Care Home: Mary Chapman Court

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What the care home does well People are looked after by staff who are kind, well motivated and friendly. Staff are very welcoming to all visitors. The service has a good admissions process that ensures people received information when they need it that helps them to make an informed choice about living at the home. Where possible, people are also involved in planning their care and therefore feel in control. The service follows a robust recruitment process that helps to safeguard the people living at the home. All new staff receive a very thorough induction training, which is followed by regular statutory training events. What has improved since the last inspection? There was evidence, obtained throughout this inspection, that the manager and her staff group have achieved improvements in the last year. These improvements include: More domestic staff hours so that the home is kept cleaner. Updated Statement of Purpose and Service User Guide, reflecting the changes that have occurred in management. The appointment of an activities coordinator 4 days per week to provide activities and social stimulation for residents. The implementation of quality audits that seek the views of residents, relatives and health professionals so that improvements can be made to the service. The quality of meals and the whole dining experience has been improved so that people can enjoy varied and wholesome meals in pleasant surroundings. What the care home could do better: Staff need to make sure they are consistent in the way they record medicines that have been prescribed to be taken `as needed`. This will help to make sure there is a clear audit trail. Improvements need to be made to the environment. For example, some of the colours used to decorate corridors and bathrooms are very strong and need to be muted. Some parts of the home also need to be redecorated and new flooring fitted. Repairs also need to be made to the new wet room so that there are sufficient bathing facilities available for residents. The manager needs to keep staffing levels under constant review so that she can be confident sufficient staff are on duty to meet the needs of residents in a timely way. The home does not meet the 50% ratio of NVQ qualified staff as set out in the national minimum standards. In addition, the manager needs to ensure that more staff are trained as first aid as so that a first aider can be employed on every shift. Key inspection report Care homes for older people Name: Address: Mary Chapman Court Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD     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: Geraldine Allen     Date: 0 5 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Mary Chapman Court Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD 01603701188 01603436848 marychapman@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Care Services Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Christine King Type of registration: Number of places registered: care home 34 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Up to thirty-four (34) Older People, not falling into any other category, may be accommodated. Date of last inspection Brief description of the care home Purpose built in 1995, Mary Chapman Court is located in a residential area on the outskirts of Norwich in Thorpe St Andrew. The home can accommodate 34 older people in 28 single (26 with en-suite) and three double rooms (1 with en-suite). The accommodation is on the ground and first floors. The first floor can be accessed by passenger lift. The surrounding lawns and garden areas are well maintained and can be accessed by service users. There is ample parking space at the front and to the rear of the premises. The local GP practices, and other health professionals support the home. Care Homes for Older People Page 4 of 28 Over 65 34 0 2 4 1 0 2 0 0 8 Brief description of the care home The range of fees charged at the time of this inspection were £362 - £525 per week. There were additional charges for items such as hairdressing, newspapers and private chiropody. The manager should be contacted to obtain full details of charges. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: This inspection took place on 5 October 2009 and was unannounced. Before the inspection took place, the manager sent us a completed Annual Quality Assurance Assessment (AQAA). The AQAA provides us with information about the service and what changes have been made during the previous year. It also provides us with statistical data. We also sent surveys to the home for completion by residents and staff, although no completed surveys had been received by the time this report was written. In addition, we reviewed all of the information we have received about this service in the last 12 months. Two inspectors visited the home on the day of inspection. We looked at various records, spoke with residents, visitors, staff and the manager and we also looked at the environment. As a result of this inspection, the quality rating of this home has changed and it is now Care Homes for Older People Page 6 of 28 a two star (good) service. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: Staff need to make sure they are consistent in the way they record medicines that have been prescribed to be taken as needed. This will help to make sure there is a clear audit trail. Improvements need to be made to the environment. For example, some of the colours used to decorate corridors and bathrooms are very strong and need to be muted. Some parts of the home also need to be redecorated and new flooring fitted. Repairs also need to be made to the new wet room so that there are sufficient bathing facilities available for residents. The manager needs to keep staffing levels under constant review so that she can be confident sufficient staff are on duty to meet the needs of residents in a timely way. The home does not meet the 50 ratio of NVQ qualified staff as set out in the national minimum standards. In addition, the manager needs to ensure that more staff are trained as first aid as so that a first aider can be employed on every shift. Care Homes for Older People Page 8 of 28 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 28 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive information that helps them to make an informed decision about living at the home. Residents are given a written contract which sets out the terms and conditions of residence and also the rights and obligations of both the residents and the service. Admission is not made to the home until a full needs assessment has been completed and the service is confident they are able to meet the assessed needs of the individual. This service does not provide intermediate care. Evidence: The service has produced a statement of purpose and service user guide and this is provided to all prospective residents or their representatives. A copy was also seen in Care Homes for Older People Page 11 of 28 Evidence: the entrance hall. People spoken with confirmed they had been given a copy of the service user guide and statement of purpose and this had provided them with information such as the services provided and fees payable. The manager said that as part of the admission process, the contents of these documents were discussed with prospective residents and/or their representatives. We also obtained evidence that people receive a contract which states the terms and conditions of their residence at the home. The contract also sets out the rights and obligations of the resident and the service. We spoke with three people living at the home and they all confirmed there had been an assessment of their needs completed before they moved in. One person said she had felt involved in the process. We looked at the residents files and found comprehensive assessments of their individual needs in place. This service does not provide intermediate care. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a care plan that sets out their health, personal and social care needs and how they should be met. People have access to all health care support as identified in their individual assessments. The service operates a safe medication administration process that is well recorded and up-to-date. People are treated in a dignified way and their care is provided in private. Evidence: We looked at three care plans and also spoke with residents, staff and visitors to the home. We found there had been an improvement in the care planning and recording and the care plans gave good information about the individual, their needs and how they should be met. We also saw evidence that people were involved in the planning of their care. As well as peoples physical and health care needs, the care plans also Care Homes for Older People Page 13 of 28 Evidence: gave some information about the social, emotional and spiritual needs of the individual and how they should be met. Staff spoken with demonstrated a good understanding of the individual needs of the residents. The care plans gave good information about all medical and healthcare visits and the records were up-to-date. On the day of inspection we were able to speak with a visiting healthcare assistants. Opticians were also on the premises, conducting eye tests in one of the lounges. The administration of medicines was observed and the member of staff followed safe procedures. Medicines were stored appropriately and at the right temperature. Records were looked at and were found to be up-to-date. However, we found gaps in the administration records in some instances where medicines are not given on a regular basis but as required. This was discussed with the manager. We observed the interaction between staff and residents throughout the day and this was respectful. Personal-care was given in private to ensure peoples dignity was supported. Care Homes for Older People Page 14 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to take part in activities and enjoy a lifestyle that reflects their individual interests, preferences and abilities. Where necessary, people are supported to maintain contacts with family and friends in the local community. People are supported to make choices and staff respect the choices that are made. People receive a well-balanced diet in pleasant surroundings, that reflects their choices and preferences. Evidence: People told us they were able to go to activities arranged in and outside of the home. The service employs an activities organiser four days per week and people confirmed they could attend events if they wished. Planned activities were seen displayed on the noticeboards throughout the home and those planned for the month of inspection included exercise to music, quiz, bingo, reminiscence sessions, card games and art. People also told us that they could go out when they wished and described going to Church, shopping and visiting relatives. The care plans gave good information about Care Homes for Older People Page 15 of 28 Evidence: the events and activities attended. The manager told us about the efforts that have been made to improve the dining experience for residents. The majority of comments made by people were positive about the choice and quality of meals. We observed lunch in one of the dining rooms and noted that the meal was unhurried. The food was well presented and consisted of home made food with fresh vegetables. The chef spoke with each resident during the morning to establish what they would like to eat. The dining tables were attractively laid and the rooms uncluttered. People needing help received discreet assistance in their own rooms. Care Homes for Older People Page 16 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a complaints procedure that is clearly displayed and made available to residents, their representatives and visitors to the home. People living at the home are protected from abuse by staff who are appropriately trained and who have been recruited following rigourous procedures. Evidence: The service had received eight complaints since the previous inspection and the manager said these had mainly been about either laundry or cleanliness of the home. She said that as a result, she was looking to increase domestic staff hours. The complaints record was looked at and it was noted that a new complaints log has now been developed that records full details of the complaint and the actions that have been taken as a result. The complaints recorded had both been resolved satisfactorily within 28 days. The homes complaints procedure was displayed in the entrance hall and also within the service user guide. In addition a copy of the complaints procedure had been given to residents and their representatives. The staff training record was looked at and showed that all staff have received training about safeguarding vulnerable people and also whistleblowing in the event they had concerns. Staff spoken with were able to demonstrate good understanding of these issues and how to deal with any concerns they might have. Care Homes for Older People Page 17 of 28 Evidence: Staff recruitment records were looked at and these showed that the service operates a robust recruitment process that includes criminal records bureau disclosures. Care Homes for Older People Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some parts of the home are in good decorative order although some areas need to improve. Bedrooms are individualised and reflect personal choices and preferences. The home is clean and no unpleasant odours were detected. Staff need to ensure that fire safety is not compromised. Evidence: A tour of the premises was conducted with the manager and all internal and external areas of the home were seen. The standard of decoration was variable and there was evidence that where redecoration is taking place it is to a good standard. However, overall the decoration could be described as tired, with corridors, especially on the first floor, in need of attention. These corridors have been painted in very intense, bright colours and the colours have also been used in other communal areas. Where hand disinfection dispensers had been placed in the corridors, spillages down the walls has caused discolouration of paintwork. Care Homes for Older People Page 19 of 28 Evidence: There had been improvements made to some of the bathrooms, although the flooring needs to be replaced where there is significant staining. A new wet room, completed in Spetember 2009, was not working properly due to insufficient water pressure and damage to the showerhead. The manager confirmed that repairs had been requested. Some bedrooms were seen and these were individualised and reflected the interests and preferences