Care Home: Kimberley Nursing Home

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What the care home does well The people who live there told us `it`s excellent`, `it`s very very nice`, `I`ve blossomed here`, `everything is fine` and `they treat you ever so well`. One person said `I`d recommend Kimberley to anyone`. Comments in surveys about what the service did well included `It is a a very friendly and homely place` and ` a relaxed and friendly atmosphere`. One person said `they keep my relative safe, warm, well cared for, well nourished, clean and tend to their personal needs well`. People we spoke to were generally very positive about the staff who work there and said they were treated with dignity and respect. We saw some good interaction between staff and the people who live there. Care staff spend time with people providing activities and see this as part of their work. The home is kept clean and provides comfortable accommodation. Some bedrooms that have been renovated are very homely in feel and appearance. What has improved since the last inspection? Better pre-admission assessments are being completed to make sure that the home meets peoples needs. These include better information about the person`s life history and social needs. Training continues to improve with a matris now in place to make sure that all care staff receive instruction in key areas such as manual handling, Safeguarding and fire awareness. More activities are being provided for the people who live there. A new user guide has been produced. This gives good information about the service provided. What the care home could do better: Suggestions from people who live there included `I hope to get out more` and `more things to do`. Comments from relatives or friends and other professionals included `more activities`, `more variety of meals` and `more choice at supper time`. One person felt that people could do more in the evenings and not be going to bed so early. We had to make Immediate Requirements about medication administration as we found a number of shortfalls in this important area. We saw that the home had taken action to address these issues on the second day we visited but we will be looking for these improvements to be sustained in the longer term. Practice around wound care needs to be improved. Important checks around Health and Safety must take place regularly to help ensure the welfare of people living there. A manager needs to be registered with the Care Quality Commission. Key inspection report Care homes for older people Name: Address: Kimberley Nursing Home 51-53 The Avenue Surbiton Surrey KT5 8JW     The quality rating for this care home is:   one star adequate 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: Jon Fry     Date: 0 4 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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: Kimberley Nursing Home 51-53 The Avenue Surbiton Surrey KT5 8JW 02083901557 02083904372 kimberleynursinghome@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Partnership of Parkin, Blown and Blown care home 38 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Kimberley Nursing Home is registered to provide nursing care for up to thirty-eight older people. Accommodation is arranged in a mixture of single and shared rooms over three floors. There is a large lounge and dining room and an attractive well-maintained rear garden, which is well used by the residents. All areas of the home are accessible to residents, including those who may have limited mobility, there are both a passenger lift and stairlift in place. The home is situated in a quiet residential road in Surbiton and there is off street parking to the front of the property. Fees are available from the home and vary according to the room and the dependency of the resident. These would be discussed prior to admission. There may be different charges payable for those who are funding their own placements as opposed to those Care Homes for Older People Page 4 of 28 Over 65 38 38 0 0 1 4 0 7 2 0 0 9 Brief description of the care home who are admitted under care management arrangements. 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: one star adequate 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 unannounced inspection took place over two days in March 2010. We spoke to fifteen people who live there, the manager, the matron and two staff members. Completed surveys were received from nine relatives or friends of people who live there and four staff members. Two care professionals also gave us feedback about the service. The home completed an Annual Quality Assurance Assessment (AQAA). This is a self assessment that tells us how the service ensures positive outcomes for the people living there. It also gives us numerical and other data about the service. 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: Suggestions from people who live there included I hope to get out more and more things to do. Comments from relatives or friends and other professionals included more activities, more variety of meals and more choice at supper time. One person felt that people could do more in the evenings and not be going to bed so early. We had to make Immediate Requirements about medication administration as we found a number of shortfalls in this important area. We saw that the home had taken action to address these issues on the second day we visited but we will be looking for these improvements to be sustained in the longer term. Practice around wound care needs to be improved. Important checks around Health and Safety must take place regularly to help ensure the welfare of people living there. A manager needs to be registered with the Care Quality Commission. 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. Good information is provided to people in the guide about the home. assessments are completed before people come to live there. Evidence: The AQAA told us that individuals are offered a tour of our home and where possible viewings of a choice of rooms available. Additionally we have updated our Service User Guide and Statement of Purpose manual. We saw that an updated User Guide was being issued at the time of our inspection. This includes more pictures of the service, a summary of charges and copies of the menus being used. We have recommended that photographs of key people be included within the complaints procedure to make it as user friendly as possible. In surveys, seven people said that they had received enough information about the home before they moved in. One person said no to this question and another Care Homes for Older People Page 10 of 28 Evidence: individual did not respond. We saw that assessments are completed before someone moves into the home. Practice has clearly improved since our July 2009 inspection and we saw that much more detailed information was being obtained about a persons background and previous history. The home should continue to look at making assessments as person centred as possible in order to inform the care plan that is put in place. