Care Home: Bronswick House

What the care home does well We found the service provides care in a flexible way, so that people living there have the opportunity to live their daily lives as they choose to. Comments included, "we like to do our own thing when we want to and the staff understand that". " We`ve got to know people and what they like to do and don`t like to do and it works well". The way we saw staff speak and treat people told us they do it with sensitivity, respect and they make sure residents needs are being met, so that they are comfortable. We talked to some of the staff team on duty who confirmed they have a good knowledge of the individual care needs, social and cultural needs of people living at the home so that they are not disadvantaged in any way. Comments included, "They all have their own ways,and we get to know that from the care plans and what families tell us". What has improved since the last inspection? We looked around the home and found there has been improvement in the decoration and furnishings of the home, which means people living there are comfortable. The designated smoking area is now in a place which does not negatively impact on people in the home. Comments included, "Its not as Smokey now". The owner told us the improvements are continuing by way of replacing furnishings in some of the rooms. The way the home records peoples needs has improved and includes evidence peoples risks are being recorded and taken into account when planning their level of care. In addition regular reviews of people needs are taking place so their care is being constantly monitored. All fire risk assessments and work to make sure the home has the necessary fire protection is completed and meets with current fire regulations so people are safe. There was evidence staff recruitment and training is improving by way of records seen and training records showing courses being made available to staff so they have the skills and competencies to carry out their roles. Staff surveys and people spoken to said they have access to training and feel supported in their roles. What the care home could do better: On going development in the homes environment means people live in a comfortable home, which is maintained to a reasonable standard. The owner told us maintenance and refurbishment will be an ongoing project. We saw the way induction training plans are recorded could be improved. They currently show no evidence of how the competency has been reached and what timescale is included in the induction training plan. By including how people have reached a competency and in what timescale will show a more consistent plan and identify areas which can be used for personal and professional development. Key inspection report Care homes for older people Name: Address: Bronswick House 16/18 Chesterfield Road Blackpool Lancashire FY1 2PP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jacqueline Riley     Date: 1 9 0 1 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 26 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Bronswick House 16/18 Chesterfield Road Blackpool Lancashire FY1 2PP 01253295669 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Savitree Seedheeyan Name of registered manager (if applicable) Miss Hazel Tracy Long Type of registration: Number of places registered: care home 14 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 14 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: Dementia - Code DE, Mental Disorder, excluding learning disability or dementia - Code MD. Date of last inspection Brief description of the care home Bronswick House is registered to provide residential care for fourteen residents with a Mental health illness. The home is set on two floors with three residents rooms on the ground floor and ten on the first floor. There is one double room situated on the ground floor. There are no en-suite facilities. The home is situated in a residential area, and is close to the public transport network. There is a good transport network Care Homes for Older People Page 4 of 26 Over 65 0 0 2 12 0 4 0 8 2 0 0 9 Brief description of the care home into town, and also local shops. A Statement of Purpose and Service User Guide is available providing information about the home. The information can be used by relatives/representatives to help them make an informed choice whether to move into the home. At the time of the site visit the weekly fees were £325.16. Any additional costs are inlcuded in the contract. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: A key inspection of the home was undertaken which included an announced visit to the service on 19th January 2010 and lasted approximately six hours. There had been a previous key inspection in April 2009 which had resulted in a poor outcome. The owner was asked to provide the Commission with an improvement plan in order to inform us of what they were going to do to improve specific areas of concern within a short timescale. In order to monitor how they were improving the home we carried out an unannounced random inspection in August 2009, to review the progress and how it was meeting the requirements made on the previous key inspection. We found the home had complied with all fire safety work to make sure people were safe. Improvements in the environment were ongoing and a manager had been appointed by the owner to manage the home on a day to day basis. The owner and manager were working together to raise the general standard of the home for the benefit of people living and Care Homes for Older People Page 6 of 26 working there. During this inspection we spoke to the registered owner of the service, manager, three staff members, and a number of people using the service. The care records and other records relating to the care people receive were looked at. We also received a good response from