of the resident. Some had been redecorated to good effect. The home has four sluices and two of these were seen. They were clean and both were in good working order. The laundry room was also seen and contained two industrial washers that had disinfection and sluicing programmes. There was also an industrial sized dryer in use. The home employs a laundry person on a part-time basis and she was spoken with. All laundry was done on site. Unfortunately, the night before inspection there had been high winds that had caused some damage to a gazebo in the garden and this needed to be cleared away. Other items, such as broken furniture, were also stored in the garden awaiting removal and the skip was placed in the front car park ready for the clearance. Most of the ground floor bedrooms open onto the rear garden and have small personal areas that some residents have planted and tend for themselves. During the tour of the ground floor, it was noted that the fire exit was impeded by a domestic trolley and this was immediately brought to the managers attention and the trolley removed. Care needs to be taken that all fire exit routes are kept clear at all times. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The skill mix and staff numbers need to be kept under review to ensure staff are able to meet residents needs effectively. The service does not meet the minimum standard for NVQ qualified staff. The service has a recruitment process that is robust and helps to protect people living at the home from abuse. For the most part, staff receive training that is relevant to their role. Evidence: We looked at the staff rota for the week of inspection. The manager told us that the home employs five care staff in the morning and four in the afternoon. However, these numbers were not acheived on the day of inspection due to the sickness of two care staff and only four care staff were therefore on duty during the morning. One of these carers was the senior, who had responsibility for administering medicines. The service must keep staffing levels under close review to ensure there are sufficient staff available at all times to meet the needs of people living at the home. Three staff files were looked at in detail and these were well laidout, with information easy to retieve. These showed that the service has robust recruitment practices that Care Homes for Older People Page 21 of 28 Evidence: include obtaining criminal records bureau checks and protection of vulnerable adults checks before new staff commence their employment. Each file also contained two written references. A newly appointed member of staff was spoken with and she described her induction training and these records were seen. Staff attend the home to receive some of the induction training before commencing working with the residents. The homes maintenance worker had completed Train the Trainer and was responsible for the induction and some other training. The training was thorough and well documented. A copy of the staff training matrix was provided and discussed with the manager. Staff have good opportunities to attend training that is relevant to residents needs however, there were some significant gaps including NVQ and first aid. The service falls well short of the required NVQ qualified care staff (50 ), with only 3 out of 18 staff with this qualification (16.5 ). In addition, the manager confirmed that only five staff have completed first aid training, meaning that some shifts do not have a first aider present. This is disappointing as in all other training areas, the service achieves good results. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is managed by a person who is competent and qualified to do so. The service seeks the views of people using the service, relatives and professionals and acts on the expressed views. People living at the home are safeguarded from financial abuse by robust financial practices. Staff receive supervision and appraisal but current arrangements need to be fully implemented to ensure this continues on a regular basis. The health, safety and welfare of people living at, working in and visiting the home is protected by good practice. Evidence: The manager had been in post for approximately one year and in that time has Care Homes for Older People Page 23 of 28 Evidence: demonstrated she is qualified, competent and experienced to manager the home and develop the service. A quality audit had been completed by the service in March 2009 and the results were shared with us at the inspection. A high percentage of the respondents were happy with how the staff treated them, how concerns were dealt with and also the quality of food. A small number were less satisfied with the activities available. There was evidence to show that the manager had responded to the comments raised and she had implemented improvements as necessary, for example with activities and odour control. The arrangements for looking after residents personal allowances was looked at and robust procedures were seen. Apart from a cash sum kept at the home for residents to draw on if they wish, all other monies are kept in a bank account. The amounts held were checked against records each week. The manager stated that at the time of inspection all staff had received their annual appraisal. Heads of departments, the manager and her deputy have all received supervision training, although at the time of inspection only the manager and her deputy were carrying out this important function. This was discussed with the manager and she needs to ensure that all senior staff undertake this role if staff are to receive supervision in line with best practice. A range of health and safety records were looked at and discussed with the maintenance worker. Very good records were seen and all were up to date, with remedial action fully recorded where necessary. The manager conducts a monthly audit of all accidents within the home to establish any patterns and ensure remedial actions are taken as appropriate. Care Homes for Older People Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 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 28 18 The service must ensure staff receive training that is appropriate to their role. This will mean that people living at the home will know staff have the skills to meet their needs. 27/01/2010 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 9 Staff should sign the medication records in a consistent way when dealing with medicines prescribed on an as needed basis. This will ensure there is a clear audit trail. Consideration should be given to the decoration, especially on the first floor, to ensure paintwork is kept in good order and redecoration takes place using more appropriate colour schemes. This will improve the appearance of the environment. Staff should be reminded that cleaning trolleys must not be left in places that may impede fire exits. This will ensure that people can safely evacuate the building in case of emergency. 2 19 3 19 Care Homes for Older People Page 26 of 28 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 4 36 All senior staff should undertake their supervisory role in full to ensure that staff receive supervision regularly and in line with best practice. This will ensure that staff are well supported. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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