Care Home: Hunter`s Lodge

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What the care home does well This is an exceptionally well-managed home with a strong ethos which places emphasis on respecting each person`s individuality and building and maintaining relationships with people. This ethos is in part embedded by the excellent dementia care training that all staff members (care, domestic and maintenance) receive from one of the registered managers, who has gained the Alzheimer`s Society Training for Trainers Award. Staff have a keen sense of individual responsibility and are given support and opportunities to develop their leadership skills by taking on responsibility for particular areas of practice, such as promoting activities or ensuring good standards of infection control. People living in the home and those which visit (such as relatives and outside professionals) praised the attitudes and skills of the staff team, "The staff are caring, well-trained and helpful." "The staff are very caring and knowledgeable." Thorough initial and ongoing assessment processes ensure that people`s needs can be met successfully. The service also builds good relationships with outside professionals to make sure that people`s health care needs are well met. What has improved since the last inspection? No requirements or recommendations for improvement were made at the previous key inspection. What the care home could do better: No requirements or recommendations for improvement were made at this inspection; the managers of the service are making modifications to the way that controlled medication is stored and recorded to improve practice in this area. Key inspection report Care homes for older people Name: Address: Hunter`s Lodge Church Lane Old Dalby Melton Mowbray Leicestershire LE14 3LB     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: Ruth Wood     Date: 1 6 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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 Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 25 Information about the care home Name of care home: Address: Hunter`s Lodge Church Lane Old Dalby Melton Mowbray Leicestershire LE14 3LB 01664823064 01664822769 office@hunterslodge.org www.hunterslodge.org Hunter`s Lodge Retirement Homes Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Heather Lillian Cowley Type of registration: Number of places registered: care home 36 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 past or present alcohol dependence past or present drug dependence dementia learning disability mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability sensory impairment Additional conditions: No person under 50 years of age falling within categories MD or DE may be admitted into the home. Care Homes for Older People Page 4 of 25 Over 65 36 36 36 36 36 36 24 24 36 36 36 36 36 0 24 24 No person under 55 years of age falling within Categories LD, A, D, PD or SI may be admitted into the Home. Service User Numbers. No person falling within categories PD, PD(E), SI or SI(E) may be admitted to the home when 24 persons in total of these categories/combined categories are already accommodated within the home. Date of last inspection Brief description of the care home Hunters Lodge is a residential care home registered to provide accommodation and care for service users with a wide range of needs who are over the age of 50. The home was built from the conversion of stables in the grounds of a large house, and accommodation is on the ground and lower floors, accessed by stairs with stair lift. There are twenty-two single and seven double bedrooms most having en-suite toilet facilities. There are four lounges and two dining rooms. Some lounges have been designated quiet areas, others are equipped with TV, stereo and video recorder. Access to the home is gained through the conservatory lounge, which also contains a pleasant water feature. The home is located in the quiet village of Old Dalby and is set within its own grounds. There are seating areas in the front garden for service users to enjoy as well as an enclosed garden to the rear of the home. Gardens are attractive and well kept, the rear containing some mature fruit trees. The home has three registered managers, one of whom is currently not actively involved in the running of the home; the remaining two share ongoing day-to-day responsibility. Infromation about current charges at the home can be obtained from the registered manager Care Homes for Older People 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 Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection visit took place on a weekday between 10:30 and 17:00. We examined in detail how the service meets the needs of three people living in the home, two of which had recently come to live there. We examined their support plans, spoke to one person about how their needs were being met and to staff about they supported people living in the home. We spoke to other people living at Hunters Lodge about their experiences and their opinion of the service they receive. We were also able to speak with one persons relative and two visiting health professionals and ask their opinions of the service. We spoke with three staff members about their training experiences and about the particular areas of responsibility they hold within the home. We looked at two recently recruited staff members recruitment records. Care Homes for Older People Page 6 of 25 We also looked at records relating to medication and fire safety and directly and indirectly observed staff working with people living in the home. In addition to the inspection visit this report is informed by the Annual Quality Assurance Assessment (AQAA) which is completed by the provider and informs us how the home has maintained and