Care Home: Knights Court Nursing Home

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What the care home does well The home has all the necessary information to offer to people that might be interested in moving into the home. The home accepts all people irrelevant of their ethic or cultural backgrounds as long as all their needs can be met in the home. The home has experienced staff to carry out the preadmission assessments of the needs of prospective residents to determine if the home would be able to meet the needs of the prospective residents before offering them a place. Feedback about most members of staff was positive. Residents and visitors think that staff are approachable and kind to residents. Feedback from many visitors suggests that they rate the medical care that residents receive as good. They say that residents receive a very good service from the GP and that staff support residents with their healthcare needs appropriately. There is a team of activities coordinators that are responsible for arranging social and leisure activities for residents. There is evidence that the home actively encourages the involvement of residents in the local community as well as encouraging volunteers in supporting the home to improve the life of residents. Residents are able to exercise choice and freedom. A few were observed moving over the units where they were accommodated unhindered and some were also allowed to move to other areas of the home. This was based on the needs of the residents and the risks that they faced rather than on rules. The home is located in a central area and is easily accessible to visitors to the home. It has a large parking area for the use of visitors. Visitors to the home are generally made to feel welcome. What has improved since the last inspection? Although there has not been any recent residents` admission to the home, there is evidence that the home takes the preadmission assessments of the needs of prospective residents seriously, to make sure that only the residents whose needs can be met in the home are accepted. Residents` needs are also assessed after a period of hospitalisation to find out if their needs have changed significantly and whether these needs can still be met in the home. Care plans on the whole address the needs of residents, are kept up to date and are reviewed with residents or their representatives. Feedback during the inspection and our findings suggest that staff follow the care plans that have been drawn up to meet the needs of residents. Care plans and risk assessments have been improved although these could be updated as soon as residents` needs change or just after a resident is readmitted to the home from hospital rather than wait for a few days to do so. Above all, the staffing levels have improved in terms of numbers of staff to the number and dependency of residents. We identified during the last inspection that the staffing levels previously provided might have contributed to dissatisfaction with the standard of service on the part of residents` representatives and funding authorities. However, we have to note that there is a low level of occupancy currently in the home and therefore the ratio of care staff to residents is higher. We discussed this with the home`s management and reassurance was given that future staffing levels will always reflect the number and needs of residents and not according to the arbitrary ratio of one member of staff to five residents. There was evidence that the home has started to address the redecoration and refurbishment of the home according to a plan. We noted that the redecoration of the Avalon unit has started and we were informed that the redecoration of the home will continue until it is fully completed. What the care home could do better: The main area where there has not been significant improvement is the quality of the environment. A visitor said in a questionnaire with regards to the environment that they have been promised so much, yet so little has been delivered. The home had stated in its improvement plan following the last inspection that it planned to complete the redecoration of the home by October 2009. As evident this was not accomplished. The home must now ensure that it complies with its redecoration and refurbishment programme to demonstrate that it is trustworthy and to improve the quality of the environment for people that live in the home. The management of pressure area care is generally good, but staff must be more vigilant to appropriately inspect the skin condition of residents and to appropriately record the findings. Failure to do so might lead to the deterioration of pressure ulcers, to the detriment of residents. The home uses medicines pen devices when these are not recommended for professional use by the Medicines and Healthcare Devices Regulatory Agency because of an increased risk in needle stick injury. According to the NMC, risk assessments for the administration of medicines in an altered state, such as crushing should be agreed with all relevant healthcare professionals, including the pharmacist. During the inspection we noted that this was not the case. A few instances were noted when not all medicines administration records charts were signed as required or a code used when medicines were not administered. This must be addressed to provide an audit trail with regards to the management of medicines. The manager is not yet registered with the commission, despite having been in post since September 08. She must be registered as soon as possible to regularise her current position. Whilst, staff generally receive training to ensure that they are competent for the work that they do, there was some lacking in the training that staff should have received. For example the training matrix shows that there was only one member of staff with an up to date certificate in first aid, and that 29% of staff have received infection control training and 42% of staff have received food hygiene training. Whilst residents` personal money is stored safely in a bank account with records being kept, we noted that the interest that is due on each individual resident`s accounts based on the money present in the accounts have not always been added as required. As a result residents may be loosing out. Key inspection report Care homes for older people Name: Address: Knights Court Nursing Home 107 High Street Edgware Middx HA8 7DB     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Ram Sooriah     Date: 2 2 0 4 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 40 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 40 Information about the care home Name of care home: Address: Knights Court Nursing Home 107 High Street Edgware Middx HA8 7DB 02083813030 02083813040 knightscourt@schealthcare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 80 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 80 The Registered Person may provide the following category of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP (maximum number of places: 40) Dementia - Code DE (maximum number of places: 40) Date of last inspection Brief description of the care home Knights Court Care Centre is a purpose built care home and was opened on the 27th November 1998 by Lifestyle Care Plc. Lifestyle Care