Care Home: Harrison House

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What the care home does well Many staff had worked at the service for several years, which helped to ensure consistency of care. There were sufficient staff are on duty at all times and staff and people using the service enjoyed warm relationships with each other. Staff told us they were positive about working at Harrison House and made comments such as `I`m proud to work here` and `it has a nice atmosphere, friendly and homely`. We found the service was highly regarded by the people using it, who feel they were treated respectfully and that their care needs were appropriately met. Peoples` comments included: `you can`t fault the workers`, `they`ve helped me on in life`, `they`re exceptionally kind, helpful and encouraging`, `I`ve no complaints`, `everything is very, very good` and `I shall be happy to come back again`. People using the service told us they liked the meals and said the food was `good`. The service was well organised and well managed and there was a clear management structure that ensured any issues were dealt with quickly and efficiently. Staff also told us that they received plenty of training and there was a variety of courses to attend relevant to their work. The premises were maintained to a clean and hygienic standard. Concerns were dealt with promptly, which resulted in no formal complaints being received by the service. What has improved since the last inspection? The service has made efforts to arrange a greater variety of activities and entertainment based on peoples` likes and dislikes. A programme of re-decoration had taken place around the building that included corridors and lounges as well as some bedrooms. What the care home could do better: The service should be more pro-active in ensuring that all people using the service know how to make a formal complaint. Care plans should contain more detail about personal preferences and social history and consistently show evidence that the person concerned has agreed to the care provided. All handwritten medication administration record (MAR) charts should be signed by two people. All staff should received updated safeguarding training every two years. Key inspection report Care homes for older people Name: Address: Harrison House Dysart Road Grantham Lincs NG31 7DL     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Janet Morrow     Date: 2 9 0 3 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 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Harrison House Dysart Road Grantham Lincs NG31 7DL 01476565901 01476571250 Dave.Wilson@lincolnshire.gov.uk www.lincolnshire.gov.uk Lincolnshire County Council Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) David John Wilson Type of registration: Number of places registered: care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 24. 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 category: Old age, not falling into any other category - Code OP. Date of last inspection Brief description of the care home The last key inspection of this service was carried out on 4/4/2007. Harrison House is a purpose built, two-storey unit, owned and managed by Lincolnshire County Council, Social Services Directorate. The service is situated approximately half a mile from the town centre of Grantham, with shops and local facilities and is on the main bus route. There is a car park to the front of the building Care Homes for Older People Page 4 of 28 Over 65 24 0 Brief description of the care home and there are large gardens to the side and rear of the premises. The service is registered to provide personal care only. The service no longer admits residents on a long-term basis, concentrating on intermediate, rehabilitation and short-term care. Intermediate care is provided within dedicated accommodation with specialist facilities, equipment and staff to deliver short -term intensive rehabilitation to enable residents to return home. The building is composed of four wings; Honeysuckle and Green Leaves for intermediate care, Primrose and Cornflower for short stay. One long stay person is accommodated on Cornflower. There is also a day care centre. This is reflected in the services Statement of Purpose and Service Users Guide. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This is an overview of what the inspector found during the inspection. This key inspection took place over five hours; it was unannounced and was carried out by one inspector. Progress against requirements and recommendations made at the previous key inspection undertaken in April 2007 was assessed. A tour of the premises was conducted, service users care records and staff records were inspected along with administrative systems. Case tracking methodology was used, which means that the records of two people were looked at in detail and the relevant people, staff and visitors were spoken with to find out what impact the service had for their well being and quality of life. Care Homes for Older People Page 6 of 28 We spoke to ten people using the service, one set of relatives, the manager and deputy manager, seven staff members and two visiting professionals during the inspection visit. Feedback was also received prior to the visit from seven satisfaction surveys completed by people using the service. Internal satisfaction surveys were also viewed as part of the site visit. We spoke to one person who had recently used the service and their relative by telephone following the inspection visit. We received written information in the form of an annual quality assurance assessment from the service prior to the visit and this informed the inspection process. Care Homes for Older People Page 7 of 28 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 28 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 28 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 28 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was comprehensive information in place prior to admission to establish that the service could consistently meet peoples needs. Evidence: One floor of the building was exclusively concerned with providing intermediate care, which is a service that aims to assist people to return home following a period of hospital care, or to prevent hospital admission, and usually lasts for about six weeks. Healthcare professionals - physiotherapists, occupational therapists and nurses routinely offer support to the care staff of the unit, and they are also usually involved in making arrangements for people coming to stay at this unit. The written information supplied by the service stated that We continue to work closely with assessment and care management and intermediate care teams across the county, providing intermediate care as well as planned and emergency respite care. We encourage people to visit Harrison House where possible prior to their stay. Care Homes for Older People Page 11 of 28 Evidence: Four of the seven service users surveys received responded that they received enough information prior to using the service. Discussions held with service users confirmed that they were satisfied with the services admission arrangements. Comments included: its very welcoming. Two peoples care records were examined. There were assessments available in the files examined. These covered all the essential areas regarding care and support and contained comprehensive detail regarding the person, although social history information was limited. There were thorough and detailed assessments from other professionals for those people using the intermediate care