Care Home: Eagle Care Home

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What the care home does well The home is well maintained and furnished and fitted to a high standard. People are encouraged to bring personal possessions with them when they move in and this makes people feel at home. The home is clean and fresh throughout and people said that this is always the case. There is a warm and welcoming atmosphere in the home. People said that they enjoyed living at Eagle Care Home and one person said "it`s a lovely place to stay”. There are a range of activities on offer for people to join in with if they choose to do so, as well as trips out and visiting entertainers. There are sufficient staff employed at the home to meet people`s needs. Staff have time to sit and talk to people and spend time with them individually. The Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.2 staff team are well trained and over half of the care staff hold the National Vocational Qualification (NVQ) in care. This means that they are qualified and competent to care for people. Everyone that we spoke to said that staff listen to them, and act on what they say and people said they like the meals and enjoy the activities. The staff understand the needs and preferences of all the people who live at the home. People`s health is looked after and the staff have the skills and experience they need to do this. The staff said that they enjoyed working at Eagle Care Home and said that they work well together as a team. What has improved since the last inspection? Since the last inspection more of the staff team have completed the National Vocational Qualification (NVQ) in care. Well over half of the staff now hold the award. This makes sure that staff are qualified to care for people living at the home. The bathrooms have been redecorated and refurbished. This provides a warm and relaxing environment for people to bathe and relax in. What the care home could do better: The staff recruitment procedure should be improved. This is to make sure that only suitable people are employed at the home. Key inspection report CARE HOMES FOR OLDER PEOPLE Eagle Care Home 104 Victoria Road Elland West Yorkshire HX5 0QF Lead Inspector Cheryl Stovin Key Unannounced Inspection 27th July 2009 10:00 DS0000059046.V378157.R03.S.do c Version 5.3 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. Eagle Care Home DS0000059046.V378157.R03.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 Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eagle Care Home Address 104 Victoria Road Elland West Yorkshire HX5 0QF 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) 01422 373141 manager@eaglecarehome.wanadoo.co.uk None Eagle Care Homes Ltd Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th August 2007 Brief Description of the Service: Eagle Care Home is a privately owned care home registered to provide accommodation and care for up to 33 older people. The establishment is situated in a residential area close to the town centre of Elland. Halifax town centre is easily accessible by public transport. The property is generally well maintained throughout and provides accommodation comprising of 27 single rooms 16 of which have en-suite facilities, and 3 double rooms. Communal areas are spacious and comfortable with a safe and accessible patio area for service users to enjoy in the warmer weather. The weekly charge at the home is £356, additional charges are made for personal toiletries, hairdressing and chiropody. There is also a charge for escorting service users to routine medical appointments. Eagle Care Home DS0000059046.V378157.R03.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 Two Star Good service. This means the people who use this service experience Good quality outcomes. This report brings together evidence of the key inspection of Eagle Care Home which included a visit to the service on 27th July 2009. During this visit a full tour of the building took place, we looked at records and talked to people living at the home, visitors and to management and staff. At the time of the visit the home had not completed and returned their Annual Quality Assurance Assessment (AQAA). 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. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Eagle Care Home. The visit to the home was carried out over one day by one inspector. The last inspection of the home took place on 6th August 2007, no additional visits to the home have been made. What the service does well: The home is well maintained and furnished and fitted to a high standard. People are encouraged to bring personal possessions with them when they move in and this makes people feel at home. The home is clean and fresh throughout and people said that this is always the case. There is a warm and welcoming atmosphere in the home. People said that they enjoyed living at Eagle Care Home and one person said its a lovely place to stay”. There are a range of activities on offer for people to join in with if they choose to do so, as well as trips out and visiting entertainers. There are sufficient staff employed at the home to meet peoples needs. Staff have time to sit and talk to people and spend time with them individually. The Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.2 Page 6 staff team are well trained and over half of the care staff hold the National Vocational Qualification (NVQ) in care. This means that they are qualified and competent to care for people. Everyone that we spoke to said that staff listen to them, and act on what they say and people said they like the meals and enjoy the activities. The staff understand the needs and preferences of all the people who live at the home. Peoples health is looked after and the staff have the skills and experience they need to do this. The staff said that they enjoyed working at Eagle Care Home and said that they work well together as a team. 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. Eagle Care Home DS0000059046.V378157.R03.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 Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 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): 1,2,3,4,5,6 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 are assessed before they are admitted to the home, to make sure their needs can be met. EVIDENCE: People said that they were given enough information about the home before deciding to go to live there. The service user guide which gives plenty of information about the services and facilities provided is displayed in each bedroom. Where possible the staff encourage people and their families to visit the home and talk to the people who already spend time at the home, their relatives and Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 Page 9 the staff. The home invites them to come and spend time there, share a meal and maybe take part in the days activities. This means that the home can get to know the persons needs and the individual has the information he or she needs to make a decision. Before moving into Eagle Care Home, peoples needs are assessed to make sure that the home is able to meet their needs. This assessment, as well as Social Services assessments when available, forms the basis for the individual plan of care and support. A contract is in place which clearly states what is and is not included in the weekly charge and the services and facilities provided. This makes sure that people know what is included in the weekly charge. