Care Home: Penmeneth House

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What the care home does well From inspection of care records it was evident that the pre-admission assessments are carried out. Good arrangements are in place to meet individual`s health needs and medical services are promptly accessed when required. Flexible visiting arrangements are in place. Those that are able have ready access to local facilities. There are social/recreational activities, but more could be done to demonstrate the home`s commitment to this. The environment is homely, clean and comfortable. The communal space is on the ground floor and bedrooms are located on all floors of the house. It was evident that positive and trusting relationships have been established between the staff and people who use the service. Staff were observed to interact with residents in a pleasant and professional manner. What has improved since the last inspection? The administration of medicines is now safer, with medicines clearly labelled and prescrobed to individuals. There is now a shower facility on the first floor for the convenience of the people that live there and the staff. Training for staff is improving, though more can be done. Quality assurance questionnaires have been received, and the registered providers are looking at the options available to publish a summary of the findings. What the care home could do better: Care plans need to be both clear and provide more detail, effectively directing staff as to the actual intervention necessary in order to meet an individuals` care need(s). Care plans should be reviewed with the client, where possible, and dated. A care plan should be in place for each client. Where entries for medicines are hand written on Medicine Administration Records, there should be two initials to show the entry has been checked as correct. Ensure that records better demonstrate the lifestyle of the people that live there and the efforts of the staff in providing a variety of social/recreational opportunities. More can be done to ensure applicants for employment are properly vetted, and to ensure that new staff receive appropriate induction training. The inspector would like to thank people who use the service, staff and the registered manager for their kind assistance and cooperation during this inspection process. Key inspection report Care homes for older people Name: Address: Penmeneth House 16 Penpol Avenue Hayle Cornwall TR27 4NQ     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: Alan Pitts     Date: 0 1 0 6 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 27 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 27 Information about the care home Name of care home: Address: Penmeneth House 16 Penpol Avenue Hayle Cornwall TR27 4NQ 01736752359 F/P01736752359 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Felicity Ann Richards,Mr Philip John Richards care home 14 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 14. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the homew are within the following categories: Old age, not falling within any other category (Code OP) - maximum 14 places Dementia (Code DE) - maximum 10 places Date of last inspection Brief description of the care home Penmeneth is situated in Hayle, West Cornwall. The property provides care and support for up to 14 elderly people. The home offers residential care for up to fourteen elderly people, some of whom could have dementia. Accommodation is provided on two floors, the first floor can be accessed by a stair lift. There are three smoke free lounges, and there is a small-seated area adjacent to one of the corridors. There is a small garden to the front of the home and a courtyard at the back with bench seating. Care Homes for Older People Page 4 of 27 Over 65 0 14 10 0 Brief description of the care home There is limited roadside car parking. Wheelchair accessibility is very limited. The registered providers Mr and Mrs Richards- live nearby, and are in control of the day-today running of the home. A copy of the inspection report is available from the registered providers, and it is suggested a copy is requested from management or obtained via the CSCI website if required. The range of fees at the time of the inspection is #318-#367 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. Care Homes for Older People Page 5 of 27 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 unannounced key inspection took place on 1st June 2009 and lasted for approximately 6.5 hours. The purpose of the inspection was to ensure that People who use the service needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that peoples placements in the home result in good outcomes for them. The inspection included meeting with some of the people currently living at Penmeneth House, staff, and a visitor to the home. On the day of inspection fourteen people were resident in the home. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the registered providers. The overall rating reflects the outcomes for residents, which are good, though that does not mean that improvements could not be made. The registered providers should Care Homes for Older People Page 6 of 27 give prompt attention to the body of the report and the requirements and recommendations made. The registered providers have day-to-day control and involvement in the home, which provides a small, friendly environment and good informal channels of communication. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: Care plans need to be both clear and provide more detail, effectively directing staff as to the actual intervention necessary in order to meet an individuals care need(s). Care plans should be reviewed with the client, where possible, and dated. A care plan should be in place for each client. Where entries for medicines are hand written on Medicine Administration Records, there should be two initials to show the entry has been checked as correct. Ensure that records better demonstrate the lifestyle of the people that live there and the efforts of the staff in providing a variety of social/recreational opportunities. More can be done to ensure applicants for employment are properly vetted, and to ensure that new staff receive appropriate induction training. The inspector would like to thank people who use the service, staff and the registered manager for their kind assistance and cooperation during this inspection process. Care Homes for Older People Page 8 of 27 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 27 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 27 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 and/or their representatives are provided with good information to enable them to make an informed choice of home. Residents have their needs assessed prior to moving into the home. This is so that the home can assure them the prospective resident that they are able to meet their individual care needs. Evidence: We were advised that a copy of the Statement of Purpose and combined Service User Guide (a document that tells a person about the home) is given to prospective residents or their representative. This also includes the Complaints Procedure. The Statement of Purpose and Service User Guide were last