improved the quality of its service in the preceding year. The AQAA also gives us some statistical information about the home. We also received seven Have Your Say surveys from people living in the home, which told us about their experiences of living at Hunters Lodge. We also received five surveys from professionals who visit the home and four from staff working there. The information from these surveys has also informed this report. Care Homes for Older People Page 7 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 Older People Page 8 of 25 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 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 and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Excellent systems of assessment ensure that peoples needs are consistently well met. Evidence: We looked at the recent admission experiences of two people living in the home. This included direct observation of their care, examining assessment documents, speaking directly to one persons relative and discussion of the process with the registered manager and staff members. Recorded information about each persons needs is very detailed and covers all aspects of their lives. The relative of one of the people described the recorded information about their mother as spot on in terms of detail and said that they had been given the opportunity to look around the home and to discuss their mothers care needs with the manager. The registered manager had made visits to both peoples existing placements and had spoken with existing carers and professionals as part of the assessment process. Care Homes for Older People Page 10 of 25 Evidence: The four professionals who responded to the Commissions survey said that the services assessment arrangements always ensure that accurate information is gathered and that the right service is planned for people. Care Homes for Older People Page 11 of 25 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated with dignity and respect, their health and medication needs are well met and their needs are accurately reflected in comprehensive plans of care. Evidence: We looked at three peoples care plans. All three are comprehensive and contain clear information about how peoples needs should be met and how particular risks should be managed. We spoke with three staff members and their knowledge of peoples needs corresponded with the information given in the care plans. Staff spoken with demonstrated a genuine understanding and empathy for the people they cared for, its about trying to get into their world not bring them into yours. Each staff member signs a contract to care, an undertaking to the people living at Hunters Lodge to work in a way that respects each persons individuality and that puts people ahead of tasks. This ethos is reflected in the atmosphere of the home and the way in which staff understand and try to meet peoples individual needs. Interaction between the people who live and work in the home is constant and is their primary focus rather than getting jobs done. One relative commented, Staffs attitude is very Care Homes for Older People Page 12 of 25 Evidence: positive and they communicate well with people. The seven people who responded to our survey said that they always or usually receive the care and support that they need and that staff are available when they need them. One person commented that staff, take the time to speak to me when I am upset and depressed. The service has developed very good relationships with health care professionals, including the local GP practice, District Nurses and Consultant Psychiatrists to ensure the ongoing health care needs of people living in the home are met. One Psychiatrist visiting on the day of the inspection said that the service supported people well and that they always contacted them if they needed any additional support or input. All five health professionals that responded to our survey said that peoples social and health care needs were properly monitored, reviewed and met by the service. One professional added, Residents with severe mental health problems are managed with care and tact avoiding the need for excessive medication. Each person has access to chiropody, dental and optical services as needed and a physiotherapist visits the home on a weekly basis to run an exercise class and to monitor any additional issues that staff bring to her attention. Staff support people who have to attend routine medical appointments and a staff member also accompanies anyone who needs to be admitted to hospital. District Nurses visit the service regularly to monitor specific health care needs; one person living in the home told us about how the ulcers on their legs had improved since they had come to live at Hunters Lodge. District Nurses also visit the home to provide specific training for staff in such areas as Diabetes and continence management. We spoke to one senior staff member about how medication is stored and administered in the home, focusing on the three people whose care needs we looked at in detail. The staff member had completed a comprehensive distance learning course in the administration of medication before shadowing another staff member and then giving out medication with supervision for three months before being able to administer medication by themselves. The staff member demonstrated a good understanding of the medication that people were taking and what it was for. They said that they had received additional training from one of the GPs in the side effects of the drugs that people were taking. We looked at how controlled drugs were managed. The registered manager advised us Care Homes for Older People Page 13 of 25 Evidence: that a new, larger controlled drugs cabinet was being ordered and showed us a new controlled drugs register, which