Care Home: Fairfield Residential Ltd - Springfields

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What the care home does well People have an assessment of their needs before being admitted to the home to make sure that all of their needs can be met and people are encouraged to come and visit the home several times before making a decision to move in. The support plans for people were detailed and informative about the person and their individual needs, personal preferences and wishes. Staff spoken to confirmed that people are supported to make decisions that are important to them and around their day to day lives. From talking to staff and observations on the day it was obvious that people are treated with respect and dignity. There is a complaint procedure available in both pictorial and large print for people. People were supported and encouraged to engage in activities of their choice and try new activities. The AQAA identified that there is an emphasis on encouraging independence and learning new skills. This was supported by staff spoken to. The home provided a domestic, homely environment that was flexible to meet people`s individual needs. Support staff had a good knowledge of the people living there and were seen to meet their individual needs. A speech and language therapist and a lifestyle personal tutor attend the home on a regular basis to support people with their communication and daily living skills. The manager was committed to improving standards within the home and he had in depth knowledge of people`s individual needs and personal preferences. Staff spoken to said they felt very well supported by the management. What has improved since the last inspection? The requirements and the recommendations made at the last inspection visit had been met. Since the last inspection visit a farm project has been set up. This is where people go to a local farm and help tend to the animals, help with the planting of vegetables and one person has a pet cat at the farm that she helps care for. The project has been a great success. Since the last visit new dining room chairs and sofas have been bought. What the care home could do better: No requirements have been made during this visit. However some good practice recommendations were made. Key inspection report Care homes for adults (18-65 years) Name: Address: Fairfield Residential Ltd - Springfields 57 Warburton Lane Springfield Partington Manchester M31 4NL     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: Geraldine Blow     Date: 2 5 0 5 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 Adults (18-65 years) Page 2 of 29 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 Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Fairfield Residential Ltd - Springfields 57 Warburton Lane Springfield Partington Manchester M31 4NL 01617762827 01617762827 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Fairfield Residential Limited Name of registered manager (if applicable) Mr Josephat Mkwakwami Type of registration: Number of places registered: care home 4 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The registered person may provide the following category of service only: Care home only- Code PC To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability- Code LD The maximum number of people who can be accommodated is: 4 Date of last inspection Brief description of the care home Springfield is a large house providing accommodation for up to four people with an autistic specific learning disability. The home is owned by Fairfield Residential Ltd and is set in its own grounds with parking facilities to the side of the building. The home is situated in the area of Partington in Trafford and is close to local shops and a bus route. 4 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 29 Brief description of the care home The cost of the service is calculated for each individual. Care Homes for Adults (18-65 years) Page 5 of 29 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 Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This report is based on information gathered by the Care Quality Commission (CQC) since the last inspection visit on 16 September 2009 and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted prior to this visit. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. The visit took place on Tuesday 25 May 2010. This report is an overview of what we found during the visit. References to we or us in this report represent the CQC. As part of the visit we spent time examining relevant documents and files. We also Care Homes for Adults (18-65 years) Page 6 of 29 spent time talking with the manager, the service manger and two members of staff. We also walked round the home and looked at the communal areas and one vacant bedroom. Feedback was given to the manager and the service manager during the course of the visit and at the end of the visit. Care Homes for Adults (18-65 years) Page 7 of 29 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 Adults (18-65 years) Page 8 of 29 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 Adults (18-65 years) Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 29 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person 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. There is a robust process for reviewing and assessing peoples needs before they move into Springfield to ensure those needs can be met. Evidence: Before a person moves into the home a full assessment of their individual needs and wishes is undertaken. This ensures that the home is able to meet those assessed needs and that the home would be a good place for them to live. We saw that there was a set format to record the outcomes of peoples needs and wishes in their day to day life. The pre admission assessments were seen to be informative and contained detailed information. We were also told that information from the persons social worker and any other healthcare professionals and family members involved in the persons care and treatment is also obtained before anybody moves into the home. Prior to a decision being made about the person moving in to Springfield the AQAA identified that they are encouraged and supported to visit the home on several Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: occasions. This includes initial visits, stays and a getting to know you visits. This was supported by observations on the day of this visit. Following the pre admission assessment process a transition plan is developed and regularly reviewed to help ensure a smooth transition for the person moving into the home. Care Homes for Adults (18-65 years) Page 12 of 29 Individual needs and choices 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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Springfield receive the right kind of support to make decisions that are important to them and to follow their chosen lifestyle. Evidence: We saw that people had their own individual file that contained personal