Plc became a part of Southern Cross Healthcare on the 26th February 2007. Care Homes for Older People Page 4 of 40 Over 65 0 40 40 0 2 4 0 4 2 0 0 9 Brief description of the care home The home is found off Edgware High street and is easily accessible by buses, the underground and by car. The bus and tube station is about five minutes walk away. The home benefits from a large parking facility for at least ten cars. There are shops, coffee shops, restaurants and other amenities in close proximity of the home. The home consists of a main 3-storey building with a 2-storey wing on each side. It provides accommodation for 80 residents in 4 units. Each unit accommodates 20 residents, is self-contained and has a kitchenette area, lounge/dining areas, bathrooms and toilets. All the rooms are single and are en-suite. Camelot and Avalon units are on the ground floor and accomodate residents with frail elderly care needs requiring nursing. Merlin and Excalibur units are on the 1st floor and accomodate elderly residents with dementia care needs requiring nursing. The 2nd floor contains the laundry, kitchen and staff areas. The home charges 575 to 900 pounds depending on the needs of the residents and the pricing policy of the funding authorities. There were 44 residents in Knights Court at the time of the inspection. Care Homes for Older People Page 5 of 40 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We visited the home on the 20th April at 10:20-18:30 to carry out an unannounced key inspection. We arranged to visit the home again on the 22nd April from 10:1517:00 to continue the inspection. The last key inspection took place in April 2009 when the service was rated as providing adequate outcomes for people using the service. Since the last inspection the home has been subject to an establishment investigation by Harrow Social Services following a number of concerns that were raised by some agencies. Harrow Social Services has suspended placement in the home since September 2009. The home then placed a voluntary embargo on itself and has not admitted privately funded people or people from other boroughs stating that it wanted to address all the concerns raised about the quality of its service before admitting people again. During this inspection we looked at the care records of five residents, the personnel Care Homes for Older People Page 6 of 40 and training files of three members of staff, toured some of the premises and spoke to five visitors to the home, seven residents and more than ten members of staff. We toured part of the premises and looked at a sample of records that the home keeps. The home completed an Annual Quality Assurance Assessment (AQAA) that has been used where possible in writing this report. We also received three satisfaction questionnaires from residents, four from the relatives of residents and three from members of staff. We would like to thank all people who have contributed to the inspection. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? Although there has not been any recent residents admission to the home, there is evidence that the home takes the preadmission assessments of the needs of prospective residents seriously, to make sure that only the residents whose needs can be met in the home are accepted. Residents needs are also assessed after a period of hospitalisation to find out if their needs have changed significantly and whether these needs can still be met in the home. Care plans on the whole address the needs of residents, are kept up to date and are reviewed with residents or their representatives. Feedback during the inspection and our findings suggest that staff follow the care plans that have been drawn up to meet the needs of residents. Care plans and risk assessments have been improved although these could be updated as soon as residents needs change or just after a resident is readmitted to the home from hospital rather than wait for a few days to do so. Above all, the staffing levels have improved in terms of numbers of staff to the number and dependency of residents. We identified during the last inspection that the staffing levels previously provided might have contributed to dissatisfaction with the standard of service on the part of residents representatives and funding authorities. However, Care Homes for Older People Page 8 of 40 we have to note that there is a low level of occupancy currently in the home and therefore the ratio of care staff to residents is higher. We discussed this with the homes management and reassurance was given that future staffing levels will always reflect the number and needs of residents and not according to the arbitrary ratio of one member of staff to five residents. There was evidence that the home has started to address the redecoration and refurbishment of the home according to a plan. We noted that the redecoration of the Avalon unit has started and we were informed that the redecoration of the home will continue until it is fully completed. What they could do better: The main area where there has not been significant improvement is the quality of the environment. A visitor said in a questionnaire with regards to the environment that they have been promised so much, yet so little has been delivered. The home had stated in its improvement plan following the last inspection that it planned to complete the redecoration of the home by October 2009. As evident this was not accomplished. The home must now ensure that it complies with its redecoration and refurbishment programme to demonstrate that it is trustworthy and to improve the quality of the environment for people that live in the home. The management of pressure area care is generally good, but staff must be more vigilant to appropriately inspect the skin condition of residents and to appropriately record the findings. Failure to do so might lead to the deterioration of pressure ulcers, to the detriment of residents. The home uses medicines pen devices when these are not recommended for professional use by the Medicines and Healthcare Devices Regulatory Agency because of an increased risk in needle stick injury. According to the NMC, risk assessments for the administration of medicines in an altered state, such as crushing should be agreed with all relevant healthcare professionals, including the pharmacist. During the inspection we noted that this was not the case. A few instances were noted when not all medicines administration records charts were signed as required or a code used when medicines were not administered. This must be addressed to provide an audit trail with regards to the management of medicines. The manager is not yet registered with the commission, despite having been in post since September 08. She must be registered as soon as possible to regularise her current position. Whilst, staff generally receive training to ensure that they are competent for the work that they do, there was some lacking in the training that staff should have received. For example the training matrix shows that there was only one member of staff with an up to date certificate in first aid, and that 29 of staff have received infection control training and 42 of staff have received food hygiene training. Whilst residents personal money is stored safely in a bank account with records being kept, we noted that the interest that is due on each individual residents accounts based on the money present in the accounts have not always been added as required. Care Homes for Older People Page 9 of 40 As a result residents may be loosing out. 