the service were going to use to record controlled medication, rather than on sheets as they do now. We noted two errors in the recording of controlled medication but other records demonstrated that people had received the correct medication at the appropriate time. Care Homes for Older People Page 14 of 25 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy a good lifestyle, which matches their individual needs and preferences and includes a healthy and varied diet served in pleasant surroundings. Evidence: We spoke to one of the staff members who has responsibility for activities within the home. They showed us that each persons activities are recorded and staff will monitor these records to make sure that people are offered a group or one to one activity regularly. Group activities include things like bingo, quizzes, art and craft work and the regular activity session run by a physiotherapist. One to one activities can include help to read the paper, do the crossword or a staff member just sitting with a person and holding their hand. We observed a craft activity during the afternoon of the inspection visit, where six people were being helped by two staff members to make Easter Bonnets. One person we spoke to said that they also enjoyed the trips out in the minibus to local villages and many people enjoy going out for walks with staff support. People living in the home are also supported to get involved in day to day tasks such as setting tables and preparing vegetables. Care Homes for Older People Page 15 of 25 Evidence: The seven people who responded to our survey said that the home always or usually arranged activities that they could take part in. Written information about arrangements for visiting are in the Residents Guide and relatives are encouraged to visit at any reasonable time and can stay for a meal with their relative at no additional cost. Families and friends are also supported to take their relatives out by the loan of equipment or staff escorting residents to important family occasions. Cooked meals are served three times per day with snacks and drinks available on request throughout the day and night. Two people that we spoke to were very positive about the food, one said The food is too good really, Im putting on a lot of weight - it really is good quality food. I can have my breakfast in my room, anything I like, cooked, cereal, porridge. The menu rotates every eight weeks to ensure a varied selection. A copy of the menu and alternatives available is given to all residents. Staff assist those residents who are unable to read. The menu is discussed at residents meetings to ensure that the food offered is what people want to eat. One person told us that when they have Chili the chef offers some additional sauce for those people who like it a bit hotter! Care plans include a Nutritional Assessment which ensures that any risks are identified and addressed. Liquefied soft food is provided for those with swallowing or chewing difficulties and options are available for anyone with other special needs such as diabetes etc. Supplements are accessed through health services for those that need higher than average daily intakes. Specialist advice is sought as needed. Care Homes for Older People Page 16 of 25 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are well protected by the procedures and practice in place and any concerns are listened and responded to promptly Evidence: One of the managers is a member of the local safeguarding board and the services training manager delivers training to multi-agency staff on behalf of the board. This means that staff members at Hunters Lodge receive up-to-date training in safeguarding vulnerable adults and the three staff members that we spoke with confirmed that they had received this. Staff have also received training giving them an understanding of the main points of the Mental Capacity Act. Each persons care plan contains a discussion of capacity and the kinds of decisions each person is capable of making. The manager is also well informed about the kinds of issues where advice needs to be sought from the external team dealing with Deprivation of Liberty Standards. People living in the home and their relatives are encouraged to bring any concerns to staff members and managers as soon as possible. The majority of people who responded to our survey said that they knew how to make a formal complaint and they all said that there was always someone available that they could speak to informally. One person living in the home said that they felt that they could put forward suggestions and they would have an impact. Care Homes for Older People 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, 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. People live in a safe, clean, comfortable, well-maintained environment, which meets their needs. Evidence: We looked at the main communal areas of the home. These were clean, comfortable and fresh smelling. The seven people who responded to our survey said that the home was always clean and fresh smelling. We spoke to one of the senior staff who holds particular responsibility for infection control in the home. They attend regular multi-agency meetings to keep updated in current policy and practice. They regularly observe staff practice to ensure that correct standards are adhered to. They explained arrangements put in place if any person living in the home has an infection. Care Homes for Older People 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 staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are well supported and protected by very well trained staff who undergo a thorough recruitment procedures. Evidence: The service has exceptionally well-developed systems in place for ensuring that staff are trained to a high