information and their support plan. The support plans covered all aspects of health, social care, cultural and religious needs, choice and control and emotional wellbeing. The plans contained detailed information of how support staff should meet each persons individual needs and personal preferences. Support plans had been kept up to date by being reviewed on a regular basis. This ensures that the information in the support plan is current. Identified risks to the safe delivery of support had been carefully assessed and had been managed well. Any decision that restricted a persons choice and personal freedom had been taken in the best interests of the individual by following good Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: practice guidelines and in consideration of the persons rights as a citizen. The AQAA identified that people are supported to make informed decisions around their day to day lives and this was supported by the staff spoken to during the visit. People using the service received the right amount of individual support to enable them to make decisions that affected their lives. Where necessary alternative forms of communication had been used to support people to take control of matters that were important to them. Care Homes for Adults (18-65 years) Page 14 of 29 Lifestyle 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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Springfield are provided with a full range of opportunities to meet their preferred social, leisure and nutritional needs. Evidence: People were encouraged to lead active lives by engaging in activities that developed their self-esteem and self-confidence. Some of the activities included horse riding, gardening, attending a family wedding with staff support, swimming, shopping and attending the farm project. It was encouraging that sometimes the people living at Springfield watch TV and eat meals together where previously this has not been possible. Staff work very closely with relatives of the people accommodated and this ensures that these important relationships are maintained. One person had gone to stay with his parents for a few days at the time of this visit and one person has shared care. Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: This is where he sleeps at home for certain nights of the week and goes to Springfield during the day and spends the remaining days and nights at Springfield. This has been a very successful arrangement. Each person has a daily timeline completed. This is where staff, each morning, discuss the routine and the persons plans for that day. This is then recorded, either in a written or picture format. This ensures the activities for the day are based on individual wishes and preferences of the person. From speaking to staff it was evident that daily routines in the home are flexible and staff respect each persons right to decide when they want to participate or spend time on their own. A tutor for Independent Life Skills visits two afternoons a week. The tutor has an individual plan for each person living at the home and they are working towards obtaining ASDEN certificates. The certificates are based on achieving different life skills. For example making a cup of tea or preparing a shopping list for a meal, buying the food needed and then preparing the meal. Also a speech and language therapist attends the home on a part time basis to assist people with their communication, this included the use of none verbal communications systems. The home have employed the services of a nutritionist and along with the speech and language therapist have developed a rolling menu of nutritionally balanced meals. People using the service receive support and encouragement to plan their meals and participate in the food shopping. Staff prepare the meals and encourage people to become involved in some aspects of the meal preparation. Special diets, for example, an Halal diet was being catered for. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support 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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to 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. People living at Springfield have their personal and health care needs met. Evidence: The support plans provided evidence that people receive personal and health care support as and when needed. The plans clearly set out how individual health care is to be met and what support is needed. Support is provided for people to access a full range of community and specialized health care services to ensure all health care needs are fully met. Medication was seen to be securely stored. Since the last inspection visit a monitored dosage system has been implemented. This is when peoples tablets are dispensed, by the pharmacy, into individual blister packs. Medication had been signed into the home and there were no gaps in the recording of medication given to people. However a tablet count for a particular medication was not accurate. It was found that one tablet was missing. This was discussed with the manager at length. To ensure that people are receiving medication as intended by the Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: GP it is recommended that they undertake regular checks and tablet counts of boxed medication to ensure all medication is given as prescribed. The manager confirmed that they do not have sight or keep copies of the GPs original prescription. Medication to be returned to pharmacy was recorded in a return book. It is recommended that there is a witness signature for unwanted medication to be returned. Medication to be returned to the pharmacy was stored in the same cupboard as the blister packs but on a separate shelf. The manager told us he would clearly identify the part of the cupboard that was for storing medication to be returned. We were informed that all staff have received medication training to ensure they are competent in administering medication. The manager confirmed that he would obtain a British National Formulary (BNF) book for staff to access. The book is published by the Royal Pharmaceutical Society and staff can use it to look up any medication they are unsure of or if new medication is prescribed. Care Homes for Adults (18-65 years) Page 18 of 29 Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. 