unit that provided the basis for peoples care plans. The care staff spoken with were clearly aware of service users care needs, how these were met and of the services admission procedures. Peoples needs were generally met and visiting professionals commented that they never saw anything worrying and described the service as excellent and said there was a good rate of success. All seven surveys received from people using the service responded that they always received the care and support needed. The statement of purpose and service user guide together provided all the information legally required by the Care Homes Regulations 2001. Care Homes for Older People Page 12 of 28 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. Thorough systems were in place to ensure people received the care and support required, which ensured their health was maintained and improved. Evidence: The written information supplied by the service stated that The majority of people coming in on planned respite care are visited by a member of the unit staff prior to admission in order to discuss their stay and update their care plan and We work closely with all of the local GP practices and several of those in surrounding villages. Service users said their individual care needs were met and that staff consistently treated them with dignity and respect, which was confirmed in the completed satisfaction questionnaires seen. Comments included: they look after me so well and everyone is helpful and kind. We examined two peoples care files and both had a care plan in place. These contained the essential information for care to be provided and covered areas such as mobility, personal hygiene and care needed during the night. We saw that information Care Homes for Older People Page 13 of 28 Evidence: regarding any health care needs was also clearly detailed, which included information regarding supporting agencies and records were updated and reviewed as necessary. However, one record had not been signed by the person concerned so it was unclear whether or not they had agreed to the care and support provided. The staff spoken with confirmed that they received comprehensive awareness training to promote service users privacy, dignity, choice, rights and independence. They told us that one of the things the service did well was encouraging independence and people using the service confirmed this. Access to health professionals was clearly recorded and visits from Occupational therapists, District nurses, mental health practitioners, chiropodists, General Practitioners (GP) and opticians were documented. The visiting professionals spoken with were fully satisfied with the care and support provided by the service and confirmed that staff appropriately followed any given instruction or advice. One relative spoken with said they were quite happy with the care and another said they were pleased with how their relative was looked after. All seven surveys received from people using the service responded that staff always listened and acted on what was said and that they always received the medical attention required. A general check on four medication administration record (MAR) charts showed that charts were completed properly with codes being used to show why someone had not received an as required medication and the amount of medication received was recorded. However, not all handwritten charts were being consistently checked and signed by two people for accuracy. Two peoples MAR charts were then examined in more detail. These were completed accurately and corresponded with the dispensing pack. The service was using controlled drugs at the time of the inspection visit. The records of these corresponded accurately with the amount of medication stored and two people were signing for their administration. The management told us that they undertook monthly audits of the medication procedures and there were records that showed that the receipt and storage of Care Homes for Older People Page 14 of 28 Evidence: medicines was checked plus the controlled drugs and the medication refrigerator. Care Homes for Older People Page 15 of 28 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. Meals and activities were well managed, which ensured that peoples quality of life was maintained. Evidence: The written information supplied by the service stated that We have a regular programme of planned activities of which all are encouraged to participate and In addition to in house activities, we bring in outside activities/entertainment such as music and movement, guide dog visits, school plays, singers and musicians etc. People using the service told us there were no restrictions as to how they could spend their time and that their visitors were made welcome. They also told us that they enjoyed the meals. Information about the activities provided was displayed in the home. Records were available for each person that showed what activity they had taken part in.This showed that personal attention was provided on a individual basis such as as well as quizzes, discussion and crafts activities. All seven surveys received from people using the service responded that there were always activities arranged. One person told us that they had really enjoyed the Christmas celebrations and several told us that they had liked a recent musical entertainer. Care Homes for Older People Page 16 of 28 Evidence: Relatives spoken with confirmed that they were able to visit at any time and stated that they were always made to feel welcome. One relative spoken with described the service as friendly and another said they looked forward to going. The service had received information on the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards. The manager had attended training on this. The manager stated that no one using the service had an advocate at the present time. We observed the serving of the lunchtime meal and those people spoken with enjoyed the food. The meals served were well presented and nutritious. The dining area was pleasant and bright and tables were laid with cloths and condiments. One person spoken with said the food was ever so good, another said it was very good and a visitor was pleased that their relative was eating better since using the service. All seven surveys received from people using the service responded that they always liked the food. Care Homes for Older People Page 17 of 28 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. Adherence to comprehensive policies and procedures ensured that people were safeguarded. Evidence: The written information supplied by the service stated that We promote an open culture and will respond positively to any complaints we receive and We see complaints as a positive thing, if we are doing something wrong or not to the required standard we need to be told about it to enable us to put it right. This will lead to service improvements. There had been no formal complaints made about the service since the last inspection visit in April 2007. There had been none received at the office of the Care Quality Commission. We saw that complaint policies and procedures were in place and information regarding these was provided to service users and displayed in the entrance hall. However, five of the seven surveys received from people using the service said they did not know how to make a formal complaint. A safeguarding adults policy and procedure was in place and the service was able to access a copy of the Lincolnshire Local Authority procedures via their computer system. The services training record indicated that the majority of