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems around the administration of medication need sustained improvement. Wound care needs improvement. Care plans could be made more person centred. Evidence: People who live there said its very very good - they pay great attention to detail, they do all they can to help you, its fine and they treat you ever so well. One person said its bitty and another individual said they try. Five put of the nine people who responded in surveys said that they usually received the care and support they needed. Four people said always in answer to this question. We looked at five care plans during our visits to the home. These contained satisfactory information about people but were too generic in many areas. Statements such as offer weekly shower or a bath, choice of food to be offered and offer social activities are not detailed enough. Care staff need to reflect each persons individual preferences within each area of need and state clearly how the care is to be delivered. Care Homes for Older People Page 12 of 28 Evidence: We saw one care plan where the staff member had been much more detailed about what the person could do for themselves and where they needed support. They stated that the person could wash their own face and that they preferred a bath to a shower. This approach needs to be used and built upon for everybody living there. As stated previously, person centred assessments may help to inform much more detailed care planning. Daily notes kept by staff should also be reviewed by the service. We saw that the majority of daily entries were repetitive and captured little or no useful information. Statements such as assisted with all care, seems to be fine and all needed care rendered may not help to inform the care plans or find out the things that are working well for the person concerned. This area could be discussed with care staff to look at the useful information that could be captured in their notes. Wound care needs to be improved as we found instances for two people living there where the plan of care was not being followed or a plan of care had not been put in place promptly enough. We have made a Requirement around this issue. On our first visit to the service, we found shortfalls with the medication administration. Eight instances were found where quantities of medication in boxes did not match the records of administration being kept. An Immediate Requirement was issued to make sure that people living there received their medication as prescribed. We checked on this issue again on the second day of inspection and saw that action had been taken to address the issues found . The Commission will now be looking for sustained improvement in this important area. Care Homes for Older People Page 13 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. Levels of activity and engagement have improved and this positive work should be built upon. Mealtimes could be made more of a highlight of the day. Evidence: The home told us in their AQAA that we have attempted to improve the social and daily activities of our residents by increasing the choices available to them. At present we have an activities organiser that attends two times a week and inbetween we offer a choice of activities to residents that are currently done on a formal and informal basis. Comments from the people who live there included they keep me entertained, I keep myself busy, at times, there are things to do and I do what I like. Other comments included Id like to go the pub - chancell be a fine thing and boring. Feedback from surveys included good entertainment from time to time, interaction with residents is good, more activities needed for residents, entertainment could be a lot better and they need more entertainment to keep people occupied. We saw that care staff spent time with people helping them engage with ball games, Care Homes for Older People Page 14 of 28 Evidence: reading and art and craft. One member of staff acts as an activity co-coordinator and they told us they were trying to develop much more person centred care within the service. We have recommended that these efforts continue and are built upon. More activity resources and things for staff to use to engage with people should be introduced. The lounge and dining area could have more things for people to do and more sessions developed around things that interest the people who live there. The use of televisions within the main lounge should be looked at as these were on but perhaps not being watched by many people at any one time. Comments about the food provided included its fine, the food is excellent, quite nice, really good and ok. One person said institutional whilst another individual said humdrum - not seasoned enough. Feedback from surveys included they need more fresh fruit and veg - less frozen and processed foods. Comments were also received about the lack of choice at supper time and the repetition in what was being provided. The mealtime we observed was generally satisfactory. People were supported individually and in an unhurried manner. We think there are opportunities for this important daily event to be improved for the people living there. The majority of people we spoke to did not know what was for lunch and this information was not clearly displayed within the home. Bibs were used routinely and there were no table cloths provided although the manager told us that new ones had been ordered. One member of staff was seen to chat with the person they were helping but others were silent as they helped individuals. The staff should look at how each mealtime could be made more of a social occasion and creative ideas used to make each one more of a highlight for the people living there. This could include more events linked to food - parties, buffets, themed meals, resident recipes, reminiscence, breakfast clubs, food tasting and international days. Care Homes for Older People Page 15 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. Concerns and complaints are addressed by the service. Care staff receive training to help safeguard people living there. Evidence: A complaints procedure is in place and is included within the user guide which is made available in each bedroom. As stated previously, the guide has recently been updated and we have recommended that the complaints procedure includes pictures of key people in the process. People that we spoke with said that they would speak to their relative or a member of staff if they had any concerns. Comments included no complaints and Id tell the matron. Eight out of the nine people who completed surveys said that they knew how to make a complaint. One Safeguarding issue was being looked into at the time of our inspection and we saw that the home was co-operating fully with the Local Authority to make sure that people were being kept safe. The training records we saw showed that staff receive training in Safeguarding Adults with a session having last been held in February 2010. Induction training covers this important area although we saw that this needs to be updated to Skills for Care specification. Care Homes for Older People Page 16 of 28 Evidence: The AQAA tells us that the home would view any complaints as feedback and a positive process which would help them improve their service.The people we spoke to generally said that they would talk to their relative or the staff if they Care Homes for Older People Page 17 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are continuing to the home environment. People are provided with clean and comfortable accommodation. Evidence: The AQAA stated that we have undertaken an extensive renovation and re-decoration to meet the functional and Health and Safety requirements and to improve the ambiance of the home. Last year we focused on communal areas and this year we have consolidated on the room re-decoration by re-decorating more rooms. The manager told us that a further refurbishment was being planned