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 10 of 40 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 11 of 40 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. Prospective residents to the home receive the necessary information to understand the service that is provided by the home. The home ensures that residents needs are appropriately assessed before they are admitted to the home. Staff in the home are competent and have the necessary skills to care for the residents. Evidence: The home has always had a statement of purpose (SoP) and a service users guide (SUG). These have been updated now as and when there have been changes within the organisation and the home. We were informed that a recent restructuring within Southern Cross Healthcare brought about some changes with regards to the Responsible Individual and that these changes have now been incorporated in the SUG. The manager says in the AQAA that prospective residents are invited to visit the home Care Homes for Older People Page 12 of 40 Evidence: an to see the home for themselves and for them to have an opportunity to meet the staff and other residents and ask questions. She added that residents can have a choice of rooms and that they are admitted on a trial basis to give them an opportunity to try the home before fully committing themselves to living in the home. A tour of the residents bedrooms showed that each resident has a SUG in their room, albeit some not always up to date. The manager stated that she would ensure that each resident has an up to date SUG in their room. People that gave us feedback said that they were aware of the range of services offered by the home and that they would ask staff or the manager if they were not sure about something. The home has not had an admission since the 30th of September 2009 when Harrow social services stopped placing residents in the home following a number of agencies raising concerns about the quality of the service provided by the home. The home then decided to place a voluntary embargo for all residents until all concerns about the home are allayed. During the last inspection we imposed a requirement on the home because a resident was admitted without a comprehensive assessment of their needs. It seems that the home has learned from that and now ensures that residents are admitted only after a preadmission assessment of their needs have been carried out. During this inspection we were not able to see the preadmission assessments of recently admitted residents to the home, because there has not been any. There was however ample evidence to show that preadmission assessments were carried out either by the manager or by the deputy manager for those residents that were admitted prior to the embargo. We also noted that the home made attempts to complete preadmission assessments of the needs of residents when the latter were ready for discharge back to the home following their admission to hospital, to identify the changing needs or any new needs of the residents. The preadmission assessments of residents in the main also look at diversity and equality issues with regards to the needs of individual residents. As a result the needs of residents with regards to culture, religion, ethnic minorities, sexuality or disability are identified. The home has a team of staff that is on the whole familiar with the needs of the residents that are accommodated in the home. As the home has separate units for people with dementia care needs and general elderly people care needs, residents are allocated to the different units according to their needs and where staff have the Care Homes for Older People Page 13 of 40 Evidence: necessary experience and training to look after residents. Care Homes for Older People Page 14 of 40 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care records of residents appropriately address their needs and were drawn up and reviewed with them or with their representatives. The healthcare needs of residents are generally met in the home but at times staff may lack vigilance in monitoring the skin condition of residents. The personal care needs of residents are met to a good standard and according to their choices. Staff in the home respect the privacy and dignity of residents. The end of life care of residents and the resuscitation status of residents is addressed in the care records and staff seem confident in addressing these issues. The management of medicines in the home is generally carried out to a good standard, although there are still a few issues that need to be addressed for further improvement in this area. Evidence: Each resident has a care plan in place that is in fair condition and that is kept at the nurses station. We inspected the care records of 5 residents to find out about the quality of the care records that the home keeps and whether these reflect the care that residents receive. Care Homes for Older People Page 15 of 40 Evidence: We noted that the needs of residents were on the whole clearly identified. The assessments of the needs of residents were completed after residents were admitted to the home and care plans and risk assessments were drawn up where needs have been identified.There was evidence that residents or their representatives were involved in agreeing the care plans and risk assessments. The care plans were reviewed at least monthly and were updated with the changing needs of residents. Pressure ulcer risk assessments were in place to identify residents who were at risk of developing pressure ulcers to ensure that appropriate tissue viability care plans could be put in place for the prevention of pressure ulcers. The equipment to use and the repositioning regime for the prevention or treatment of pressure ulcers was identified in the care plans of individual residents, but in at least one case this was not kept up to date. A resident had a particular item of equipment (mattress replacement system) identified in their care plans but there was a different item of equipment in place (mattress overlay). This could be significant because a person reading the care plan might get the wrong information and believe that the resident is using the right equipment and getting the right pressure area care, when they might not. We were informed that a resident was re-admitted to the home from hospital with a pressure ulcer. Our inspection of the care records showed that there were no entries about the person returning to the home with a pressure ulcer. In fact the records show that the residents body mapping was done when they returned from hospital and that the resident did not have any pressure ulcer.The pressure ulcer was first recorded five days after the re-admission of the resident to the home by day staff. Care plans and records were then put in place , including a photograph of the pressure ulcer. However, staff should have noted the pressure ulcer earlier and put all the necessary records in place. The records made between the admission of the resident to the home and