Care Home: Kingsgate

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What the care home does well Kinsgate is a friendly home where staff work hard to make sure that residents living there are comfortable and well cared for within a homely environment. Prospective residents are provided with good information to read prior to moving in, and are visited by the manager to assess their individual needs. A care plan of their individual care, social and personal needs is written by the senior carer and the key worker and monitored regularly by their key worker and senior carer to ensure that the service can continue to meet their needs. This care plan is the property of the resident and they are included when this process is carried out to include there personal likes, views, goals and social lifestyle they wish to follow while living at the home. Visitors consulted said that they always feel welcomed into the home by the staff and it was clear that the home and staff’s welcoming atmosphere encourages people to visit. People living at the home are offered choices throughout the day especially with their choice of meals, activities and where they wish to spend there time. There were very positive comments received from residents regarding the sociable activities arranged within the home. Any complaints are listened to and acted upon appropriately.KingsgateDS0000027278.V378676.R01.S.docVersion 5.2There is enough staff on duty to meet the needs of the residents currently living at the home. The AQAA (Annual Quality Assurance Assessment) states that the providers have carried out a survey obtaining opinions from residents regarding different aspects of the home and through this survey changed some aspects of food choices. What has improved since the last inspection? There were no requirements issued from the last inspection to follow up. The care plans are well written and follow the activities of daily living format to include resident’s personal tastes, views and how they wish to be occupied. There has been an extension of sociable activities including more outside entertainers being invited to assist residents with gentle exercise, reminiscence discussion group and craft sessions as well as musical entertainment. The proprietors state that they have received a very positive feedback from residents regarding the craft sessions. There have been several areas that have been redecorated and upgraded offering a comfortable homely environment to residents. The providers have invested in improving the training of staff including a high proportion of staff obtaining the recommended vocational qualifications in improving standards of care. What the care home could do better: The care plans could be improved further if they included more detailed information about the past life of residents to help staff gain a better understanding of them as people. The manager has commenced supervision of staff although this needs to become part of an ongoing regime of supervision to help when planning training and the personal development plans for the staff.KingsgateDS0000027278.V378676.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Kingsgate 25 - 27 North Street Sheringham Norfolk NR26 8LW Lead Inspector Mrs Hilda Stephenson Key Unannounced Inspection 7th December 2009 09:00 DS0000027278.V378676.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.2 Page 2 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 Kingsgate DS0000027278.V378676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsgate Address 25 - 27 North Street Sheringham Norfolk NR26 8LW Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01263 823114 01263 821779 enquiries@kingsgateresidentialhome.co.uk David John Taylor Mrs Virginia Taylor Mrs Virginia Taylor Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Kingsgate DS0000027278.V378676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2007 Brief Description of the Service: Kingsgate is a care home providing personal care and accommodation for up to 31 older people. Mr D Taylor and Mrs V Taylor own the care home. The home is located close to the centre of the seaside town of Sheringham, close to shops, pubs and other local amenities. The home consists of a three-storey building with 27 single and 4 double rooms on the ground, first and second floors, serviced by a shaft lift. There are a variety of communal lounges and a large dining hall where other social activities can take place. There is also an enclosed paved garden area with seating. The fees range from £370 to £485 per week. Additional charges are made for hairdressing private chiropody and personal requisites including toiletries. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home took place during the day on 7th December 2009. Both of the proprietors were in attendance during most of the day. During the inspection a tour of the building was undertaken, staff practice was observed, records and files were read and checked, and some residents and visitors were consulted to provide the evidence when compiling this report. The Proprietors returned the AQAA (Annual Quality Assurance Assessment) to CQC after the inspection had been undertaken so the Inspector had written information regarding the service prior to compiling the report. This information was very well detailed and backed up the evidence found during the visit. The home has a 3 star rating showing that people living at Kingsgate receive excellent outcomes. What the service does well: Kinsgate is a friendly home where staff work hard to make sure that residents living there are comfortable and well cared for within a homely environment. Prospective residents are provided with good information to read prior to moving in, and are visited by the manager to assess their individual needs. A care plan of their individual care, social and personal needs is written by the senior carer and the key worker and monitored regularly by their key worker and senior carer to ensure that the service can continue to meet their needs. This care plan is the property of the resident and they are included when this process is carried out to include there personal likes, views, goals and social lifestyle they wish to follow while living at the home. Visitors consulted said that they always feel welcomed into the home by the staff and it was clear that the home and staff’s welcoming atmosphere encourages people to visit. People living at the home are offered choices throughout the day especially with their choice of meals, activities and where they wish to spend there time. There were very positive comments received from residents regarding the sociable activities arranged within the home. Any complaints are listened to and acted upon appropriately. