Care Home: Heathdale Rest Home

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What the care home does well There are good arrangements in place for people who live at the home to maintain contact with their family and friends. The home is well decorated and comfortably furnished for the benefit of people living at the home. The home offers prospective residents whatever length of time they need to decide if they wish to live at the home. Detailed information is collected about a new resident to ensure staff can provide the necessary levels of care and support to the person. Residents have the opportunity to pursue their religion if they wish to. People living at the home enjoy home cooking and a varied diet. Residents are treated with dignity and respect. People living at the home receive a high standard of care and support from staff. There is an excellent standard of staff training. There is a very good standard of record keeping. What has improved since the last inspection? There is an ongoing programme of decoration and refurbishment around the home. A new medication system is to be introduced. A new care planning system has been introduced. The home is run in the interests of the people who live there. Safe guarding training has been up dated for staff. What the care home could do better: More opportunities should be provided for people living at the home to go into the community when the weather is suitable. The home should continue to explore ways of communicating and engaging with people with severe memory loss by keeping up to date with latest dementia care research and best practice. "Best interest" decisions should be recorded on the care files of people who live at the home as required, after training is completed. More regular staff and resident meetings should take place to involve the staff and residents in the running of the home. Key inspection report Care homes for older people Name: Address: Heathdale Rest Home 63-65 Marine Avenue Whitley Bay Tyne & Wear NE26 1NB     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: Karena Reed     Date: 0 9 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 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Heathdale Rest Home 63-65 Marine Avenue Whitley Bay Tyne & Wear NE26 1NB 01912970274 01912970423 ellen@freenet.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Heathdale Care Ltd care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 20 The registered person may provide the following category of service only: Care Home only, Cope PC. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category, Code OP, maximum number of places 1 Dementia, Code DE, maximum number of places 20 Date of last inspection Brief description of the care home Heathdale is a large, terraced property situated in a residential area in Whitley Bay. It is close to local shops, doctors and public houses. It is also very close to the Northumbrian coast and the sea front. It is registered to provide personal care to twenty residents, the categories of registration are for one older person and nineteen people with memory loss. The accommodation is provided over three floors and a passenger lift is available. Bedrooms are all for single occupancy, some are situated on the ground floor. There are two lounges, a dining room, conservatory and a small patio Care Homes for Older People Page 4 of 28 Over 65 0 1 20 0 Brief description of the care home area to the rear of the premises. There are sufficient lavatories and bathrooms around the home to meet the needs of service users The bathrooms contain equipment that can be used to assist with getting in and out of the bath. A Statement of Purpose and service user guide are available for prospective residents and their relatives to give them information about the services provided by the home and the relevant charges. CSCI Inspection reports are also available at the home detailing the quality of care provided. Fees payable for living at the home at the time of inspection in June 2009 vary between 396.93 and 412.10 Additional charges are payable for hairdressing, private chiropody, personal toiletries and personal newspapers. 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: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: An unannounced visit was made on June 9th 2009. During the visit: We talked with people who use the service, relatives,staff and the managers. We looked at information about the people who use the service and how well their needs are met .We looked at other records which must be kept, checked that staff had the knowledge, skills and training to meet the needs of the people they care for. We looked around parts of the building to make sure it was clean,safe and comfortable. We told the managers what we found. Care Homes for Older People Page 6 of 28 What the care home does well: What has improved since the last inspection? What they could do better: More opportunities should be provided for people living at the home to go into the community when the weather is suitable. The home should continue to explore ways of communicating and engaging with people with severe memory loss by keeping up to date with latest dementia care research and best practice. Best interest decisions should be recorded on the care files of people who live at the home as required, after training is completed. More regular staff and resident meetings should take place to involve the staff and residents in the running of the home. Care Homes for Older People Page 7 of 28 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 Older People Page 8 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 