Care Home: Harrow Road, Flats A, B and C

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What the care home does well The service is provided in purpose built, single storey accommodation, with good access for people using wheelchairs. The accommodation is well located on the Harrow Road, close to public transport, shops and other services. Service users, who have high needs, get good support from the staff team. The Westminster Society has developed user involvement systems, which include representation on its management board, regular forums and surveys and participation in staff selection. Service users take part in a range of individual and group activities. Good relationships are maintained with families and friends, with regular contact from staff, including with relatives who live out of London. Staff have access to a comprehensive training programme that includes NVQ 2. Team Managers are experienced and qualified and receive regular support from the Service Managers who visit often. Staff work closely with the multi professional learning disability team. There is an established monitoring and review system for the service, which includes the views of users. What has improved since the last inspection? Incidents are reported promptly to CQC and to the safeguarding team. Managers and Assistant Managers have received training in reporting notifications and incident books are regularly checked by Service Managers. Risk assessments in relation to bathing have been revised following an incident. Staff are completing core training, including health and safety training. Service Managers visit regularly, with monthly reports available. What the care home could do better: Steps taken to improve the handling of medication need to be continued to reduce the error rate further. Risk assessments must be available when bed rails are used. Key inspection report Care homes for adults (18-65 years) Name: Address: Harrow Road, Flats A, B and C Flats A, B and C 291 Harrow Road London W9 3NF     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: Sheila Lycholit     Date: 0 1 0 6 2 0 0 9 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 25 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 25 Information about the care home Name of care home: Address: Harrow Road, Flats A, B and C Flats A, B and C 291 Harrow Road London W9 3NF 02072663072 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: najiboye@wspld.org The Westminster Society for People with Learning Disabilities care home 13 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who may be accommodated is 13. The registered person may provide personal care (excluding nursing) and accommodation to service users of both sexes whose primary needs on admission to the home are within the following category:- Learning Disability (Category LD). Date of last inspection Brief description of the care home 291 Harrow Road is located close to the transport links, shops and amenities of Paddington and Westbourne Park. The home is registered to provide accommodation and care for 13 men and women with learning and physical disabilities. Flats A and B were registered by the Commission in March 2007 to provide care for 8 people. Flat C provides care for 5 people and has been registered for a number of years. Each person living in the home has his / her own bedroom and access to shared amenities. The home is wheelchair accessible and is fully equipped to enable people to pursue a full and active life. The care is provided by the Westminster Society for People with Learning Disabilities, a Care Homes for Adults (18-65 years) Page 4 of 25 Over 65 0 13 Brief description of the care home local voluntary organisation. The property is owned by Kensington and Chelsea Primary Care Trust. The current fee for the service is £1,736.17 per week. Care Homes for Adults (18-65 years) Page 5 of 25 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: The unannounced visit took place on Monday 1st June 2009 from 10.15am until 4.30pm. The Team Managers for flats A and B were on duty and the Service Managers for flats A and C visited the service and made themselves available to answer any queries. The service is fully occupied with 13 people in residence. Service users were at home or attending community activities. One person was attending hospital for regular treatment accompanied by staff and returned later in the day. Three survey forms were returned by service users, all of which were positive about the care and support they receive. No annual quality assurance assessment was available, as it had been sent out by CQC to the wrong address in error. Care Homes for Adults (18-65 years) Page 6 of 25 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 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 7 of 25 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 8 of 25 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. Service users needs are regularly assessed and steps taken to ensure that the service is able to meet any changes identified. Evidence: Although no new service users have moved to the project since the last inspection, records seen show that existing service users needs are regularly re-assessed. The records of three service users were looked at, which showed that each had received a recent re-assessment by relevant members of the learning disability team. As a result of the assessment of one service user in flat A, an additional waking night staff had been agreed to meet her needs and to ensure other people were safe. Care Homes for Adults (18-65 years) Page 9 of 25 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. Care plans are person-centred, detailed and produced in an accessible format. Regular reviews take place, with the involvement of the service user. Risk management is generally sound, but staff must ensure that the use of equipment such as bed rails is used only following a risk assessment and consideration of alternatives. Evidence: The individual files of 2 service users in flat A and 1 in flat C were looked at. The documentation of these service users was selected because of recent incidents and concerns. Staff use the Westminster Societys all about me format, which encourages the use of multi media to promote service user involvement. Support guidelines and care plans were well written, showing the involvement of the service user. The care plan seen in flat C did not contain photos although the format encourages their use. Communication plans were also on file. Records also indicate the detailed knowledge of staff regarding service users needs Care Homes for Adults (18-65 years) Page 10 of 25 Evidence: and preferences. Placement and care plan reviews take place regularly. Consideration should be given to compiling regular summaries to ensure that support to service users remains focused. A number of meetings have taken place with the learning disability team to review the changing needs of individual service users and to seek advice on managing