surveys sent to people using and working in the service. Every year the person in charge or manager is asked to provide us with written information about the quality of the service they provide, and to make an annual assessment of the quality of their service. This document is called an Annual Quality Assessment (AQAA). We use this information, in part, to focus our inspection activity. Care Homes for Older People Page 7 of 26 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 8 of 26 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 26 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents, families and friends have information about what services they can expect to live at the home. Admission and assessment procedures are in place so that the home knows they can meet the individual needs of people. Evidence: We looked at the records of three people living at the home. The records we looked at showed there has been improvement in how they are organised, maintained and reviewed so people needs are clearly identified and staff can follow the information provided to them. Comments included, we can use the care plans to see what people need, the information is always being updated. We saw they had assessment details in place from social workers, and other health care professionals. In two more recent admissions there had also been a pre admission assessment carried out by the homes manager, as well as social workers and health care professionals. The information showed the home is informed through these assessments of the needs of people being admitted to the home. Staff spoken to said they use this assessment Care Homes for Older People Page 11 of 26 Evidence: information to determine the level of care people need. Staff comments told us the information is important so that they know what the needs of people are. We were shown revised written information about the home and what services it provides. This information is given to prospective residents or their families or advocates, so that they know what the home can provide and make an informed decision. People we spoke to told us they had been given the new information and said It tells us about where we live and what to expect. Care Homes for Older People Page 12 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Promotion of health is taken seriously. Peoples welfare is monitored and their health needs are identified and met. Evidence: Since the previous inspection the home has reviewed and put in place new care planning records which are clear, concise and easy to follow. The three care planning records we looked at were accurate and up to date. There was good information about individual needs including health and personal care, as well as how those needs were going to be met. Staff we spoke to told us the information is clear and they can follow the information in the plans to make sure peoples needs are being met. People we spoke to told us, the staff are good because they know me and what I need, they are always a round when you need them, and they spend time with you. The records we looked at show there are risk assessments in place for people which highlight what the risk is, how it can be managed and the outcome for the person. The manager told us she has developed the risk assessments with people, so they are involved in the planning process and are encouraged to be involved in the Care Homes for Older People Page 13 of 26 Evidence: management of the planning process, to help them feel valued. We saw evidence of the risk planning being used helping people improve their quality of life by being supported in tasks they had previously been unable to carry out. Comments included, I can go out now because I am supported by the manager and staff, the staff have really helped me move on, to do things I couldnt do before. The care plans we looked at had clear review dates in place, and information showing the information in the care plans is being looked at regularly and changes made where necessary. Staff told us they are involved in the care planning process and are encouraged by the manager to record information in the plans so there is a consistent approach to communicating with each other. By looking at the records we saw there is a good link between the home and other health care professionals, including doctors, district nurses, Social Workers and Psychologists. In addition we saw hospital appointment records, optician records and notes for the manager to follow up. We found there are good links with the mental health team who carry out reviews of people living in the home, so staff have up to date knowledge of their mental health needs. Medication records and observation of practices told us it is safe. There has been a review of the medication administration and recording practices since the previous, inspection. We looked at three records and found they were accurate according to the prescription sheet and were kept in a purposeful locked facility. Most staff have received training in medication administration and recording. The manager is constantly updating the training records so that all staff responsible for medication administration carry it out only after accredited training has taken place. We saw peoples privacy and dignity is respected by observing how staff talk to and respond to people. We found staff to be respectful and sensitive to the needs of people throughout the inspection of the service. People we spoke to told us, all the residents have character and we all get along really well, most people have been here a long time and you get to know them really well, we all get on well. Care Homes for Older People Page 14 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social activities and meals are being well managed, creative and provide daily variation and interest for residents. Evidence: We spoke to