briarfield House

What has improved since the last inspection? Since the last inspection care plan documentation has been reviewed and people now have specific plans to assess the risk of developing pressure damage or malnutrition. Appropriate care plans have been developed where a risk is identified. This is to make sure that staff meet all of the needs of the people who live in the home. The footpath to the conservatory has been widened to make it more accessible for wheelchairs. Three bedrooms have also been refurbished. What the care home could do better: Medication which has a limited shelf life once opened should have the date of opening recorded on the bottle. Where medication is prescribed as one or two then the actual number given should be recorded. The home could purchase a more specialist set of weighing scales that can be used with people with mobility problems. This will ensure that peoples` weights can be monitored more accurately. Key inspection report CARE HOMES FOR OLDER PEOPLE Briarfield House 8 Easson Road Redcar TS10 1HJ Lead Inspector Sue Lowther Key Unannounced Inspection 22nd April 2009 11:00 DS0000000079.V375160.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. Briarfield House DS0000000079.V375160.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 Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briarfield House Address 8 Easson Road Redcar TS10 1HJ 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) 01642 488218 F/P 01642 488218 Mr Stephen Metcalf Miss Louise Metcalf Mrs P Creed Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 12 The maximum number of service users who can be accommodated is: 12 24th April 2008 2. Date of last inspection Brief Description of the Service: Briarfield House is a large detached two-storey house, built in 1902. It is a mellow building, which blends well with the surrounding properties and has an enclosed garden. The home is situated in a quiet residential road near to the racecourse. There are shops and a large supermarket within walking distance, and a nearby bus stop provides access to the town centre and sea front. The home provides accommodation for twelve elderly service users, in ten single rooms and one double room with en-suite shower, wash basin and lavatory. Bedrooms are comfortably furnished, and service users are able to personalise their rooms by bringing some possessions with them when they move into the home. Downstairs there is a bathroom/shower room, and separate lavatory and upstairs there is a bathroom and separate lavatory. There is a large spacious lounge, and a pleasant dining room. Smoking facilities are available in the conservatory at the rear of the house. The manager told inspectors that it costs £ 437:75p per week for a resident to stay at Briarfield House. This does not include the cost of personal newspapers, hairdressing or chiropody. Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection of Briarfield House took place on the 22nd April 2009 by two inspectors, Sue Lowther and Jean Pegg. Records were examined and a tour of the building took place. Time was spent talking to people living at the home, staff and visitors. The manager supplied some information prior to the inspection on a form called an AQAA. This is an annual quality assurance assessment for home’s to provide information about their service. The inspection focussed on key standard outcomes for people living at the home. We also checked whether requirements and recommendations from the previous report had been met. “We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken.” What the service does well: A good standard of care is provided at Briarfield House. All of the people who returned surveys were extremely complimentary with regard to the care. One person commented, “I am very happy here. The staff are exceptionally caring and good to me”. One member of staff said, “Residents always come first. Care is always a priority. We always aim to allow people to maintain their independence as far as their risk assessments allow and encourage them to do so”. People living at the home are helped to do things that they like and make choices they are happy with. “I knit, I read, I get lots of visitors. I am a member of the church and I go to church each week. They know your needs and they make them selves aware of your needs.” People live in a clean and comfortable home that is well maintained. “It’s beautiful, when I first came, I came because it was a small home. It came well advised; my family came to have a look at it. This is the room shown to my family. You can see squirrels and ducks from the nearby park.” Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 6 The home are committed to having a highly trained workforce. All of the care staff are trained to NVQ Level 2 in care, and most of them are also trained to Level 3. 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. Briarfield House DS0000000079.V375160.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 Briarfield House DS0000000079.V375160.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): 3. 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. Sufficient information is available for people to decide whether they would like to live in the home. Assessment procedures are in place to ensure that the home can meet all of the needs of the people who go to live there. EVIDENCE: People are only admitted after a full assessment of need is carried out by an appropriately trained person. This is usually the manager. This is to make sure that the home can meet the care needs of the people who go to live there. The family of one person who had recently gone to live in the home confirmed that they had looked around the home and had been supplied with all of the information they needed to make a decision about whether or not their relative would like to live there. All of the people who responded to the survey said Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 9 that they had received enough information about the home before they went to live there. The home does not admit people for intermediate care therefore assessment of standard 6 is not required. Briarfield House DS0000000079.V375160.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): 7, 8, 9 and 10. 