to continue to bring all areas up to standard. As at the July 2009 inspection visit, we saw that the home provides clean and comfortable accommodation to the people living there. The communal areas are satisfactory but still require some work. The AQAA told us that the home planned to keep updating areas that have been basically renovated such as the lounge. The dining room would also benefit from further re-decoration to make it a nicer place for people to enjoy their meals. The radiator covers and paint work in this area and adjacent hallways also need some work. The bedrooms we looked at on the top floor provide extremely pleasant and homely accommodation for individuals. We saw that these rooms had been personalised with Care Homes for Older People Page 18 of 28 Evidence: peoples own furniture and were kept very clean. The home told us that they planned to continue updating bedrooms throughout the home to this standard. We saw a number of rooms where there were areas of damage to wall or ceiling decoration. The AQAA told us that within twelve months, we aim to have renovated some of our bathrooms fully with baths appropriate to current care standards. We recommend that the home look at the layout of the main lounge and the number of televisions currently provided. There may be scope to have a dedicated area for watching television and other parts of the lounge used for other things. Care Homes for Older People Page 19 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. People who live there have confidence in the staff and feel that there are enough around to meet their needs. Staff training continues to improve. Evidence: Feedback about the staff who work at the home was generally very positive. These comments included theyre pretty good - polite and respectful, they help you, very good to me, they have a lot of empathy and they are very kind and very gentle. Comments in surveys included the staff are all so kind and attentive, the nursing care is very good and the general care is good. Four staff surveys were returned and these individuals were all positive about the training and support provided to them. All four staff members said that they had received an induction and this training covered the initial things they needed to know about their role. We have recommended that the service look at the Skills for Care induction materials to ensure all key standards are being met. A training matrix is in place to make sure that all care staff are attending mandatory courses such as Safeguarding, manual handling, infection control and fire awareness. We saw upcoming training courses advertised for both day and night staff. We have recommended that the home look at developing further training around important Care Homes for Older People Page 20 of 28 Evidence: areas such as person centred care and dementia care. We looked at the recruitment records for two members of staff. These showed that the necessary pre-employment checks are carried out to help protect the people living there. Care Homes for Older People Page 21 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A manager must be registered with the Care Quality Commission for this service. The home would benefit from a prolonged period of stable management. Health and Safety checks require some improvement. Evidence: A matron has been in post since September 2009 but a manager has not yet been registered with the Care Quality Commission. The service would clearly benefit from a prolonged period with stable management in post and this may be particularly important in 2010 with new standards coming into force for nursing homes. The AQAA told us that an annual improvement and audit of achievement is available and resident and family feedback has been recorded. The home needs to make sure that issues we found during this inspection are picked up effectively by its own quality assurance system. Medication and wound care are two key areas that the service needs to get right given its core business. Care Homes for Older People Page 22 of 28 Evidence: The home needs to make sure that important Health and Safety checks take place regularly. We saw that weekly fire point checks had not been completed since December 2009 and we made an Immediate Requirement for these to carried out with full records kept. We saw that hot water outlet checks are being carried out and we have recommended that these focus on weekly checks of bath and shower outlets where there is total body immersion. Care Homes for Older People Page 23 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 24 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 1 38 13 Weekly tests of the fire alarm 08/03/2010 must take place with full records kept. This to ensure the health and welfare of all people living and working within the service. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 17 Full care plans must be put 23/04/2010 in place for any identified wounds. These plans must state the treatment required and documentation kept to evidence that this treatment is being given as planned. To make sure that people are receiving the care that they require. 2 31 8 A manager must be registered with the Care Quality Commission. To ensure that people living there benefit from a well managed service. 30/04/2010 Care Homes for Older People Page 25 of 28 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 1 7 The complaints procedure provided to people could include pictures of key people in the process. Care plans need to be more detailed and state exactly what support is required by the individual. Each plan needs to reflect the person and their preferences for how the care is to be delivered. Daily notes should be looked at make sure that useful information is being captured. Care staff should look at the purpose of daily notes and what information would be helpful in developing the support being provided. 3 12 The home should continue to develop the activities on offer. More resources and things to do should be provided to maximize engagement and occupation. The good work being carried out by care staff should be continued. The positioning and use of the televisions within the lounge area should be reviewed. The use of bibs at mealtimes should be reviewed. Napkins could be used as a more homely alternative. The wearing of blue plastic aprons by staff should also be reviewed. The home should look at how mealtimes could be made more of a social occasion for the people living there. The home should ensure that the supper time menu provides choice for people and is not repetitive. 4 5 12 15 6 15 7 19 Planned renovations should continue. The dining area could be made a more pleasant area for people to take their meals in. Paintwork and radiator covers in the dining areas and hallways would benefit from some repair and re-decoration. 8 19 The layout of the lounge could be reviewed. This is with particular attention to the televisions provided and creating a dedicated for this activity. The home should make sure that their induction training is to Skills for Care specification. Further training courses could be provided around person centred care and dementia care. Weekly hot water checks should focus on bath and shower Page 26 of 28 9 10 11 30 30 38 Care Homes for Older People 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 outlets where there is total body immersion and therefore higher risk to the people living there. 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. 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