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. Systems are in place to protect people from abuse. Evidence: There were appropriate systems in place for dealing with concerns and complaints. The complaint procedure was available in large written text and in pictorial form. We were told that they had not received any complaints about the service since the last inspection visit. Staff spoken to were aware of what to do if somebody wanted to raise a concern or complaint. The manager said that they talk daily to the people living at the home and are in very regular contact with their familys and people are encouraged and supported to raise any concerns they may have. This was supported by staff spoken to. We saw a copy of the Trafford Social Services safeguarding adults procedure and the manager was able to clearly describe the process to be followed in the event of an allegation of abuse being made. The majority of staff had received appropriate safeguarding training. They have a policy on the use of physical intervention/restraint. They told us they use the Team approach to physical intervention. They told us this was approved by Concept in Education and this it was accredited for the British Institute of Learning Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: Disabilities (BILD). As recommended in the previous inspection report there are detailed records of any physical intervention which includes all actions taken prior, during and after the incident. Care Homes for Adults (18-65 years) Page 20 of 29 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. 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 using this service are provided with a clean, safe and homely environment. Evidence: We saw that Springfield provided accommodation for four people over two floors. There were three bedrooms and a shared bathroom on the first floor. One bedroom with en suite facilities was on the ground floor and there was a separate toilet. The kitchen, with separate laundry facilities, a dining room and lounge were situated on the ground floor. We saw that the accommodation provided a domestic style accommodation for people. We were told that people are encouraged to personalise their bedrooms and rooms can be decorated with colours and soft furnishings of their choice. We saw that peoples comfort and safety had been considered with regard to the living environment. For example a sound proof window had been fitted to one bedroom to minimise any external noise. Also furniture in peoples bedrooms is assessed to help minimise any identified risks. We found the house to be bright, clean and tidy. The atmosphere felt homely and relaxed. Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: The garden for the property was at the front of the house and car parking was available at the side. The home is situated close to local bus services and local shops. Care Homes for Adults (18-65 years) Page 22 of 29 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Springfield are protected by the homes recruitment practices. Evidence: At the time of this visit there were two carers and the manager on duty to meet the needs of two people who were at the home. During this visit we observed the staff communicating and supporting a person in a positive and respectful manner. The staff were seen to have a good relationship with this person. We looked at a sample of staff files. We saw that appropriate information had been obtained for newly recruited staff. This included two written references, completed application forms and evidence that appropriate Criminal Record Bureau disclosure checks had been carried out. It was recommended that photocopied documents such as proof of identity and address are signed and dated to evidence that the original documents had been photocopied. The AQAA stated and the manager confirmed that 4 permanent care staff were employed. We were told that of those four staff one had completed National Vocational Qualification (NVQ) Level 4 and three were undertaking NVQ Level 3. Staff Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: spoken to said that they were encouraged and supported to undertake the training. On the files looked at we saw evidence of staff induction. The induction program is produced by the registered providers, Fairfield Residential Limited. We were told that all staff must undertake the staff induction program and they have a shadowing policy for new staff. This ensures that staff are safe and competent to undertaken their role. We saw that staff had an individual training record and the manager told us he was in the process of developing an overall training matrix. We saw evidence of staff training and staff spoken to confirmed that they do have access to appropriate training. However it was noted that staff had not undertaken Food Hygiene training and staff confirmed that they have the responsibility for food preparation. A review of all training should be undertaken to ensure that staff are appropriately trained and competent to meet the needs of the people living at Springfield. Care Homes for Adults (18-65 years) Page 24 of 29 Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. 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 in the best interests of the people living there. Evidence: At the time of this visit the manger was in the process of applying to CQC for registration. The people living at Springfield benefit from a committed manager and staff team. The manager operates an open management style and encourages people and staff to make use of the open door policy. The staff we spoke to said that the manager was always available and was very supportive. Monthly audits are undertaken by an independent person employed by Fairfield Residential Limited. In addition to this the manager also does monthly audits to ensure the service is being run in the best interest of the people living there. There are monthly meetings for the people living at Springfield and monthly staff meetings. This gives people the opportunity to give their views on the service being Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: delivered and look at ways the service can be improved. The manager and staff also told us that they get constant feedback for the people living at the home and their relatives on the service being delivered. We saw that policies and procedures were in place to protect the health, safety and wellbeing of people. They told us in the AQAA that maintenance records were up to date and this was confirmed by the manager. Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 29 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 2 20 20 It is recommended that a witness signature is obtained for all medication that is being returned to the pharmacy. It is recommended that the home keep copies of the GPs original prescription to ensure that the medication dispensed by the pharmacy is the same as was prescribed by the GP. It is recommended that regular checks and tablet counts of boxed medication is undertaken to ensure that people receive their medication as intended by the GP. It is recommended that photocopied documents are signed and dated to evidence that they were taken from the original document. To ensure all staff are suitably qualified and competent to meet the needs of the people living at the home it is recommended that a review of staff training is undertaken to identify any shortfalls, with particular reference to Food Hygiene training. 3 20 4 34 5 35 Care Homes for Adults (18-65 years) Page 28 of 29 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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