the point when the ulcer was discovered indicated that the resident skin was intact when there might have been a pressure ulcer and raised questions about whether staff checked the condition of the kin of the resident carefully and thoroughly. The homes tissue tracker system has not worked in this case. The tissue tracker is a system to monitor and keep track on the condition of the skin of residents. The manual handling risk assessments were generally clear about the equipment to use and the manoeuvres required to move residents. In one case we noted that the Care Homes for Older People Page 16 of 40 Evidence: manual handling risk assessment and the care plan were being updated to reflect the fact that a standing hoist could no longer be used with the resident because their needs had changed. These were not updated immediately after the resident returned from hospital. In April 2009 we found that the manual handling risk assessments had not always been completed appropriately and updated with the changing needs of residents. Residents were weighed monthly and those at risk of loosing weight were more closely monitored by the weight tracker system that the home uses. This is a record of the weight of all residents who are at risk of loosing weight which helps to monitor residents weight changes with time. In one case there was a discrepancy of about nine kilograms in the weight of a resident within one month. There was no evidence that staff reweighed the resident to check whether this was an error when weighing the resident. It was indeed an error as the following month the weight of the resident returned back to nearly what it was originally. Residents presented as appropriately dressed and cared for. Male residents were shaved as required and female residents were appropriately groomed. There were records about the personal hygiene of residents and about their baths or showers. we checked the feet and toes of three residents with their permission as in the past there were concerns that the feet and toes of residents were not regularly washed.We found that the feet and toes of residents were clean. During the last inspection concerns were raised about the frequency of the toileting of residents and that the care plans for the management of incontinence were not always being followed. Feedback from residents relatives suggests there has been an improvement in this area but that on a few occasions this has been an issue, depending on the members of staff and the number of staff on duty. The manager said that the management of the home is closely monitoring this area of care to add to the improvement that has been made. Care records showed that residents were referred to the GP and other healthcare professionals as required. Residents were seen by a chiropodist regularly. This service is contracted and paid for by the home and was started after the previous provider for the chiropody service could not continue providing a reliable and consistent service. We noted that there were a number of residents who had special seating equipment because their gait and posture meant that they could not sit in a normal armchair. Those residents who require special seating arrangements were referred to the GP for Care Homes for Older People Page 17 of 40 Evidence: assessment by an occupational therapist, albeit this taking months before an assessment can be arranged. However, this is not within the control of the home. There is a clinical room on each floor. The home kept suction equipment in each clinical room. We noted that these were not prepared and ready for use should these be required in an emergency such as when a resident is choking or has vomited and is at risk of aspiration. The tubing did not also appear clean and there was water in them. This is not conducive to good infection control practices as a moist and warm environment creates the ideal condition for the growth of microorganisms. We looked at the management of medicines on Avalon, Excalibur and Camelot units. Medicines administration records (MAR) sheets were kept as required and medicines were generally entered on the MAR sheets appropriately. The majority of medicines were signed when administered but on a few occasions there were no signatures or codes to describe the reason for not administering the medicines. We counted the amount of a few medicines at random and noted that the amount tallied with what should have been in place. The management of controlled medicines was carried out appropriately and the records were kept as required. The controlled medicines record book should be signed where required instead of initialing it as that is what is requested in the book. There were two instances when medicines were being crushed to give to residents because they could not swallow the medicines. Whilst, the risk assessments have been agreed with residents or their representatives and the GP, we noted that the chemist had not been involved. The Nurses and Midwifery Council recommends that crushing medicines or administration of a medicines in an alternative format should be agreed with a chemist, as far as possible. During the inspection we found that the home used insulin pen injection devices to administer insulin to residents. Pen injection devices are designed for self administration and not for professional use as they increases the risk of needle stick injury. (MHRA, (2005). Medical Device Alert- Pen injection devices and pen needles. MDA-2005-009). The MHRA advises that Healthcare workers should minimise the risk by avoiding the use of a pen injection device when administering medication to patients. All the care records had information about the end of life care of residents and to some extent addressed the wishes and instructions of residents with regards to end of life care. The care records of residents also contain a form about the resuscitation Care Homes for Older People Page 18 of 40 Evidence: status of residents. In most cases these were completed and signed by the GP and the resident or their representatives. The manager confirmed that the representatives that were allowed to sign the form about the resuscitation of residents were only people who have been appointed Lasting Power of Attorney or Deputy of the Court of Protection as they are the only people who can make decisions on behalf of residents about the residents welfare and health matters. Care Homes for Older People Page 19 of 40 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. The home generally provides a range of recreational and leisure activities for residents to take part in, but at times these do not meet the expectations of residents or their representatives. The range of food that is provided is nutritious but may not always be to the liking of some residents Evidence: The assessment of the needs of residents includes an assessment of their social and recreational needs. All care plans that were inspected contained a plan of care to address these needs. Some residents had a Map of Life which consisted of the key events and key people in a persons life. A few had a Personal Preference Plan that included information about residents backgrounds and their social and recreation needs. There is a full time activities coordinator for all the home and a part-time