staff had not received updated safeguarding training since 2004. However, the manager confirmed that a training DVD had been purchased and planning was underway to ensure staff Care Homes for Older People Page 18 of 28 Evidence: were up to date on safeguarding procedures. Staff interviewed confirmed that they were aware of their responsibilities in reporting any potential abuse and knew the correct action to take if any allegations were made. The written information supplied by the service stated that there had been no allegations of abuse since the last inspection visit in April 2007. Care Homes for Older People Page 19 of 28 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. The premises were well maintained, which ensured people had safe and comfortable accommodation. Evidence: All areas viewed were clean, tidy and well maintained and there were no unpleasant odours. There was a pleasant outdoor garden area that was well tended and was accessible for people to use and enjoy. All seven surveys received from people using the service responded that the premises were always fresh and clean. One survey commented that its so lovely and clean. There were specific facilities for those people receiving intermediate care such as a physiotherapy room and ample stores of equipment to aid mobility. Domestic staff were deployed each day to keep all areas clean and odour free. Health and safety policies and procedures were in place for staff, who received awareness training regarding this and cleaning equipment and products were safely stored. People spoken with thought their laundry was done well and care staff, who had Care Homes for Older People Page 20 of 28 Evidence: responsibility for this, confirmed that there were clear systems in place for dealing with laundry. The written information supplied by the service stated that The team have a good understanding of infection control procedures and infection control is a regular topic at staff meetings and supervision. Staff spoken with were knowledgeable on how to control infections and confirmed that there was a plentiful supply of gloves and aprons. They also said that their communication systems at hand overs worked well and ensured that all staff knew promptly of any infections in the service. Care Homes for Older People Page 21 of 28 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were sufficient, well qualified staff who had access to a very thorough training programme, which ensured that people using the service were in safe hands. Evidence: The duty rota for the weeks ending 27th March 2010 and 3rd April 2010 showed that there were three care staff on duty in the mornings and afternoons plus a senior carer and two at night, plus kitchen staff and domestic staff each day. Six of the seven surveys from people using the service responded that there were always enough staff and one responded that there were usually enough. The written information supplied by the service stated that the provider offer many opportunities for staff training, as such we have a very well trained staff group. Many of the staff are committed to personal development often training to a higher level than is required for their role. A comprehensive amount of training, which was ongoing, was undertaken by staff who confirmed that they were satisfied with the training opportunities provided. Staff spoken with confirmed that mandatory health and safety training took place as well as courses relating directly to care. Training records showed that courses in areas such as dying and bereavement, Parkinsons Disease, stroke awareness, epilepsy awareness and dementia had all occurred in 2009. Care Homes for Older People Page 22 of 28 Evidence: The written information supplied by the service also stated that nineteen of twentyfour staff had achieved a National Vocational Qualification at level 2 or above. The service was therefore exceeding the target of having 50 of staff qualified to level 2 or above and is commended for its commitment to qualification training. We examined two staff files for recruitment information. This showed that a proper recruitment process was in place and that all the information required by the Care Homes Regulations 2001 was in place, including Criminal Record Bureau (CRB) checks, identity information and two written references. The staff members spoken with confirmed that they had received induction upon commencing work at the service and that there were enough staff to meet service users needs. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service was well managed in peoples best interests and gave excellent support to staff. Evidence: The manager had many years experience of working with older people and was able to demonstrate in discussion that he was familiar with the diseases and conditions associated with old age. The written information supplied by the service stated that We encourage open and honest discussion/feedback from staff, service users and visitors to the unit. Staff told us the management was supportive and said that their suggestions were listened to. A quality assurance system had been developed that included monthly audits of health and safety areas plus areas such as staff training. Feedback on the service was received from internal surveys when people were discharged. We examined the most recent and this told us that people using the service were very satisfied with the Care Homes for Older People Page 24 of 28 Evidence: service provided. Some of the comments were: staff could not have been better, I would recommend it, very well looked after and very clean and comfortable. The service users we spoke with confirmed that they were satisfied with the management of the home, the care provided and that they felt supported to express their views and that these would be acted upon. Staff members told us they received very good management support. Comments included: the management are easy to talk with, Im happy to work here and issues are usually addressed. Policies and procedures were in place to protect service users where the service had any involvement in their finances. The manager told us that generally people were encouraged to look after their own money. We examined one persons financial records and these were accurate. Health and safety issues were addressed. The written information supplied by the service showed that fire fighting equipment was checked in December 2009, gas safety in March 2010 and portable electrical appliances in August 2009. Staff training records, and staff spoken with, confirmed that mandatory health and safety training was being undertaken; for example, infection control training, moving and handling and fire safety had all occurred in 2009. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 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 7 Care plans and records should have more personalised information that take account of individual needs and social history. All care records should be signed by the person concerned, or have some evidence to show agreement with the care and support provided. All handwritten medication administration record (MAR) charts should be signed by two people. The service should be more pro-active in ensuring people know how to make a formal complaint. All staff should receive updated training in safeguarding vulnerable adults and this should occur every two years. 2 7 3 4 5 9 16 18 Care Homes for Older People Page 27 of 28 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). 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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