Care Home: Honeybourne House

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What the care home does well Comments from relatives about Honeybourne House included "I really can`t fault the service. My son is very well looked after", "The Management and staff appear to be genuinely concerned with the welfare of their residents", and "They deliver the best possible care and love to my brother at all times". Honeybourne house is extremely well managed, the focus of all of the work is the needs and wants of the people who live in the home. Staff are highly motivated and well trained. It is this combination of management, staff and culture focused on the needs and wants of the people who live at Honeybourne house that makes it an excellent service. The accommodation is of a good standard, clean and suited to the needs of the people accommodated. The people who live at the home are provided with a range of activities both at home and in the community. Meals are well cooked and people are provided with the support they need in relation to their diet. What has improved since the last inspection? The service was recognised as being excellent at the last inspection, and the service continues to provide an excellent service. What the care home could do better: There is a good system for recruiting staff, however it could be further improved by ensuring that there is a record of all gaps in employment history are accounted for, prior to employment. Such a complete employment record helps ensure that appropriate references are taken, including one from the last time the applicant worked with vulnerable people. We also advised that a risk assessments is completed in relation to legionnaires disease. Key inspection report Care homes for adults (18-65 years) Name: Address: Honeybourne House 98 Sheridan Road Manadon Plymouth Devon PL5 3HA     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: Helen Tworkowski     Date: 1 5 1 2 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: Honeybourne House 98 Sheridan Road Manadon Plymouth Devon PL5 3HA 01752242789 01752242789 honeybourne8@aol.com www.alliedcare.co.uk Honeybourne House Limited care home 21 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability sensory impairment Additional conditions: LD - Learning Disability, 21 service users male or female LD(E) - Learning Disability - over 65, 13 service users male or female PD - Physical Disability, 21 service users male or female PD(E) - Physical Disability - over 65, 13 service users male or female SI - Sensory Impairment, 21 service users male or female SI(E) - Sensory Impairment over 65, 21 service users male or female The home will recruit an individual who is registered as a first level nurse with the Nursing & Midwifery Council, and has a current pin number, who also has the appropriate nursing experience to meet the needs of the clients in receipt of nursing care, and will work full time and be responsible as the `Clinical Manager` for the delivery of appropriate nursing care to the clients who are accommodated in the 8 (eight) places that are registered for nursing care at the home. Care Homes for Adults (18-65 years) Page 4 of 25 Over 65 13 13 21 21 21 21 There will be a maximum of 21 beds in total of which 8 (eight) beds are to provide nursing care Date of last inspection Brief description of the care home Honeybourne House is a detached property that is a part of Allied Care Ltd, a national organisation caring for people who have a learning disability. It provides both personal and nursing care. It provides personal care for a maximum of 13 people, aged over 18 years, with a learning disability, some of whom may also have a physical disability and sensory impairment, and who reside in Honeybourne House. In the Bungalow they provide nursing care for up to 8 people within the same categories previously stated but for young adults over 18 years. The home has a Registered Manager and also a Clinical Manager specifically for the Bungalow. The Home is in the residential suburb of Manadon on the outskirts of Plymouth. It is close to local shops and other amenities. There are 12 single bedrooms in the main house, 6 bedrooms being on the ground floor. In the Bungalow there are eight single bedrooms, all with en-suite facilities with a ceiling track hoist from the bed to the ensuite. Communal space in the main house is on the ground floor and consists of a dining room and lounge. The managers office is on the first floor and this area is also used for some staff training. The Bungalow has its own lounge and dining room space. A further building is used for activities and this has a separate sensory room. The home has its own transport, consisting of two minibuses, each with disabled access including wheel chair lifts. The homes fees are based upon the homes assessment of need using a comprehensive tool that provides the full breakdown of charges for each service provided and a total cost. 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: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection was unannounced and took place on the 15th December 09, beginning at 9.30 a.m. and ending at 5.00 p.m. As part of this inspection visit we looked around the home and saw all of the rooms, we interviewed three of the staff and met with the Manager and Deputy Manager. We looked at the care of four of the people who lived in the home, at the care provided and the care notes. We looked at how medication was administered and managed, and how people in the home were kept safe. We also looked at the way staff were recruited and staff training, and how the home was managed, how quality was assured. We sat with some of the people who live at Honeybourne house during lunch, and we also met with a relative of one of the people. In addition we contacted a number of relatives by email, and received four surveys in response. We also spoke with two visiting health care professionals. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who move to Honeybourne House can be reassured that their needs will be known about and understood prior to a move.They have the opportunity to visit prior to a move and will be supported to make Honeybourne House feel like their home. Evidence: The homes Statement of Purpose and Service User Guide were available on a notice board in the entrance hall, so that visitors could read them. We did not look at these documents as part of this inspection visit, however the previous inspection report noted that these documents contained valuable information about the home and the standard of care that can be expected. The Manager, Jackie Carter, said that it was anticipated that a new resident would be moving to Honeybourne House in the next few days. We were told that the individual had had the opportunity to come and visit the home, this had been so that the prospective resident could have a chance to see if the place suited them. The Manager told us that such visits helped them to confirm the assessments that had been made, and for people already living in the house to meet the prospective resident. The Care Homes for Adults (18-65 years) Page 9 of 25 Evidence: Manager explained that people who moved to the home could bring their own furniture, and hence the room they were to move into was empty of furniture. Care Homes for Adults (18-65 years) Page 10 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Honeybourne House can be confident that their health and care needs will be met and that this will be done in a manner and at a pace that suits their wishes. They and their relatives will be involved in decisions about their lives. Evidence: We talked with one of the relatives about the care provided to her son. She explained how satisfied she was with the care provided. The relative said staff knew her son well, and that they were aware of what wanted, and when he was comfortable or not. She also said that staff cared for people for who they are, not what they could do. We looked at the plans of care for four people, these were comprehensive documents which detailed what peoples needs are and the actions to be taken by staff. These documents were well written and focused on the person and their preferences, they had been regularly reviewed. There are also comprehensive risk assessments that are part of the process of keeping people safe. The Manager told us that in addition to completing their own plans of care, the service was also required to complete a Care Homes for Adults (18-65 years) Page 11 of 25 Evidence: person centred plan and a health action plan, by Social Services. These documents duplicated much of what is in the homes care plans. The staff we spoke with told us that they read the care plans, and knew the help needed. We saw that there were good daily records, there were also records relating to food eaten, visits by health care professionals, records of weights and of incidents of epilepsy. Records indicated that the staff at Honeybourne House monitored and were aware of changing health needs. In the Bungalow, there are nursing staff on duty 24 hours per day, to provide constant nursing support. One relative told us in a survey Since Ts health has been declining we have been kept advised of changes and Honeybourne House have developed a programme to ensure that he can continue to be cared for by them. The programme has been discussed with us and has our full support. Where people are not able to speak for themselves and do not have relatives independant advocates have been sought. One advocate commented Honeybourne House is one of the few homes that full accepts the concept of independant advocacy and has referred all of their elidgle residents. We noted that each persons room was individually decorated. We discussed with the Manager and deputy how they were able to understand each persons preferences. We were told that many of the people were not able to express their wishes or dreams, but that staff got to know what each person liked or responded to, and in this manner were able to come to a view about the individuals preferences. Care Homes for Adults (18-65 years) Page 12 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. The people who live at Honeybourne House have the opportunity to engage in a range of activities suited to their preferences. They are provided with a good standard of food and support needed to enjoy meals. Evidence: In looking around Honeybourne House we saw that many of the people who live in the home were engaged in activities for part of the day. Each person has a plan for the week with suggested activities for each day. The home has a sensory room, which was in use during the inspection. The Manager told us that that many of the residents enjoy going on holidays, and therefore they arrange for three or four holidays a year. The Manager told us about how they where people were not well enough to go to particular destinations they tried to bring the destination to them, by providing a similar experience. It was impressive to see the degree of imagination used so that the people at Honeybourne House do not miss out. One relative commented in a Care Homes for Adults (18-65 years) Page 13 of 25 Evidence: survey My son seems to be looked after very well. His needs are well catered for and he has a much more active life than he had with me. We were told how people were encouraged to take part in activities in the community, such as attending football matches. We ate lunch with some of the people at Honeybourne House, the meal was clearly to the taste of the people in the home. Where people needed assistance appropriate aides and support was provided. The meal was a relaxed, people were given the opportunity to make choices about what they ate and drank. One person was show two different squash bottles, so that she could point to the one she wanted. Many of the people in Bungalow have specialist dietary needs and this is supervised by the nursing staff, and appropriate records kept. Care Homes for Adults (18-65 years) Page 14 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Honeybourne House are provided with an excellent level of support to meet their personal and health care needs. Evidence: We spoke to three of the staff about the help and support they provided to the people who live at Honeybourne House. They were clearly well motivated and very proud of the high standard of care provided. Staff told us that their were sufficient staff to meet the needs of people. We saw from the way that people were dressed, that care had been taken to ensure that not only were the clothes clean and well fitting, but that they suited the individual. Care had been taken to make the best of each individual. Looking around the home we saw that the home has appropriate equipment such as hoists and variable height beds, and specialist bathing facilities. Consideration had even been given it the way that the home was decorated for Christmas, so that the people in the home could get the most out of the decorations. Staff told us that there were no rules about when people got up or went to bed, the routines of the home run around the needs and preferences of the individuals who live Care Homes for Adults (18-65 years) Page 15 of 25 Evidence: in the home. We looked at the two medication systems that are operated, one in the main part of Honeybourne House, the other in the Bungalow. Both systems were well managed, their were good records of administration, and it was possible to audit medication held. We were told that only suitably trained staff were able to give medication. Care Homes for Adults (18-65 years) Page 16 