activities coordinator for the Merlin unit. During the inspection we observed residents choosing books from the homes library, some one to one interactions between residents and staff, a church service being conducted and a few residents sitting outside. We also noted that the activities coordinators were making arrangements to celebrate St Care Homes for Older People Page 20 of 40 Evidence: Georges day. They said that they always make arrangements to celebrate the key occasions during the year. We were informed that the home has a gentleman club and a ladies club that are led by volunteers. Two male residents that we spoke to said that they enjoy the gentleman club which gives them an opportunity to meet other men. We were informed that the home has established contact with a local school and that the residents often visit the school and students from the school also visit the home. During the inspection we noted that a few students from a local school on work placements were interacting with residents. Relatives of residents raised concerns that nothing much happens when the full-time activities coordinator is on leave or when she is not in the home. One questionnaire summarised this and said alternative arrangements should have been made for activities to continue in her absence. This quite often happens when she is away. Another relative said that staff sit in the lounges but are busy doing paperwork and do not always engage with residents. Feedback about the activities was mixed. Some people said that they enjoy the range of activities. People particularly liked some activities where there is interaction with residents such as that provided by London mobility which they say light up even the most withdrawn residents. Others said that as the residents become more dependent, some of the activities that are provided are not suitable for the residents and that they require more one to one activities. One person said that the home used to arrange a bingo session that residents enjoyed but that this is rarely arranged as there are not enough people to help residents with bingo. Another person mentioned that the activities listed to take place are at times canceled and that when the activities programme lists residents choice, this means that nothing is planned and nothing will happen for many residents. There is a religious service for the Roman Catholics every two weeks and one for the church of England also every two weeks. A pentecostal service is arranged in the home for those residents with this faith. As mentioned previously the care plans appropriately address the spiritual and religious needs of residents. During the inspection we observed many visitors in the home. We spoke to many of them and some told us that they have a very good relationship with staff and others said that they have a good relationship with some members of staff. They say that on Care Homes for Older People Page 21 of 40 Evidence: the whole they feel welcomed to the home. We noted that some were offered drinks when they came to the home and others were able to make their own drinks that they had with the residents that they came to visit. We observed meals being served on the Avalon and Excalibur units. We noted that residents were encouraged to sit at the dining tables whilst some stayed in their armchairs and were given tables to have their meals on. The dining area and the tables were appropriately prepared to provide a congenial environment for residents to have their meals. For lunch on the first day of the inspection there was cream of celery soup, roast chicken, mixed bean casserole, rice, new potatoes, mashed potatoes, cauliflower and mixed vegetables and chocolate bread and butter pudding. The supper consisted of cream of cauliflower soup, sausage roll or sausages, beans and chips, assorted sandwiches, fruit jelly and ice cream. We noted that the soup was made from powder and the mashed potatoes was also made from powder. Whilst, nutritionally there may not be a difference between soup and mashed potatoes that are made in house as compared to food that is made from powdered ingredients, there is normally a difference in texture and taste. We would always recommend that food is prepared from fresh ingredients. A few visitors mentioned that a number of meals that are listed on the menu are not to the taste of residents. They say that whilst the food represents the diverse culture of people in the home, there are many residents who prefer plain English food. There were minutes of a meeting of residents and their relatives with the chef and activities coordinator, which was arranged to look at the meals and the activities provided in the home. It is hoped that this kind of meeting will help resolve the situation and that if the suggestions are taken on board eventually a menu and a programme of activities will be produced with which people will be broadly satisfied. Those residents who needed assistance were supported by staff with their meals. Visitors said that the fact that there were less residents in the home meant that members of staff had more time to spend with residents to feed them. Residents were offered nutritional supplements if it has been identified that they were at risk of loosing weight. One of the concerns raised about the home in the past, was that at times the home over-relied on supplements instead of encouraging people to eat their main meals and offering the supplements after the meals, as a supplement. Care Homes for Older People Page 22 of 40 Evidence: We observed a few mealtimes and can conclude that this was not generally the practice in the home but did observe one occasion when staff encouraged a resident with a supplement just before lunch. We were informed that the supplement had been given in the morning and that the resident was finishing the supplement. The kitchen was clean and tidy and we were informed that the kitchen scored 4 stars during the latest visit from the Environmental Health Officer. We looked at a sample of records which showed that these were maintained as required. A few visitors mentioned that at times there are no crockery in the kitchenettes to make a cup of tea for themselves or for residents. Care Homes for Older People Page 23 of 40 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. Residents or their representatives are on the whole aware of the complaints procedure and use it when required. Allegations and suspicions of abuse are dealt with appropriately to ensure the safety of people that use the service. Evidence: The homes complaints procedure is available in the foyer of the home and in the SUG. We looked at the complaints register that is kept by the home. There have been 9 complaints and 2 of these were also referred to the local borough as safeguarding alerts. The complaints were on the whole appropriately investigated and responded to. In one case however, no records were kept about the outcome of the investigation and the response that was made to the complainant. Feedback from residents and their relatives in questionnaires suggests that they are aware of the complaints procedure and the person to complain to. Two persons however said that that do not always get feedback or a response from the manager when they have raised issues with her. Whilst, formal