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 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): 7,8,9,10 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. Peoples personal and healthcare needs are met. People are generally protected by the medication administration systems. Staff treat people with respect, care and consideration at all times EVIDENCE: The care records of six people living at the home were seen. Each contained a care plan. The current system is rather confusing as information is held in different sections of the care records. A new system has been devised and some care plans have been completed in the new format. These were very Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 Page 11 clear and detailed the actions to be taken to meet people’s assessed needs in accordance with their preferences. The care plans include risk assessments and management plans where someone is at risk of falling, developing a pressure sore, becoming malnourished or any other area the staff feel may put the individual at any risk. Health care visits and treatments are recorded in detail and everyone who we spoke to said they always receive the healthcare they need. One person told us that “the staff do things the way I like and they are always kind and caring”, another person said “I feel everybody is so kind and nothing is too much trouble”. During the visit staff were seen to be treating people with respect and promoting their dignity. The medicines are kept safe and secure in locked cabinets. The medicines are supplied by the pharmacy in a monitored dosage system. We looked at the Medicines Administration Record (MAR) charts, which show clearly the quantities of medicines received and in stock for each person, to make sure the records were accurate. The medicines appeared to be recorded accurately. The medicine trolleys were locked when unattended. The controlled drugs were securely stored and the records were accurate. The refrigerator used to store some medicines was checked on most days, to make sure the temperature was correct. All staff who are responsible for administering medication have received training to make sure that medicines are given safely. A weekly audit of medication is undertaken to make sure that stocks are accurate. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 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): 12,13,14,15 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 are offered a variety of activities to take part in, if they wish. People are offered a good choice of meals to make sure their dietary needs and preferences are met. EVIDENCE: The atmosphere in the home is warm and friendly with a homely feel, and people said this was always the case. The home’s staff lead the activities and people take part or not as they wish. When we visited people were enjoying the relaxed, social atmosphere of the home and there was an arts and craft session on the afternoon of our visit. A range of activities are offered as well as games such as scrabble, card games and quizzes as well as trips out, and visiting entertainers. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 Page 13 There is a notice board in the entrance hall on which newsletters, activities programme and other information is posted. This keeps everybody up to date with what is happening in the home. Some people living at the home have an interest in gardening and a new greenhouse has been erected for them to enjoy their interest. People are encouraged to keep in contact with their friends and family and visitors were seen to be warmly welcomed into the home. Visitors said that they are always kept informed of important issues affecting their friend or relative. One person said “we are very happy with the home as I and my family are kept informed about everything there is to know”. The cook plans the menus to include the wishes of the people who are living at the home and to meet any special dietary needs. There are always alternatives available if people do not want the choices on the menu. As well as a cooked meal at lunchtime, there is a choice of hot and cold dishes at teatime. The lunch being served on the day of the visit was: meat and potato pie, or gammon and pineapple, swede, garden peas and new potatoes, followed by ginger sponge and custard or pears and cream. People said that they enjoy the meals and the food is always hot when it is served. People are offered hot and cold drinks throughout the day and snacks are available at any time of the day and night. The dining tables were attractively laid and the dining room is light and airy. The mealtimes are relaxed and staff are available to help anyone who needs assistance. The home has recently been inspected by the environmental health department and has been rated as a four star establishment. This means that kitchen hygiene and food handling systems have been assessed as good. The people who live at Eagle Care Home said they can do what they want, when they want. This confirmed our observations that the staff support people to live their life in the way they choose. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 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): 16,18 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 are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. The staff have received suitable training and understand the adult protection policies and procedures. EVIDENCE: The home has a complaints procedure which is given to everybody living at the home and their representatives. A copy is also displayed in the home. People spoken to were aware of who to speak to if they were happy about anything in the home. One person said: I have no complaints, excellent couldn’t ask for better. A record is kept of all complaints received at the home. No complaints have been received since the last inspection and none sent directly to the commission. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 Page 15 All staff have received training in the Protection of Vulnerable Adults (POVA) and are aware of the safeguarding procedures to follow if they suspected or witnessed people not being treated properly. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 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): 19,20,21,23,24,25,26 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 well maintained and clean and safe environment. EVIDENCE: The home is situated in a residential area of Elland with local shops and community facilities nearby. The town centre of Halifax is easily accessible by public transport. The home is well maintained throughout and furnished and fitted to a good standard. New carpets have been fitted throughout and the environment is bright and cheerful. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 Page 17 The majority of the bedrooms are highly personalised reflecting people’s interests and tastes. People are encouraged to bring personal items in to the establishment to make them feel at home. The bedrooms are comfortable and people we spoke to said they were satisfied with the facilities provided in them. There is a lockable space in all rooms to make sure that people can store their items securely. There are plans to fit locks to all bedroom doors and people will be subject to a risk assessment to check if they can handle a key safely. This will make sure that people’s possessions are kept safely. A new ‘wet room’ has been installed and the assisted bathrooms have been redecorated and refurbished to make them warm and welcoming. This makes the bathing experience enjoyable for people using them. The communal areas are spacious and comfortable with sufficient space for social activities to take place. There are safe and accessible garden areas for people to sit out in during the summer months and plenty of car parking facilities for staff and visitors. There are infection control measures in place and all staff are provided with protective clothing and equipment. This makes sure that people are protected from any possible cross infection. A full tour of the building showed that all areas of the home were clean and hygienic throughout. A visiting relative told us that the home is always “spotlessly clean”. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 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): 27,28,29,30 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. Sufficient staff are employed to meet peoples needs. Suitable training is provided to make sure staff have the skills and knowledge they require to be able to meet peoples needs. EVIDENCE: The staff rotas, and peoples comments, confirmed our observations that there are enough staff on duty to meet peoples care, social and leisure needs. There is one team leader and three care assistants on duty during the day and evening and two waking night staff as well as housekeeping and kitchen staff. This number seems to be sufficient to provide care and support for the people who stay at the home. All new staff complete induction training which meets the Skills for Care criteria. This gives them good basic training to help them do their job effectively, and provides a sound basis for taking a National Vocational Qualification (NVQ) course. Well over half of the care staff have achieved an Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 Page 19 NVQ in care at level 2 or 3, this means that the staff are qualified to care for people living at the home. There is also plenty of other training available for staff to keep their skills and knowledge levels up to date. The home keeps good records of staff training, which also shows when updates are needed. People said that the staff were kind and attended to their needs in a sensitive manner. We saw staff responding to people’s requests for assistance promptly and in a caring manner. One person said that the staff were “so kind”. A visiting relative said that they would “like to say a big thank you to the staff for caring for my Mum so well”. A recent routine contract monitoring visit by the local authority identified that there were gaps identified in staff recruitment procedures. However these were immediately investigated and rectified by the provider, who ensures us that the recruitment procedures are now robust. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 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): 31,32,33,35,36,37,38 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. The home is managed in peoples best interests. EVIDENCE: The home is currently being run by an acting manager who has not as yet been registered by the Commission. The records and the staff confirmed that all staff have one to one supervision meetings with their line manager. Supervision meetings support staff to plan their personal and professional development and give them the opportunity to discuss any areas of concern in a confidential setting. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 Page 21 The staff said that they are well supported and they work well together as a team. Regular staff meetings are held and staff are encouraged to make their views known and contribute to the running of the home. Peoples personal information is stored securely when it is not being used. The homes policies and procedures are generally kept up to date; to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner, including fire safety training for the staff. These measures make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. There is a quality assurance system in place and the results are displayed on the notice board. The latest quality monitoring report showed that the majority of people are highly satisfied with the care and facilities provided by the home. There are suitable financial procedures in place to make sure that any money held on behalf of anybody living at the home is kept safely. At present there are no people living at the home who are subject to a deprivation of their liberty authorisation, under the Mental Capacity Act 2005. At the time of the visit the home had not returned their Annual Quality Assurance Assessment. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 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 3 3 3 3 3 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 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 3 3 Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 Refer to Standard OP29 Good Practice Recommendations To make sure that only suitable people are employed at the home all the required pre-employment checks should always be carried out. These include Criminal Records Bureau and Protection of Vulnerable Adults disclosures. Two written references must also be obtained before staff are employed. Eagle Care Home DS0000059046.V378157.R03.S.doc Version 5.3 Page 24 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@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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