9 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good procedures in place to ensure that prospective residents are making an informed choice about living at the home. Good arrangements are also in place for assessing the needs of people before they are admitted into the home. This provides staff with the information they need to safely care for people living at Heathdale. Evidence: The homes Statement of Purpose and service user guide were examined. They contained the necessary information as required by the Care Homes Regulations 2001.They were comprehensive and described in detail the services provided by the home. In surveys received people who live at the home and their relatives felt that they got enough information from the home and other agencies to make a decision about whether to use this home. A relative said;It was the best home of all the ones I visited, when looking for a place for my mother and my opinion hasnt changed. Care Homes for Older People Page 10 of 28 Evidence: Records for four people who live at the home showed that when they were admitted to the home an assessment of their care needs had been carried out before their admission. A copy of the social services assessment and care plan for each person had been obtained before they moved into the home. The manager or senior staff carry out a pre-admission assessment to ensure that it can meet each individuals needs.The person living at the home and relevant people are involved in the assessment. The homes assessment form encourages staff to explore issues relating to equality and diversity as it refers to gender, culture, religion and spiritual preferences. It also looks at mood, speech, behaviour, mental health and risks. People have the opportunity to visit the home as often as they need in order to decide if they want to live there. A prospective resident may come for meals, have overnight stays and be introduced to other people who live at the home at a pace suitable to the individual. Care Homes for Older People Page 11 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. There are good arrangements in place to ensure the health and personal care needs of people living at the home are met by staff. Evidence: A new care planning system has been introduced to be used by staff.After a person has moved into the home a care plan is designed around their assessed needs so that staff know how to provide the right amount of support . Care plans detail the night time needs of people living at the home. Care plans cover areas such as continence, personal hygiene, mental health and social care needs. The sample of care plans examined were written in a respectful way that promotes the individuality and dignity of the person living at the home.The sample showed that all care plans had been evaluated regularly. Staff comments include: I think the staff do well at providing care and meeting the individuals needs,promoting dignity and respect at all times. Care Homes for Older People Page 12 of 28 Evidence: The staff care for the needs of the elderly respecting their dignity at all times,catering for their individual needs. The home presents a homely atmosphere and makes sure the residents dignity and personalities are maintained. Staff are kept up to date about the needs of residents. Staff look after residents to the best of their ability. Staff cater to the needs of residents,a good sense of dignity is provided and maintained at all times. A relative commented; The home maintains a happy,content environment where residents are respected and given feelings of security. Individual welfare is a prime concern to staff. Records were in place to show how the medical and nutritional needs of people living at the home were being met. Residents care plans recorded information about their social and leisure needs. Health care records were available on the files of residents to show they are supported to have access to health care services such as GPs, dentists, district nurses and continence advisors. Risk assessments are in place for residents covering areas such as health care including prevention of falls, continence and nutrition. Moving and handling assessments have also been carried out to show the moving and handling needs of more dependent residents. Technical aids and equipment are available for people who are unable to move independently. The home has a medication policy that is available for staff to read. All medication is stored in an appropriate locked cabinet to which only senior staff have access. Records Care Homes for Older People Page 13 of 28 Evidence: covering the administration and disposal of medication are kept. The records examined were satisfactory. All staff administering medication have received accredited training,there are plans for this to be up dated. A new monitored dosage system for medication is to be introduced into the home, the pack will include the monitored dosage of liquid medication. Staff are polite, respectful and courteous to people in their care. Care Homes for Older People Page 14 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. People living at the home have opportunities to make choices about activities and daily routines so that they may lead a lifestyle that matches their social care needs. Evidence: There is a planned programme of activities within the home. At the time of inspection a dancing session was taking place with residents and staff,old time music was playing. Activities include:videos, sing-a-long, manicurist, dominoes,gardening, religious services, hairdressing,memory skills,quizzes,massage,board games,exercise,song