complaints are on the whole dealt with appropriately by the home, the persons who talked to us might have been referring to informal complaints. It is therefore for the person who receive the concerns from people to confirm whether the issues that are raised are formal or informal complaints and the outcome that they seek. Care Homes for Older People Page 24 of 40 Evidence: The home takes allegations and suspicions of abuse seriously and ensures that staff are informed about the action they should take if they witness abuse. The training records show that most staff were up to date with training in Safeguarding Adults. Staff members that we spoke with also confirmed that they have had this training. In the past staff members have come forward when they have witnessed abuse Care Homes for Older People Page 25 of 40 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. At the time of the inspection the home was not in good decorative order. There was however a plan to improve the quality of the environment for the benefit of residents. Evidence: During the inspection the grounds of the home did not look very attractive. Bushes, shrubs and flowerbeds were not well maintained. The fence looked in a state of disrepair and a wooden door giving access to the side of the home was broken. The pathways round the home and into the garden is pebbly and visitors say that they cannot push residents in wheelchairs up these pathways if they want to go for a little walk in the grounds of the home. The deteriorating state of the grounds of the home was noted during the last inspection as well as the fact that the home needed redecorating, particularly the corridors and communal areas. The bedrooms were generally in good decorative order because they were mostly decorated by the homes maintenance staff. Despite an improvement plan by the home to address previous requirements, that stated that the home would be redecorated by October 2009, nothing was done until March 2010 when the decorators started work in the home. During this inspection we noted that the lounge in the Merlin and the Avalon units Care Homes for Older People Page 26 of 40 Evidence: looked in a poor state. The wall paper in the Merlin unit had come off in places and there were stains on the wall in the Avalon unit where there was a leak. We understand that the leak had been repaired and we were informed that the lounge would be decorated in the near future. Visitors were not pleased about the state of decoration of the home. Most visitors who spoke to us told us that the redecoration of the home had started because the home knew that there was going to be an inspection. They said that nothing much happened all this time and that things started moving just before the inspection. We observed that the home was in the process of being decorated at the time of he inspection. The corridors in the Avalon unit were being decorated and we were informed that the decorators would next start decorating the lounge in the Avalon unit and then they would move to the other units. We also observed that some of the furniture in the lounges was looking past their useful life. The relatives of residents stated that some small tables for the use by individual residents in the lounges were unstable and could be a risk to people. The material of a few arm chairs and of at least one settee was slightly torn. One visitor said that they brought tape to put on the areas where the material of an arm chair was torn. Residents in the lounges of some units had to content with televisions with small screens. Many visitors said that the television on the Avalon unit was too small for the size of the lounge. The manager said that the home would provide bigger flat screen televisions, when the lounges are decorated. Whilst, it would be nice for the lounges to be decorated, this should not be a reason to delay the provision of the televisions if residents could immediately start benefiting from the new televisions, particularly when these have been promised some time ago. The decorators could easily paint the wall around the brackets for the televisions. As the home had already provided an action plan in the past to say that the home would be decorated by October 2009 with which it has not complied, we wanted to see detailed evidence that the home would indeed comply with its plan to redecorate and refurbish the home. A redecoration and refurbishment plan was seen with timescales and there was evidence that purchase order forms for the work that would need completion, have been agreed with line management. We were informed that the redecoration plan also addresses the landscaping of the garden area to improve the outside facilities for residents. Whilst, things seem to be happening at a faster pace Care Homes for Older People Page 27 of 40 Evidence: than previously, the redecoration and refurbishment plan must be complied with within the timescales that the home has given as, a reassurance that the home takes the redecoration of the home seriously. The bedrooms of residents were on the whole in good condition and there was some evidence that many have been personalised to provide a homely environment for residents. In some instances the relatives of residents brought duvet covers, bed covers, pillows, pictures, photographs and items of decoration to make the bedrooms of residents homely. Some also brought small items of the residents furniture. In cases where residents did not have relatives there was evidence that staff have tried to personalise some of the bedrooms but there was still a few bedrooms that looked bare. It is unfortunate that the issue of the personalisation of residents bedrooms has not yet been fully addressed despite the home running at nearly half its capacity. Most visitors that we spoke to and three out of the four feedbacks from residents relatives questionnaires informed us that they remain dissatisfied with the standard of laundry. They say that clothes get lost, are washed together with other type of linen and of different colours, which run and that at times clothes are damaged by the washing or loose their original colours. The manager said that she was aware of this issue and has been addressing it. While touring the premises we made random checks and noted that clothes were appropriately stored in residents wardrobes and drawers. Clothes in the wardrobe of residents were on the whole ironed. The home was generally clean but a few areas could have been cleaner such as picture frames, the top of cupboards and the bed frames which were dusty. There was an odour on the Camelot unit on the first day of the inspection but a regime of rigorous cleaning and shampooing led to the odour disappearing on the second day of the inspection. Some visitors raised concerns about the standard of cleaning and said that this has improved as the inspection was imminent. A few visitors pointed out that a ceiling fan on the Avalon unit does not get cleaned regularly. We indeed noted that the fan could have been cleaned more regularly as it was dusty. The clinical/medicines rooms were untidy with nutritional supplements and other things being stored on the floor rather than on shelves. Shelves were broken and the room needed redecorating and tidying. Care Homes for Older People Page 28 