some of the residents and staff about routines in the home. They said they are flexible and people can get up and go to bed when they choose. We saw there were a number of people choosing to use their rooms during the day. Two people we spoke to told us they have all they need in their rooms and use them more as a bed sit. Staff recognise this and were seen to be courteous when entering their rooms. Some other people were using the lounge and dining areas throughout the day. We saw people are free to move around the home when they choose to. The lunchtime meal was being prepared and seen to be wholesome and nutritious. We spoke to people about the food and surveys also gave us feedback about how the home meets the nutritional needs of people living there. Comments told us people liked the meals and they can eat them when they choose. If they are out during mealtimes there is always a meal on their return, as confirmed by talking to people during the inspection process. Comments included, If Im out there is always something saved for me when I come back, the food is really good, its all home Care Homes for Older People Page 15 of 26 Evidence: made. Menus we looked at were balanced and the use of fresh produce is made available whenever possible. Staff members spoken to said they like preparing the meals for people, and that they know that due to the home being of a moderate size they know the likes and dislikes of individual residents and they respect this. We were told that there have been instances where special diets are necessary, but the staff always work with the doctor or other health professional for advice and guidance. The manager told us there is a current review of social activities designed for the needs of people living there. This is ongoing and looking at what people want. We saw instances where staff accompany people out into the community. Outings to local places have been arranged and well received. In house entertainment is also occurring. Staff told us there had been a full activity programme over the recent Christmas period, which people had enjoyed. Surveys and comments from people living at the home told us they like whats going on. I like to go out more now, they tell us about things going on, and I can join in if I want to. There are no restrictions for visitors to the home. We were told people are always welcome. Comments form people spoken to said, there are usually people bobbing in the see someone. Care Homes for Older People Page 16 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for recording and responding to complaints are good making sure people feel listened to. Staff have access to safeguarding training for the protection of users of the service. Evidence: We looked at the homes complaints procedure, which is made available to people and relatives or advocates during the admission process. We were told by staff and a resident they are aware of the complaints procedures and how to use them. Comments included, I would talk to the manager if I wasnt happy about something, we have had training in protecting people and dealing with complaints. The information the home provided the Commission with prior to this inspection told us they had received three complaints and investigated them using their own procedures. None of the three complaints had been upheld. We spoke to the manager about how people are protected they told us staff are receiving training in safeguarding people, so they are protected. Some of the staff files we looked at confirmed training is taking place so that staff are equipped with the knowledge and skills for the protection of people using the service. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a suitably adapted, clean and comfortable environment which meets their needs. Evidence: We looked around the home and found there have been improvements to the decoration, furnishings and carpets throughout. New carpets had been put in place throughout the hall stairs and communal areas of the home. In addition some of the residents rooms had replacement carpets and furniture. People we spoke to said, its got better, and I have new furniture, they have been busy decorating and its looks a lot better. Some people had personal items with them including individual pieces of furniture and personal items such as photos, pictures and ornaments. We found a few people living there like to use their rooms at all times and this is not seen as a problem by the staff team. The main lounge areas have been decorated and were seen to be warm and comfortable. Some people choose to use the lounges and dining areas when it suits them. People we saw were able to use all areas of the home as it suited them. The number of bathing facilities meet the needs of people currently accommodated. In Care Homes for Older People Page 18 of 26 Evidence: addition a ground floor bathroom has had the shower repaired so its available to people living there. Comments included, I can have a shower now, its more powerful than it was. We found the designated smoking area has been moved to the rear sun lounge, which is well ventilated and does not affect the main part of the home. People we spoke to said this had improved the environment in general. Comments included, it doesnt smell of smoke anymore in here. We saw the home was clean throughout with no offensive odours. There are current guidelines in place for infection control and most staff have received training in tis area. The manager is taking into account the need for training in this area so all staff have access to it. Care Homes for Older People Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are procedures in place for recruiting staff, ensuring the safety and protection of people. Training is being developed so that the staff team have the necessary skills to meet peoples needs. Evidence: We looked at how