behaviour. A follow up meeting was taking place in flat A on the afternoon of the inspection visit. Notes of residents meetings in flat B were seen which showed that people are supported to take part in decision making in the service. Detailed risk assessments were seen on each of the files looked at, including assessments of bathing. No risk assessment was available where bed rails were being used to prevent one service user from falling out of bed. The rails had been supplied by the OT following an assessment and multi professional meeting. Senior staff at the service expressed their reservations about the use of bed rails and were concerned about the risk of injury and the issue of restraint. A further meeting to review the advice had been arranged and a re-assessment had been requested. No protectors had been supplied with the equipment and no risk assessment had been completed. Care Homes for Adults (18-65 years) Page 11 of 25 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. Service users are supported to take part in a range of activities in the home and in the community. Good relationships are maintained with families and friends. Steps have been taken to promote healthy eating, although there is room for further improvement. Evidence: Individual files and activity plans show that service users take part in a range of individual and group activities, in line with their interests. Use is made of local day services, which people attend on various days and to take part in events and outings. A worker specialising in drama and movement comes into the home for individual sessions. The Councils outreach team provide individual support to a number of service users or assist staff in supporting people outside the home. Flat C has the use of a vehicle with a tail lift, which can transport someone seated in a wheelchair. Service users religious and cultural needs are identified in their support plans. Care Homes for Adults (18-65 years) Page 12 of 25 Evidence: Records and discussion with staff show that steps are taken to support family relationships, including inviting relatives to meetings and events at the home and accompanying people to visit families and friends. Staff also make regular phone calls to update relatives and to maintain contact and involvement. Catering was looked at in flats A and C. Each person in flat A has food prepared individually for them because of their particular needs and varying routines. Meals are recorded in daily logs. In flat C service users usually have a main meal together. An excellent slection of menu cards is available to prompt peoples choices. From discussion with staff, it seems that while some meals are cooked from fresh ingredients, a number are prepared from frozen or pre-prepared dishes. Little fresh fruit or vegetables were available in flat C, although a member of staff going out shopping with a service user was reminded to buy some. The Service Manager commented that he believed that in part the lack of cooking skills of some staff led to an over reliance on pre-prepared food. He was hopeful that time could be found in the training schedule for opportunities for staff to improve their skills and confidence in preparing meals. Both kitchens were clean and tidy. Fridge and freezer temperatures were seen, which are recorded by waking night staff. Care Homes for Adults (18-65 years) Page 13 of 25 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. Detailed guidance on how service users wish to be supported is available, indicating that staff know peoples individual needs well. Service users, some of whom have complex health care needs, receive good support from staff to access health services. A series of medication errors have led to management action to improve the handling of medication, including training and performance management. Evidence: All service users reguire some support with personal care. The 3 individual files looked at contained detailed plans, setting out how the person preferred to be supported. Support plans indicate that staff compiling the plans know the person and their needs well. Health care files were seen for 3 people with high needs. Each contained an up to date health action plan and details of referrals to health care professionals. One person receives hospital treatment several times a week, where she is accompanied by staff. Written guidance for staff anticipates possible problems and shows that staff take every step to minimise the stress and upset of these visits. Since the last inspection there has been an increase in the number of medication Care Homes for Adults (18-65 years) Page 14 of 25 Evidence: errors in the service. Discussion with Service Managers and the Team Manager in flat A confirm that senior staff have taken steps to improve the handling of medication, including re-training for staff, discussion at team meetings and performance management. Each incident has been investigated and CQC and the care management team informed. In spite of action taken, errors are still occuring, with 5 incidents in flat A since the beginning of the year. The reasons for the high error rate are unclear, as staff use a measured dosage system, receive training and the administration of medication is witnessed by a second member of staff. A clear medication policy and procedure is available. MAR sheets seen in flat A were up to date and fully completed. Reasons for giving medication prescribed as required were recorded on the reverse of the MAR sheet. It is recommended that guidance regarding as required medication including maximum dosage, is kept in the medication file, rather or as well as in service users individual files. Storage of medication was seen in flats A and C, which was in secure locked cabinets. Care Homes for Adults (18-65 years) Page 15 of 25 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. Staff take steps to elicit complaints and concerns, which are acted upon in line with the services complaints procedure. Safeguarding procedures have been improved since the last inspection, with issues referred to the local Councils safeguarding team and CQC. Evidence: The complaints record for flats A and B showed that staff record complaints and concerns with action taken. Complaints are also notified to the Westminster Societys head office, where progress in investigating and resolving complaints is monitored. The majority of complaints noted were inter-resident complaints, though one person had also complained about being given the wrong medication. The Team Manager confirmed that an apology had been given regarding the medication error. A complaints procedure is available in an accessible format. Since the last inspection, CQC has been notified of safeguarding concerns and of other incidents. Referrals have been made in line with local multi agency procedures to the safeguarding team and strategy meetings held. At the time of the inspection one safeguarding issue, which involved the challenging behaviour of one person, was under review. The