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. The people who live in this home can be confident that any concerns raised will be dealt with appropriately and that they will safeguarded from abuse. Evidence: The Manager said that they had received no complaints regarding the service. We saw that the complaints procedure was prominently displayed in the hallway. We asked one of the relatives if she would be confident to raise any concerns and she confirmed that she would. All of the staff we spoke with felt that the Manager was very approachable and should they have any issues they could be easily raised. We discussed with the Manager issues relating to ensuring that peoples best interests were protected, where they lacked the ability to make decisions themselves. The Manager was able to give examples of how they had ensured peoples rights and interests are protected. We also saw that where there were concerns about particular incidents that had occurred a full investigation had been carried out. The Commission had been informed of the outcome of the investigation and has received full reports. Care Homes for Adults (18-65 years) Page 17 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 people who live at Honeybourne House are provided with accommodation that is clean, comfortable, and generally suited to their needs. Evidence: As part of this inspection we looked around all to the accommodation. We found the house to be clean and tidy. All of the bedrooms are single rooms, and those in the bungalow have en suite facilities. Each room that we saw reflected the different tastes and interests of the occupant. Hoists, including with overhead tracking. The bathrooms were also adapted to accommodate the range of need of people at Honeybourne House. There is a sensory room, which is well equipped and was in use during the visit. We were shown around the garden, whilst there is limited space, it was all well used and designed to accommodate the interests of the people who live at Honeybourne House. We saw the laundry, which is in a building between the main house and the bungalow. It is well equipped with machines suited to the need. We saw that there was aprons and gloves in areas where they might be needed, and that there was liquid soap for hand washing. Care Homes for Adults (18-65 years) Page 18 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at Honeybourne House benefit from competent and well trained staff, who are highly motivated and in sufficient numbers. Evidence: We looked at the recruitment records relating to three people who have recently started work at the home. There was a well organised system, which helped to ensure that no one started work without the appropriate checks being completed. Checks included: two references, a check on criminal records and a check of a list of people not suitable to work with vulnerable people. We saw that a full employment history had been obtained for each person. We discussed with the Manager the importance of keeping a written account of any gaps in an employment history. We were shown a copy of the induction procedure, this consists of six modules and takes place over months. Such systems should help ensure that staff learn about their role in a planned and structured manner. We spoke with one new member of staff who was in the first stages of induction and was observing what was happening. We looked at the training records, these provided good evidence on an individual basis that staff had received a range of training to ensure that they had the necessary skills to carry out their work. We discussed with the Manager setting up a training matrix, which might assist in giving a better overview of the training needs of staff. Care Homes for Adults (18-65 years) Page 19 of 25 Evidence: We spoke with three of the care staff about their work at Honeybourne House. Comments included Working here is a pleasure, Its brilliant, you can build relationships with individuals and their families and I feel fulfilled at the end of each day. There are really high standards of care. Staff told us that they had received good training, and there are clear work objectives. They also told us that if there is a slip up, you can say. Staff said that there was very good communication within the teams and with the management of the home. We asked the staff if there were sufficient people on duty, and they confirmed that there were. We observed from the level of activities, and from the standard of care that there are sufficient people on duty in the home. Care Homes for Adults (18-65 years) Page 20 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Honeybourne House benefit from a very well managed home. The Manager and the management team are well organised, competent and focused on needs, wants and aspirations of the people who live in the house. Evidence: As part of this visit we spent time talking with the Manager, the deputy and other senior staff in the home. It was apparent that this was a very competent management team. Individuals were well organised, when we asked for particular records or about particular issues, information was readily available. We saw on the notice board the results of the most recent quality assurance survey, relating to May 09. The surveys showed that people who came into contact with the service were very satisfied with the standards. We also looked at visits made by representatives of the company that runs Honeybourne House. The reports of these visits were also very thorough, demonstrating a commitment to quality. The home was in good repair, and there were risk assessments relating to many Care Homes for Adults (18-65 years) Page 21 of 25 Evidence: aspects of safety in the home including a fire risk assessment. We discussed with the Manager that some of the guidance by doors on what to do in the case of a fire did not reflect the actions staff were expected to take. We also discussed issues relating to fire drills at night, and suggested that the guidance of the Fire Officer be sought. In looking around the home we checked the temperature of water in baths and showers, to see if it could pose a risk of scalding. The water in all of the taps checked was of an appropriate temperature. We discussed with the Manager the need to not only ensure that water can not pose a risk of scalding, but that are safe working systems to ensure that water is not contaminated with Legionella. Information about how to complete a Risk Assessment is available from the Health and Safety Executive. Care Homes for Adults (18-65 years) Page 22 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 23 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 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 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. 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