the staff team are utilised to meet the needs of people during the day and night time periods. We found the home is using a skills mix of staff so that there is always a member of staff on duty with the knowledge and skills in a senior position. We saw there are sufficient numbers of staff to meet the needs of the people living there. Staff we spoke to and surveys we received told us they were happy with the way they are supported and how they work in the home. Comments included, we work as part of a team, There have been some changes but we are all settling down now. The way staff are trained is being reviewed and we saw there is evidence the staff team are going on courses to meet the needs of people living in the home. A Staff training profile is being used to identify where staff need to develop and how their training needs are going to be met. There is ongoing development of staff gaining a care qualification, with current numbers up to 62 . The manager told us she is focusing on all staff to ensure they gain a care qualification so they have knowledge and skills in current care practices. Training in the area of mental health is another Care Homes for Older People Page 20 of 26 Evidence: area for development and the manager told us they are seeking a suitable training course for this topic so that the staff team will be equipped with the specialist knowledge and skills. Staff spoken to said they were keen to continue with their development and gain qualifications especially in the area of mental health so they have a better understanding of peoples needs. We looked at two induction training records and found the area of induction covers all aspects of caring for people using the service. Whilst the induction records were complete they did not show how the person had achieved the individual competences other than a tick and date. There should be more evidence of how people are competent in the specified areas and the programme should be spread over a timescale so the person has time to complete each area and can demonstrate examples of competency so it can be confirmed by the manager. We looked at two staff files. They showed us staff are recruited safely using procedures which take into account information about their skills and competences for the role applied for. Information about them included application and interview records, references which have been checked, Criminal Record Bureau (CRB). Protection of Vulnerable Adults (POVA)checks to make sure they are safe to work with people who may be vulnerable. Care Homes for Older People Page 21 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed for the benefit of all users of the service with systems and policies in place for the safety and protection of people living and working there. Evidence: We saw the manager is running the home on a day to day basis in the best interests of residents and staff. Comments included, we feel supported by the manager, things have changed, but its all settled down now and I like living here, the manager is always around for us. The manager is currently undergoing a manager registration process with the Commission so they meet the requirements of registration by having a registered person to manage the home on a day to day basis. We saw the manager is developing a communications system which means people living and working in the home have the opportunity to voice their opinions and ideas about how the service is running and how it may develop further. There has been one Care Homes for Older People Page 22 of 26 Evidence: staff meeting and the manager talks to people individually to gain their opinions and ideas about future development. People we spoke to said they liked the way this happens and comments told us, the manager talks to me about living her and if I want anything different. Staff told us it was useful and more meetings are planned as the service develops further. We found that all records and systems in the home have been reviewed or are at the review stage, so that the information is comprehensive and up to date. Staff were able to follow clear instructions in the records for the health and welfare of people living there. We saw there is a clear line of management responsibility and that the manager communicated well with the owner throughout the inspection process. We spoke to the manager about how peoples money is handled and were told , no money is currently managed by the home, and all allowances are paid directly to the person weekly, with records to show this is occurring. We saw there are now monthly unannounced inspections taking place by a company manager to oversee the operation of the home and how it is meeting its aims and objectives. Records are now in place recording the outcomes of these visits. By looking at records we saw regular tests and servicing of essential equipment including, gas, electric and fire they were safe. All fire safety work made a a requirement in the previous twelve months has been carried out in line with Fire Safety regulations. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 31 8 Whilst a manager has been 31/12/2009 employed by the owner, they must be registered with the Care Quality Commission for their day to day responsibility at the home. This will ensure the home is being run by a competent manager registered with the commission Care Homes for Older People Page 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 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 30 The records for induction should show the period of training over a designated time specification, and for there to be evidence of how the person is competent in individual areas, so they can demonstrate their competency. Care Homes for Older People Page 25 of 26 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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