multi professional team was involved in providing advice and an appointment made to investigate any medical causes of the changed behaviour. Additional waking night staff had been put in place to ensure the welfare and safety of service users in flat A. Care Homes for Adults (18-65 years) Page 16 of 25 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. The building is well located, close to shops, public transport and other services. All areas are accessible to wheelchair users. There is a good range of specialist equipment to promote independence and to assist with transfers. Evidence: A tour of flats A and C confirmed that a pleasant environment is provided which meets the needs of people living at Harrow Road. Communal areas are spacious and comfortable, with access to outdoor space. There is direct access from flat C to a secure garden, which was well used on the day of the inspection. Two bedrooms were seen in flat A and two in flat C. All were pleasantly decorated with a range of personal possessions. Bedrooms in flat A, which was opened in 2007 are particularly attractive, being light and bright. Bathrooms are spacious and contain specialist equipment for bathing and showering. Support staff undertake all cleaning, which is carried out to a good standard. Laundry facilities are available on site. Care Homes for Adults (18-65 years) Page 17 of 25 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. Good staffing ratios are provided. There is a sound recruitment procedure, which involves service users. Staff have access to an established training programme. Evidence: Staffing rotas provide at least two staff on early and late day shifts. In addition a member of staff works a mid shift at weekends to allow service users to undertake individual activities. The rapid response team provides additional support to service users, including joining a member of staff in accompanying one service user to her regular hospital appointments. Staff interactions with service users observed during the inspection visit were warm and positive. Staff recruitment is undertaken with the Societys HR team who carry out preemployment checks. A number of service users have taken part in training in recruitment and appointing staff and are involved in staff selection. The Service Manager confirmed in discussion that staff do not start employment without a satisfactory criminal record check. Staff have access to an established training programme, which includes NVQ 2. A recently appointed member of staff, who is an experienced support worker, was interviewed. He confirmed that he had been provided with a structured induction, which had started with 3 days at the Societys head office. in addition he has attended Care Homes for Adults (18-65 years) Page 18 of 25 Evidence: training workshops weekly and has had two supervision sessions with the Registered Manager. As he has not completed the Societys medication training, he is not yet handling medication. He described support from colleagues as fantastic. The majority of posts are filled by permanent staff. Any vacancies are normally covered by in-house bank staff. Notes of regular staff meetings were seen in flat B. Discussion is well recorded, although the notes would benefit from being typed, rather than hand written. Staff are supported by regular supervision and an annual appraisal. Care Homes for Adults (18-65 years) Page 19 of 25 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 service has an experienced and qualified Manager, who is well supported by the Team Managers in flats A and B and by the Service Managers. Records are well maintained. Good attention is paid to the health and safety of service users and of staff. Evidence: On the day of the inspection the Registered Manager was absent on a planned period of sick leave. Acting arrangements had been put in place and the Service Manager had increased the frequency of his visits. The Registered Manager has worked at the service for a number of years and has completed NVQ 4. The Team Managers in flats A and B were on duty. Both have relevant experience and qualifications. Three Service Managers cover the flats and visit regularly to provide support to staff and to monitor the service. The Westminster Society has an established service user involvement strategy, which includes participation at board level, regular forums and an annual survey. Staff from other projects support service users to complete feedback forms to increase objectivity and to elicit any concerns. Care Homes for Adults (18-65 years) Page 20 of 25 Evidence: Record keeping is of a good standard, with formats, in particular daily logs, that encourage service users contribution. The Service Manager confirmed that since the last inspection, progress has been made in ensuring that all staff complete core training, including health and safety refresher training. Incident and accident books were seen for each flat, which were compled in detail. Fire safety records seen were up to date. A fire risk assessment is available and detailed fire evacuation plans were seen on each of the three service users files. Records of fire drills before April 2009 had been archived but monthly drills had taken place in April and May 2009. The fire detection system and equipment is regularly serviced. The Service Manager confirmed that checks to prevent the risk of Legionella are made annually. Records of visits on behalf of the provider were seen in flats A and B . These show that visits take place at least monthly, including out of hours visits, with a report made available. Care Homes for Adults (18-65 years) Page 21 of 25 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 22 of 25 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 1 9 13 Where bedside rails are used, a risk assessment must be available and steps taken to prevent the service user from injury. To prevent any unnecessary restraint and reduce the risk of injury. 30/06/2009 2 20 13 Steps taken to improve the handling of medication must be maintained until the number of incidents is further reduced. To ensure that service users receive medication as prescribed. 30/06/2009 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 6 Consideration should be given to key workers compiling regular summaries of progress made in relation to PCPs Care Homes for Adults (18-65 years) Page 23 of 25 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 and action plans to ensure that support to service users remains focused. 2 3 17 20 Further promotion of healthy eating should be considered to reduce the use of processed and pre-prepared food. Guidance on as required, PRN, medication should be available on the medication file, including maximum dosage. The comprehensive notes made of staff meetings would be more accessible to staff if typed copies were made available. 4 36 Care Homes for Adults (18-65 years) Page 24 of 25 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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