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.2 Page 6 There is enough staff on duty to meet the needs of the residents currently living at the home. The AQAA (Annual Quality Assurance Assessment) states that the providers have carried out a survey obtaining opinions from residents regarding different aspects of the home and through this survey changed some aspects of food choices. What has improved since the last inspection? What they could do better: The care plans could be improved further if they included more detailed information about the past life of residents to help staff gain a better understanding of them as people. The manager has commenced supervision of staff although this needs to become part of an ongoing regime of supervision to help when planning training and the personal development plans for the staff. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.2 Page 7 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. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 given good quality information about the service and are assessed, so the home can meet their care needs before moving into Kinsgate. EVIDENCE: The written records are made available for all prospective residents and their relatives explaining details about the service. These are written in a format for people to be able to understand the facilities the service offers. Each new resident is invited to visit the home prior to admission when the manager goes out to assess their individual care and social needs. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 10 The records of the latest resident who had recently moved into the home was read, these contained detailed information about their care needs and a detailed contract explaining the services provided by the home. Although the past life history details were brief, it was recommended that the key worker obtain these details to help them care for the person as a whole who has a past. The manager confirmed that she visits all prospective residents to discuss how the home and the staff can care for them. The home does not offer intermediate care as such, but does offer short term respite care if a room is available when the same admission procedure is followed. The home has a facility to offer two residents the opportunity to live in a self contained flatlet with assistance from staff when required, and the opportunity to have their meals in the main dining room. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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’s health, care and social needs are being met. EVIDENCE: Two care plans were looked at in significant detail. Both of these residents were spoken to in private. The residents care plans were found to be in very good order following the activities of daily living. These were devised by the manager or senior carer and key worker with input from individual residents. The plans contained clear information pertaining to the residents care needs and how they should be met. They also contained information on their preferences in respect of daily routines, likes, dislikes and activities. The plans had been reviewed on a monthly basis and daily records were being maintained and kept up to date. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 12 Each care plan seen had been signed by the resident. Each resident had a key worker who looked after smaller tasks such as shopping, arranging their laundry, keeping their rooms tidy and generally caring that little extra for them. Evidence of good health care support was seen with regular health professionals visiting the home to offer support and advice. There was also hoists and specialist equipment in place to assist staff with more dependant residents to maintain a good level of care. Staff were observed looking after residents in a way that promoted dignity and respect. The medication procedures were looked at and found to be in good order. The senior on duty is responsible for the administration of medication. The system used is supported by the local pharmacy who provide the medication and administration records. Each resident has their own medication record file with a photograph included and the records were completed as required. There were no gaps within the records showing good practice by the staff. Medication was stored in a trolley, which was secured to the wall and controlled drugs were stored appropriately in a locked unit within another locked cupboard. The controlled drugs register was in order. Evidence of medication training was seen within the staff files, and the senior carer was observed during the lunch time period safely administering the medication to residents. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 supported to make their own choices and live their own lifestyle. EVIDENCE: People that are able are encouraged to remain involved with their daily life activities such as tidying their room and small household chores, although this does not suit everyone. It was observed that some residents were happy to be involved with laying tables for lunch and keeping the lounge tidy. Improvements to the residents past lifestyle, interests, hobbies and family background could be introduced to enable staff to gain a better understanding and aim the activities to become more personalised. There is a weekly actives programme displayed in the dining room and lounge so residents can make there own mind up whether to attend, these are mainly arranged during the quieter afternoon periods, although this varies depending on the activity. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 14 The week during the inspection there was a concert arranged one evening by the Shanty men and with the run up to Christmas the Salvation Army was invited to perform a carol service. Several of the residents spoke about past activities how they take part in exercising, reminiscing, and how the craft sessions have become a large part of the resident’s lives. The manager explained about past outings and how the staff takes residents out shopping or for a trip to the sea front. They also encourage family to continue to take residents out. It was observed that residents are offered a sherry before their lunch time meal and several residents spoke of how they enjoyed the little personal touches such as this. Several visitors were spoken with during the visit with one saying ‘the staff are so friendly here and always ask Nan if she wishes to be included in the things going on during the day’. The majority of residents go to the main dining room for their lunch and tea time meal. The kitchen is next to the dining room. Today’s meal of liver and bacon or sausage casserole with a variety of fresh vegetables was being served, with the option of two desserts. Fruit juice was also offered to residents who wished for a drink with their lunch. The majority of residents spoke highly of the meals served at the home. The chef explained that they cater for a variety of dietary needs. The menu which is rotated over a four week period showed a well balanced variety of meals. Breakfast was flexible and some residents preferred this in their room, and the manager explained that a cooked breakfast was also offered although residents usually took this at weekends. Tea and coffee was offered during the day at regular intervals with a selection of biscuits or home bakes. Supper consisted of a selection of hot or cold dishes; the care staff served this meal to residents. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 are listened to and are protected. EVIDENCE: All residents are given a copy of the complaints procedure explaining that if they have any concerns that these would be dealt with in an unbiased manner. The residents who were spoken to confirm that they felt comfortable talking to the manager if they had any concerns. Any complaints the manager receives are dealt with in a timely and professional manner. One visitor said ‘I have no complaints about this home; the staff are so kind and helpful here’. Evidence was obtained by speaking with staff and reading there staff files showing they had received updated information regarding adult protection through the NVQ training and induction programme. The homes policies were read and signed by staff when they had understood them. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 live in a comfortable and homely environment. EVIDENCE: Kingsgate can accommodate up to thirty three residents. A selection of single and double ensuite bedrooms are available. There are also two assisted living flatlets available with there own separate entrance. A tour of the premises was undertaken and the home is well decorated throughout. Several of the residents own rooms were seen, these contained their own personal possessions and furniture expressing their individual style. The general maintenance of the building is of a high standard with good clear records kept. The general appearance of the communal rooms is that they are Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 17 comfortably furnished with a variety of seating and furniture. There are several communal rooms, some have a television and others are used for quiet reflection or reading. There is a bird cage in one of the lounges and one of the residents spoke about how she enjoys looking after it. There is a large dining room which doubles up for parties and the regular concerts that are organised. This also has a small television and seating area. The provider showed details of the maintenance and decoration plans for the following year. The enclosed garden at the rear of the home contains seating and raised flowerbeds for residents to enjoy during the warmer weather. Both staff and residents can smoke outside. The two flatlets for supported living can be accessed from the rear garden. Both residents living in these two units have a call bell system for them to call staff for assistance just the same as residents living within the main building. Dedicated staff take care of residents laundry. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 cared for by sufficient numbers of well trained staff. EVIDENCE: The home is registered to accommodate thirty three people and there were twenty nine people in residence on the day of inspection. Five care staff were on duty excluding the manager who was supernumerary. There were also adequate numbers of domestic, laundry and kitchen staff on to compliment the numbers. Inspection of the staff rota, observation of the home and discussion with residents and visitors demonstrated that there is enough staff on duty to meet the people’s needs. Inspection of the staff files showed that the manager follows there own recruitment procedure by obtaining two references and the required crb check before staff commence employment. All new staff are required to undertake an induction programme and are supervised by the senior carer before working with residents on there own. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 19 The staff files also showed that staff received appropriate training to help them assist residents, with the majority of the staff team either completed or working towards the accredited NVQ award and the staff team and proprietors should be commended for the high numbers having achieved this. Training for staff was organised at regular times during the year with evidence of infection control, adult protection, moving and handling, first aid and food hygiene taken place. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 place and are supported by a good management structure. EVIDENCE: The manager Mrs Taylor manages the home with support from her deputy manager. Mr Taylor ensures the premises are well maintained and records are kept up to date. Between the two proprietors the home is well managed with safe procedures in place. Staff confirmed that the home is well managed and they attend regular staff meetings. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 21 One said ‘I can ask the manager about anything, she doesn’t mind being disturbed’. Evidence of this was seen by inspecting a random selection of records and maintenance which were clear and up to date as well as minutes from the past staff and residents meetings. The home has improved the quality assurance and a survey and regular monitoring is now being carried out by the providers; this was read during this visit. A second survey to monitor quality care was being issued during December. Feedback is discussed at the residents meetings, when future plans for the outings and activities are also discussed. It was evident through discussion with both residents and staff that they felt ‘included’ in the home. The manager advised at previous visits that residents’ money is not held or managed by the home and information provided during this inspection indicates this has not changed. The manager is currently reviewing the staff’s personal development plans this has reduced the amount of times that supervision has been undertaken during the year, to improve this the manager or deputy manager should aim to supervise staff regularly during the year. Records show that health and safety issues are attended to with regular maintenance of fire equipment and staff training. The accidents and deaths rates at the home showed no abnormalities and are recorded appropriately. Risk assessments for individual residents were seen in care plans, with general assessments following the homes policy and procedures to ensure the safety of the staff too. The appropriate insurance and registration certificate is on display. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP36 Good Practice Recommendations The care plans should contain some past history regarding resident’s family, work and past interests. Improvements for formal supervision of staff should be recorded. Kingsgate DS0000027278.V378676.R01.S.doc Version 5.3 Page 24 Care Quality Commission Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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