standard and have the skills and understanding to perform their role effectively. Staff who responded to our survey recorded a high level of satisfaction with their induction programme, support and ongoing training. One person commented I feel that as a new member of staff I have had a great deal of support from the other staff members. We spoke to three staff members on the day of the inspection and they confirmed that they received regular ongoing training in all statutory areas such as moving and handling, first aid, food hygiene and nutrition and health and safety. This training is delivered by the services training manager who holds training for trainers awards in these areas and also a City and Guilds qualification in training. The staff members spoke very enthusiastically about the dementia care training that they had received and how this had actively informed their practice and helped them to understand how to support and respond to people. This training is delivered by Monica Gardner, one of the registered managers, who has gained the Alzheimers Care Homes for Older People Page 19 of 25 Evidence: Society Training for Trainers Award. All staff members, including domestic and maintenance staff undertake this training, which ensures that everyone working in the home has the same ethos and approach to the people living at Hunters Lodge. The relative we spoke to said, there always seem to be enough staff on duty and this carries over in to how people are viewed by staff and respected. This view of staff was echoed in many of the survey responses we received from people living in the home and professionals who visit the home, the staff are kind and caring. The staff are caring, well-trained and helpful. The staff are very caring and knowledgeable. There are three members of senior staff who are qualified NVQ Assessors, which means that National Vocational Qualifications can be undertaken on an on-going basis. The service told us in their AQAA that 80 of care staff hold an NVQ qualification at level 2 or 3 and that a further two staff have almost completed their Level 2 award. The percentage of staff holding an NVQ 3 is 46 . The service has well-developed recruitment practices and we looked at two recently appointed staff members recruitment records. All staff complete an application form and are formally interviewed before being offered a post in the home. Two references are obtained together with Criminal Records Bureau checks to ensure that people are suitable to work with vulnerable people. The four staff members who responded to our survey confirmed that full recruitment checks had been completed before they started work at Hunters Lodge. Care Homes for Older People Page 20 of 25 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Excellent management actively promotes the health, safety and welfare of people living and working in the home and ensures that the service is run in the best interests of the people living there. Evidence: The service has two active registered managers, Alison Cowley (who is also the responsible individual) and Monica Gardner. Monica Gardner has completed her NVQ level 4 in management and care, together with her Registered Managers Award. Registered Manager Allison Cowley has a NEBSS Management Certificate and extensive experience in care and management. Both managers regularly take part in training and external professional bodies and interest groups, to ensure that their skill base remains up - to- date. Throughout the inspection visit the ethos of the home as a place where individuals are valued and people are placed above tasks was evident. Staff have a well-developed sense of individual responsibility and are encouraged to develop their own leadership Care Homes for Older People Page 21 of 25 Evidence: skills, taking on responsibility for mentoring junior staff and for particular areas of practice such as infection control and promotion of activities in the home. They are well supported by the registered and training managers in these roles and senior staff have access to supervisory management training. A formal Quality Management audit is carried out annually. This includes a satisfaction survey of all residents, relatives and stakeholders. A summary of these results is sent out to all residents and their relatives and is included in the Residents Guide. A copy is also displayed on the notice board in the home. Regular residents meetings are also held and one person living in the home said that they felt they could bring forward suggestions and they would have an impact. Residents monies are not administered by the home. Any charges are initially met by the home and relatives or the residents solicitor are subsequently invoiced. Residents with the capacity to manage their own financial affairs are provided with secure facilities in their bedrooms and are given low level support to enable them to retain independence. The home does not accept valuables for safe-keeping as lockable facilities are provided in each bedroom. A comprehensive fire risk assessment is in place and the services training manager ensures that all staff receive regular training in this area as well as training in other statutory areas such as moving and handling. Care plans include comprehensive assessments of identified risks and instructions to staff about how to minimize those risks. Staff members receive training in food hygiene and a recent visit from the environmental health officer concluded that, overall very good standards of cleanliness were observed. Care Homes for Older People 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 Older People 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 Older People 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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