of 40 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. At the time of the inspection the home provided staffing levels that was suitable to meet the needs of residents. The recruitment procedure is complied with to ensure that only suitable people are chosen to work with the residents. The home provides training to staff to ensure that they are skilled and competent to care for residents, but there are a few areas where not all nursing and care staff have received training. Evidence: At the time of the inspection the home had only 44 residents out of a maximum of 80. The unit with the most residents was Merlin with 16 residents and the unit with the least number of residents was Excalibur with 7 residents. The staffing for Merlin during the day consisted of 1 trained nurse and 4 carers, for Camelot (9 residents) there was 1 trained nurse and 2 carers, for Excalibur there was 1 trained nurse and 2 carers and for Avalon(12 residents) there was 1 trained nurse and 3 carers. At night there was 1 nurse and 1 carer for the Excalibur and the Merlin units each. The Avalon and Camelot unit shared 1 trained nurse and two carers at night. The above numbers seems adequate for the number of residents in the home at the time of the inspection. The homes management provided reassurance that the staffing levels will also change in relation to the number of residents in the home. Care Homes for Older People Page 29 of 40 Evidence: During the last inspection we concluded that the quality of the service provided in the home could have been a direct result of the low numbers and competency of staff provided which resulted among other things in residents not being toileted as appropriate, low level of interaction of staff with residents and the quality of the care records lacking because staff did not have time to fully complete these. All the relatives questionnaires mentioned the fact that at times there are no members of staff in the lounges to supervise residents and that the home does not replace staff when there is shortage such as when staff are sick or unable to come to work. Staff questionnaires also stated that members of staff get tired as at times they have additional work to do when one of their colleagues is sick or has not come to work. Many members of staff have been with the home for some time and are familiar with the needs of the residents that are accommodated in the home. Residents and visitors feedback was positive about most members of staff. One relative said that most members of staff are friendly and welcoming. There are members of staff, albeit a minority, that the relatives of residents feel do not meet their expectations in terms of their standard for caring and interacting with residents. The personnel and training files of three members of staff recently appointed by the home were chosen for inspection. All three applicants had two references, evidence that a CRB check had been conducted, proof of identity and eligibility to work in the UK. All applicants had a work history but there were no records to show that a small gap in the work history of one applicant had been sufficiently explored at the time of the interview. The training files that we saw showed that induction was provided to the employees. New members of staff also confirmed that they receive induction. We however noted that a trained nurse had not been clearly shown the first aid equipment in use in the home and the checks that need to be conducted from time to time to ensure that all first aid equipment is primed and ready to use in an emergency. A training matrix was kindly provided to us. We noted that most members of staff were up to date with mandatory training. The training matrix also showed that 29 of staff were up to date with infection control training, and 42 were up to date with food hygiene training. Whilst a significant number of staff working on the dementia units have had training in dementia awareness and challenging behaviour only five (6 ) members of staff have had additional training in dementia. In 2007 training was arranged in the Alzheimers Societys training programme Yesterday, Today, Tomorrow. Ideally, this number should be nearer to 50 , since half of the home is Care Homes for Older People Page 30 of 40 Evidence: dedicated to caring for people with dementia care needs. We noted from the training matrix that the home has only one person who has been trained in first aid within the past three years (2008), therefore with a valid first aid certificate. Although no requirement was imposed in the April 2009 inspection report with regards to first aid training, this was mentioned. The home should have been proactive in arranging first aid training for its staff. According to the AQAA the home has about 39 carers and out of this number, 18 have an NVQ qualification in care and 14 are in the process of acquiring this qualification. The percentage of people with an NVQ qualification should significantly increase once staff who are on the programme complete their course. Care Homes for Older People Page 31 of 40 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an appropriate management structure in place to ensure that it is run appropriately. The home has a quality assurance system that is used to monitor the quality of the service. Records about the personal money of residents are kept as appropriate but the homes procedure has not always been complied with as interest payments on the balance of money that residents have, have not always been added to their accounts. Health and safety issues and the maintenance of equipment are addressed to ensure the safety of all people that use the premises. Evidence: The current manager has been in post since September 2008. She is a registered nurse and has over twenty years experience in managing care homes. She is supported by the deputy manager and the Southern Cross area manager. The manager of the home is not yet registered. Care Homes for Older People Page 32 of 40 Evidence: Southern Cross Healthcare has recently undergone a restructuring, that included changing the management structure in place within the organisation. Whilst, this did not affect the management structure in the home, we were informed that the restructuring has been brought forward to streamline management processes, reduce the time for decision taking, increase efficiency and decrease bureaucracy. We noted that there has been significant input from Southern Cross into the home to improve the quality of the service, following the home being rated as providing adequate outcomes for people living in the home during the last inspection and it being under close scrutiny by the authorities that have commissioned a service from the home. There were therefore visits by staff from Southern Cross quality assurance team to monitor the quality of the service that the home provides and to carry out audits. Visitors told us that they have met staff from the quality team and were impressed by them. They said that the home should have had the quality inspectors from Southern Cross previously and said that they hope that the Southern Cross inspectors would come to the home regularly to look at the quality of the service. Visitors said that the inspectors identified issues about cleanliness, staffs interaction