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. A good standard of care is provided for the people who live at the home. People said they enjoyed living there, and that the staff were kind and helpful. Comments received were very positive about the care. EVIDENCE: The manager said that all of the people who live in the home have care plans so that staff know how to look after people on an individual basis. Three were examined during the inspection. These were comprehensive and contained individual plans of care. Since the last inspection care plan documentation has been reviewed and people now have specific plans to assess the risk of developing pressure damage or malnutrition. Appropriate care plans have been developed where a risk is identified. This is to make sure that staff meet all of the needs of the people who live in the home. People spoken to during the Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 11 inspection said that they are happy with the care received and the level of information given. Records examined showed that people receive visits from other healthcare professionals. These include district nurses, doctors, and care managers. We discussed the use of domestic type scales for monitoring the weight of people living at the home and recommended that a more specialist set of scales be purchased that could be used with people who had mobility problems. The home has a comprehensive medication policy. Medication is administered by staff who have been appropriately trained. Accurate records of all medicines received, administered and those leaving the home are maintained. Medication which has a limited shelf life once opened should have the date of opening recorded on the bottle. Where medication is prescribed as one or two then the actual number given should be recorded. Since the last inspection the policy with regard to the administration of medication has been reviewed and is now specific to the home. A drug fridge has also been acquired to make sure that medications are stored safely. People spoken to said that staff always treat them with dignity and respect. Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15. 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. People living at the home are supported in maintaining a lifestyle that matches their expectations EVIDENCE: We spent quite a lot of time speaking to one person who lives at the home. They described how the home had helped them to live a life that suited their needs and expectations. For example we were told “I knit, I read, I get lots of visitors. I am a member of the church and I go to church each week. A gentleman comes for me. They know your needs and they make them selves aware of your needs.” We spoke to the person who organises activities in the home and they told us how they had spent time getting to know each person who lives at the home to find out what they liked and what they did not like. “It is important that they get to know me for rapport.” We were told about some of the activities that took place and what was planned for the future. “I have introduced exercises a couple of times. I studied from a book and got advice from Occupational Therapists about gentle exercise. We do it to ABBA Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 13 music and also do ‘Head Shoulders Knees and Toes.’ Quite a few people have relatives visiting. In the cupboard there are games for example dominoes, Boules and jigsaws. We have had an Easter party, the photos are up on the board. We tend to do an activity on a morning. They (the people who live at the home) don’t always want to do that (exercise) but they will sit and talk and do photographs. The carers will take someone out in the wheelchair; we also have the summerhouse to go in. People go out with relatives for the day or for lunch. Relatives will also take them out in the wheelchairs.” We noticed that some people chose to mix in the communal lounge area that had a television, DVDs, newspapers and magazines available. Some other people chose to spend their time in their rooms. “I don’t mix downstairs I don’t get any conversation from them, stimulating conversation!” One person gave us an example of how they were supported in making decisions and choices about their day-to-day lives. For example we were told “I get up at six in the morning, the girls come in and get my toothbrush and tooth paste ready then go away and comeback to get my clothes ready. I eat in my room. The cook comes up and tells me what she is doing, if you don’t like it she will find something else. She is an excellent cook I press the buzzer if I need a drink. I don’t need help going to bed. They come around to ask if we wanted a safe or a special lock on the door, but I didn’t want one.” There was ham and mushroom flan for lunch with tomatoes and potato fritters and custard cream delights to follow. To drink there was iced lemon water on the table. The cook asked the people sat at the table if they preferred lemon or orange water. They the lemon was nice but they preferred orange. The dining room was clean and tidy with two tables set for six people each. The dining room was decorated and furnished in a style that was in keeping with the age of the house. The meals were presented in a nice manner. The cook offered people salad cream or mayonnaise as an alternative to the condiments on the table. One carer delivered plated meals to those who chose to eat in their rooms. The cook told the carer “The one with new potatoes is for X, she doesn’t like fried things.” We spoke to the cook who told us that there was only one person on a fortified diet. “The dietician was in last week and I had a meeting with her.” The cook explained how individual likes and dislikes were catered for and how food intake was monitored for those on special diets. The cook also told us “I have a choices menu. I am planning for new menus to start next week. I have consulted with people and changed the menu. We print the menus off for the ladies who stay in their rooms.” Food safety records were seen. The home has been awarded a four star Tees Valley Hygiene Award on 28 March 2008. Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 14 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): 16 and 18. 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. People can be confident that their concerns and complaints are dealt with appropriately and that safeguards are in place to protect them from abuse. EVIDENCE: Information about complaints, how and who to make them to, is made available to the people who live in the home and their families through information displayed in the entrance to the home and in the Service Users Guide. The manager stated on the AQAA that there has been one complaint recorded since the last inspection. This was investigated by the home. All of the people who returned surveys indicated that they would know how to complain. They said that the manager and the owners are always willing to speak to them and are available on a frequent basis. One person told us “I have had some little niggles here and there, we have a complaint sheet which goes through the immediate management then the management above. They try to sort tings out.” The home had a comprehensive adult protection procedure. This gives staff the support they need to make a referral should this be required. The staff spoken to during the inspection were asked about abuse and what they would do if Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 15 they saw or heard anything inappropriate. All said that they would tell someone, for example the manager, or make a referral themselves if this was more appropriate. Training is provided for all staff in adult protection. Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 16 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): 19 and 26. 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. People live in a clean and comfortable home that is well maintained. EVIDENCE: We were shown around the home both inside and out. Outside the home we saw well-kept gardens and a summerhouse for people to use. We were told how the pathways had been widened to allow better wheelchair access. Inside the home was very well maintained in a style that was in keeping with the age of the house. All bedrooms have a sink unit for people to use but no en-suite facilities were available. One person told us “It’s beautiful, when I first came, I came because it was a small home. It came well advised; my family came to Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 17 have a look at it. This is the room shown to my family. You can see squirrels and ducks from the nearby park.” The last inspection report recommended that a more appropriate area be found for hairdressing. The manager said that this is under constant review and will be addressed as soon as possible. Since the last inspection the footpath to the conservatory has been widened to make it more accessible for wheelchairs. Three bedrooms have also been refurbished. We asked the person about how well the home was cleaned and we were told “They come in most days to see if there any crumbs around, then they hoover.” We did not notice any unpleasant smells in the home during our visit. The last inspection report recommended that more appropriate facilities be made available for the disposal of soiled waste. The manager said that a new policy has been implemented. All the rooms were clean and tidy. Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29 and 30. 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. Staff are appropriately recruited, trained and employed in sufficient numbers to meet the needs of the people who live in the home. EVIDENCE: From the rota supplied at the inspection there was sufficient care staff on duty to meet the assessed care needs of the people who were using the service. The home had staff files in place, which provided evidence that the appointment of a new staff member is in the main made through proper recruitment processes. This includes the vetting of staff through the use of references, POVA first checks and Criminal Record Bureau (CRB) checks. The home are committed to having a highly trained workforce. All of the care staff are trained to NVQ Level 2 in care, and most of them are also trained to Level 3. As well as mandatory training, recent training has also taken place in adult protection and health and safety. Staff said that they are also supported with regard to personal training needs. Staff comments in this area were positive. Comments included There is always plenty of training going on and Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 19 you can ask for additional training if you want to. Another said, I have regular supervision with the manager where personal training needs are discussed. Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35 and 38. 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. People can be assured that the home is well managed and they are given the opportunity to comment on how the home is run. Policies and procedures are in place to safeguard their health, safety and wellbeing. EVIDENCE: The manager is qualified and competent to run the home. She has commenced an NVQ Level 4 in care and hopes to complete this shortly. There was an open and friendly culture between the management team and staff working at the home. Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 21 There was evidence in staff files to show that supervision was taking place and that the staff were being appraised. Staff confirmed that supervision takes place on a regular basis and that they are well supported. People living at the home and visitors who were spoken to during the inspection confirmed that the manager is approachable and that they would go to her if they had any concerns. Staff also confirmed this to be the case. Regular meetings are held and there are a number of systems in place to consult with people living at the home. Relatives and the people who live in the home can approach the staff at any time. The owner carries monthly visits and does regular audits covering all environmental and care aspects. The manager also carries out regular audits. Any issues identified are considered and improvements made where possible. The home does not hold personal monies on behalf of the people who live in the home. If someone did not have sufficient money to purchase an item or service, the home would pay for this out of petty cash. They would obtain a receipt and the money can be paid back at a later date. The manager confirmed that all equipment in the home is regularly checked. The maintenance certificates that were seen at this inspection were found to be in order. Health and Safety checks are carried out regularly to safeguard people living and working at the home. Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 22 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 Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP9 OP8 Good Practice Recommendations Medication which has a limited shelf life once opened should have the date of opening recorded on the bottle. Where medication is prescribed as one or two then the actual number given should be recorded. A more specialist set of weighing scales that can be used with people with mobility problems should be purchased. This will ensure that peoples’ weights can be monitored more accurately. The manager should complete a qualification to NVQ Level 4 in Care, or an equivalent. 4. OP31 Briarfield House DS0000000079.V375160.R01.S.doc Version 5.2 Page 24 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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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