and dance,movies,music sessions,family visits,tea dances, fitness sessions,arts and crafts,jig saws,reminiscence,bingo,cake decorating and skittles. Various seasonal parties are arranged which are supported by relatives. Social evenings are also arranged in order to boost the residents amenities fund. Residents enjoy sitting in the garden when the weather is suitable. They enjoy ice cream and barbecues.Entertainment is also provided in the home by entertainers such as singers,choirs and other seasonal entertainment. People living at the home have the opportunity to go out with relatives. Local outings are also arranged by the home to the coast, the local town centre and whatever is of interest to the resident. Residents enjoy attending a local tea dance,it has become so Care Homes for Older People Page 15 of 28 Evidence: popular the home has arranged their own tea dance and buffet for residents to be held monthly. Comments from people living at the home and their relatives include: I would like more outings. The home could ensure all activities are kept going and outside interests brought in. Always the prospect of refining/extending the range of activities for residents could be improved and this has been developed in recent years, but always capable of being under review. Staff support people living at the home to keep in touch with relatives. Staff ask each resident about their wishes,interests and choices. Training has taken place for the staff team about memory loss. This training should help ensure residents are given more choice in order to keep some control in their lives. Training is planned about how to implement the Mental Capacity Act. Following this training ,the senior staff will look at what choices and decisions each person with memory loss is able to make for themselves. The cook talks with the residents to collect up to date ideas for making the menus and finding out about the food likes and dislikes of residents. At least two hot meals are provided daily and an alternative is available. Residents were positive about the food. On the day of inspection the luncheon menu offered people living at the home liver and bacon or mince and dumplings with potatoes,cabbage and carrots followed by strawberry cheesecake, yoghurt or fruit. Tea was bacon omelette,chips and beans or assorted sandwiches and egg custard. Comments from people living at the home include: Meals are nourishing and varied and looked forward to. The home feeds us well. Very good wholesome cooking. They make good meals. Care Homes for Older People Page 16 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. The home has a complaints and protection system,which helps to protect people who live at the home. Evidence: The homes complaints procedure is given to new people as they move into the home. The procedure assists and supports them and their relatives to bring any matters to the attention of staff outside of the home in case they felt uncomfortable bringing any complaints or concerns to the attention of staff within the home. There is a complaints procedure on display within the home for the use of residents and their relatives. The home keeps a record of complaints . There have been no complaints received about the home since the last inspection.There have been no safeguarding issues which have neded to be investigated using the council safeguarding strategy. Surveys returned stated people living at the home knew how to complain if they needed to .Comments from people living at the home include: I have no problems. I have nothing to complain about. Care Homes for Older People Page 17 of 28 Evidence: There is nothing I can think of to improve the standard of the home. The home has a copy of the Local Authorities Vulnerable Adults procedure. This provides staff with clear guidance on how to deal with adult protection concerns. Staff have received the local authority multi-agency training about Protection of Vulnerable Adults. Staff have also received training about behaviour that may be difficult to work with, this should help them understand the different support needs of individuals. Staff have received training about dementia care to give staff more insight into the needs of people with memory loss. Care Homes for Older People Page 18 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 home provides a comfortable and safe environment for those living there. Evidence: The home is accessible and situated near to the seafront in the centre of Whitley Bay. There is an ongoing programme of decoration and refurbishment around the home. Since the last inspection the kitchen,a rear hallway and some bedrooms have been decorated. Carpets have been replaced in some bedrooms. The garden has been planted for the summer and new patio furniture has been purchased. Furniture and fittings were domestic in design and the home was well decorated and comfortably furnished. The home has an appropriate amount of sitting, recreational and dining space. People living at the home all enjoy their own bedroom which is comfortably furnished and personalized with some of their own belongings. The home is clean,well maintained and has a very good standard of hygiene.Staff have received training about infection control which helps to reduce the spread of infection within the home. Care Homes for Older People Page 19 of 28 Evidence: Comments from people living at the home include: The home is always clean and the staff are always nice. The home is always clean. The home is very clean ,friendly and inviting. Care Homes for Older People Page 20 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff for the occupancy levels of the home. They are appropriately recruited, and trained to meet the needs of the people living at the home. Evidence: Examination of staff rosters and discussion with the managers and members of the staff team showed that staff numbers are as follows: 3 staff members 8.00am - 8.00pm 2 staff members 8.00pm - 8.00am These numbers do not include the managers. There is a senior staff member on each shift when the manager is not on duty. Other members of staff are employed for duties such as cleaning, food preparation and maintenance work. There is an excellent level of staff training. Almost 100 of carers have achieved a National Vocational Qualification(NVQ) at level 2. Over half of the carers are studying or have achieved an NVQ at level 3. Staff have received the necessary statutory training and developmental training is Care Homes for Older People Page 21 of 28 Evidence: planned to ensure that staff can meet the specialist needs of people with memory loss e.g. Deprivation of Liberty training.Safe handling of medication is also planned to be up dated. Other training carried out includes: infection control,moving and handling, communication skills, housekeeping,first aid, health and safety, food hygiene,fire safety,continence, bereavement, swallowing and feeding,falls awareness, end of lifepalliative care and mental health training. Staff were observed to be polite and respectful to people living at the home and residents comments include: The staff do well. The staff are good. The staff could listen a bit more. Staff look after me well. The staff are wonderful. The staff are very good. Staff comments include: I enjoy working here, the staff have accepted me joining them having been here only a short time. Owners and management and all staff have supported and helped me in first starting. Clients seem very happy and the staff are too. Care Homes for Older People Page 22 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 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 the home live in a home that is well run and run in their interests and where the welfare of all is promoted. Evidence: The current manager has the relevant qualifications for managing the home. There are plans that she will relinquish responsibility for the day to day running of the home as a new manager has been appointed to take over this responsibility. The new manager is finishing studying for the relevant qualifications in management and care so that she can become registered with the regulatory authority as registered manager.This will allow the current manager to oversee the running of other homes in the group and have more of an executive position. The home is well well run and there is an ethos of involving staff and residents in the running of the home. The last residents meeting held in January discussed areas such as activities and food .Residents are also involved in decision making in their daily living. This could be further extended to include people with memory loss.This will help Care Homes for Older People Page 23 of 28 Evidence: people with memory loss to still have some control in decision making in their lives. Comments from people living at the home and relatives include: Communication within the home is well facilitated and vsisitors are always welcome. The home gets the priorities right. The home presents a homely atmosphere. Heathdale provides a homely feeling for both clients and staff. It is a lovely home well run and everything I wish. Excellent. Staff meetings take place quite regularly, the last one took place in January. Supervisions take place every two months with each staff member,as well as an annual appraisal when staff will help identify their training needs. There was a good standard of record keeping and documents detailing fire safety and other statutory records were all up to date.There was a record of Regulation 26, monthly visits by the proprietor to the home, to carry out an audit of the care provided, as part of the homes quality assurance process. A sample of staff files were examined.The necessary checks are carried out before a person is appointed to work at the home. Two written references were available on staff files examined. An application form had been completed for each staff member. Employment histories were available. CRB checks are carried out before a person is appointed. Staff photographs were available on staff files examined apart from on the file of a person who had just started working at the home. Proof of identity was available on staff files examined. Lockable facilities are available for residents to keep their own money if they wish. Care Homes for Older People Page 24 of 28 Evidence: Staff training relating to health and safety was up to date. 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 2 13 14 The home should extend opportunities for people living at the home to go out into the community more regularly. Best interest decisions should be recorded on the care files of people who live at the home as required, after training is completed. The home should continue to explore ways of communicating and engaging with people with severe memory loss. Management and staff should continue to keep up to date with latest dementia care developments, to receive up to date information, to ensure that specialized care continues to be given to people with memory loss. More regular staff and residents meetings should be held to involve staff and residents in the running of the home. 3 14 4 32 5 32 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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