with residents and the general care of residents including the toileting of residents. Residents representatives were concerned that efforts have been put in the home to improve it just before the inspection and that once it is re-rated then the input from Southern Cross would stop and the home would revert to what it was previously. They were also worried that the promises made to improve the environment of the home would not be fulfilled. There was evidence that the area manager was closely monitoring the action plan that had been drawn up by the home to address areas where improvement was required. We were informed that decisions about the home are now taken quicker as the management structure has been streamlined. To prove that we were shown plans that have been signed off with regards to the redecoration and refurbishment of the home, and capital expenditure forms that have been agreed. There was evidence of regulation 26 monthly visits by Southern Cross senior management team and of audits that were completed. We also noted internal audits of care plans and the management of medicines. We looked at the management of residents personal money by randomly sampling the accounts of two residents. We noted that records were kept about all deposits and Care Homes for Older People Page 33 of 40 Evidence: expenses on behalf of residents. Residents money is kept in a bank account and all residents have a sub-account that bear interest. We however noted that whilst interest has been added monthly to residents accounts, that was stopped in Feb 2009 and no further interest has been added to residents accounts. This must therefore be addressed as soon as possible and the interest on each residents account must be calculated and reimbursed as required to make sure that residents do not loose out. We looked at the health and safety records that are kept by the home. All checks as identified in its health and safety manual were carried out as required. These included weekly fire detector tests, monthly emergency lights test, water temperature checks, bedrooms checks, bed rails checks and wheelchair checks. Copies of safety certificates and of maintenance certificates were also in place. The fire risk assessment and the health and safety risk assessment were up to date. Care Homes for Older People Page 34 of 40 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 19 23 The grounds of the home must be maintained to a good standard. To provide a pleasant environment for residents to enjoy. 13/07/2009 2 20 23 The communal areas of the home must be maintained and decorated to a high standard. Furniture in the communal areas must be in good order. To provide a pleasant environment for residents to enjoy. 17/08/2009 Care Homes for Older People Page 35 of 40 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 1 8 12 All suction equipment must be prepared, clean and ready for use in an emergency. To ensure that all equipment is ready for use when needed in an emergency. 14/06/2010 2 8 12 All examination of residents 12/07/2010 pressure areas and skin integrity must be carried out thoroughly and carefully. To make sure any break in the skin of residents is detected early so that action can be taken as soon as possible to prevent deterioration. 3 9 13 The homes procedure for the management of medicines must be complied with at all times. To ensure the safety of residents. 12/07/2010 Care Homes for Older People Page 36 of 40 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 4 19 23 The home must ensure that it complies with its own redecoration and refurbishment plan within the timescales that it has given. To ensure that the home provides a pleasant, well decorated and maintained facilities for residents 30/07/2010 5 26 13 The clinical rooms must be 30/07/2010 in a good state of decor, tidy and nutritional supplements must be stored appropriately on shelves or in cupboards. To ensure that the clinical rooms are among the cleanest and tidiest places in the home. 6 26 16 The home must be kept clean at all times. To provide a clean environment for residents 14/06/2010 7 30 18 The home must review its 16/07/2010 training programme to address areas where not so many members of staff have had training such as in infection control and food hygiene. More in-depth training for staff that work with residents with dementia care needs must be considered. Care Homes for Older People Page 37 of 40 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 To ensure that the work force is well trained and fully competent to do their job. 8 30 18 The home must have staff 16/07/2010 that have been appropriately trained for them to be responsible for first aid in the home.The induction of all new members of staff, particularly that of trained nurses should include information about the equipment that is available for first aid in the home. To ensure that the home provides appropriate first aid when required. 9 35 17 The interest on the balance of the personal money of residents that is held in the homes residents account must be added to their individual account as required. To ensure that residents are not loosing out from interest payments that they are entitled to. 16/07/2010 Care Homes for Older People Page 38 of 40 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 8 That residents are re-weighed again as soon as possible rather than wait for another month, if their weights show large discrepancies. This is recommended to make sure that the actual weights of residents are correctly recorded. The use of medicines pen devices in the home such as insulin pen devices by nurses should be reviewed as their use could increase the risk of needle stick injury. As far as possible, all risk assessments for the crushing of medicines must be agreed by the chemist. The home should make arrangements to meet the social and recreational needs of residents when the activities coordinators are not in the home. The amount of crockery in the kitchenettes should be reviewed so that there is enough crockery if visitors feel like having tea with the residents that they have come to visit. Feedback should always be provided to people who have raised concerns whether formally or informally. Records should also be kept in regards to this matter. The home should consider replacing the small televisions that are provided in the lounges with bigger televisions as soon as possible to improve the viewing pleasure of residents. The bedrooms of residents should be personalised as far as possible to provide a homely environment for residents. The home should continue to monitor the quality of the laundry service and take action where required to try and improve the satisfaction of residents and of their representatives in this area. The home should always ensure that there is replacement staff whenever there is a shortage of staff such as when staff are sick or when they are unable to come to work. A record should be made when any gaps in the employment history of applicants are explored at the point of interview. 2 8 3 4 9 12 5 15 6 16 7 19 8 9 24 26 10 27 11 29 Care Homes for Older People Page 39 of 40 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. © 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. 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