reviewed in 2008, though the document was not dated. The registered providers and documentation confirm that contracts and terms and conditions of residence are provided to each resident or their representative. Documentation evidenced an assessment had occurred taking into account prospective Care Homes for Older People Page 11 of 27 Evidence: residents physical, emotional, social and diverse needs. The home also obtain relevant information from other health and social care agencies. The home does not provide intermediate care, though respite care is offered. Care Homes for Older People Page 12 of 27 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 health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Evidence: One of the people case tracked did not have a written care plan. The care plans did note peoples personal routines and preferences and their religious beliefs on admission. The care plans would benefit from further detail so that care staff are informed, guided and directed as to what caring interventions are needed to ensure consistent care to individuals. One file gave confusing guidance to staff in what the current care need was (e.g. the whole person picture said encourage to use stairlift alone, but the risk reduction plan said make sure staff are with them at all times). Old documentation is also kept with the current care plan, rather than archived, and this can alo cause some confusion. Staff knew the individuals well and were able to describe what assistance a person needed. When people who use the service or their representatives are consulted in the care planning or review process this should be recorded so that the home can evidence Care Homes for Older People Page 13 of 27 Evidence: their participation more fully. Risk assessments were present on files and did identify if a certain activity was a low, medium or high risk and what actions/equipment is needed to assist a person for example if they had a fall. The daily records for people who use the service evidenced the care provided that day. People who use the service are registered with local GP practices. Care records show that health care needs are monitored and attention obtained promptly when needed. The registered providers were in touch with other health agencies on the day of the inspection. Staff were seen and heard to interact with residents in a respectful and relaxed manner whilst carrying out their duties. Medication is administered safely and clear records are maintained (though care should be taken to start a fresh line when appropriate, rather than amending an existing entry). Medicines are stored safely. The pharmacist safely disposes of any medicines that are no longer required. The medication policy was not inspected on this occasion. Where entries for medicines are hand written on Medicine Administration Records, there should be two initials to show the entry has been checked as correct. Arrangements for staff to receive training in the safe administration of medicines were made at the time of the inspection. Training in this respect will be provided on 10th July 2009 by an external trainer. It is imperative that this training takes place as a requirement was made at the previous inspection for arrangements to be made for staff to receive this training. A visiting relative had no concerns about the care provided and was complimentary of the staff and the registered providers. Care Homes for Older People Page 14 of 27 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 records do not fully reflect the social/recreational activities available. Visitors are welcomed to the home at anytime. Choice is available to residents. Evidence: Individual files detail peoples social and activity interests. The home does not have a member of staff with specific responsibility for organising activities. The home aims to provide a range of planned activities such as outings and music entertainers, and the registered providers said that more went on than was apparent, but the records do not reflect this. The registered providers have purchased an electronic organ for entertaining the residents. Discussion took place regarding the variety of activities, activity records, and the need to comply with data protection, and also to ensure that the records give more detail (e.g. whether the individual enjoyed the activity (or not), participated (or simply watched). The registered providers and the visitors book show the visiting arrangements to be open and flexible. People can bring in possessions and furniture at admission by agreement with the provider, and this is recorded. Many bedrooms are presonalised with individual belongings and pictures. The rooms are decorated individually. There is a 3-week rolling menu. Each persons preferences and choices are known. Care Homes for Older People Page 15 of 27 Evidence: The menu does not currently show that a choice is available, though the registered providers confirmed that staff are aware of peoples likes and dislikes and an alternative would be made available if it was seen someone was not enjoying their meal. Hot and cold drinks are served between meals. The kitchen was seen to be clean and ordered at the time of the inspection. Meals were served in the dining area at the time of the inspection, and were seen to be well presented and in sufficient amounts. Appropriate assistance was given to those residents needing it. Care Homes for Older People Page 16 of 27 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 have access to a robust, effective complaints procedure. Staff knowledge protects residents from abuse. More can be done to promote best practice and staff training. Evidence: The complaints procedure is appropriate and provided to each resident and/or their representative in the homes Statement of Purpose. The complaints procedure includes relevant contact details. No complaints have been received either by the home or by the Commission. A visiting relative confirmed that they would feel able to complain if they had reason to do so. The registered providers should obtain the latest guidance and local multi-agency safeguarding procedures. The adult safeguarding (protection) policy needs some development. The policy needs to state the correct procedure to follow if there was an allegation of abuse (including contact details for the relevant person/agency and the action to take to ensure the safety of the abused. The matter should not be investigated by the registered persons unless they are delegated to do so. The registered providers have obtained the No Secrets training video, and said that all staff have now seen this. Safeguarding training has been booked for all staff later this month (provided by an external trainer). Residents are protected by the day-to-day involvement of the registered providers. More can be done to ensure residents are protected by the homes recruitment procedures. Care Homes for Older People Page 17 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is accessible, well maintained and safe. A homely, clean and comfortable environment is provided that is maintained to the required standard. Evidence: The building is well maintained (by Mr Richards), clean, pleasantly decorated and homely. There is a small but pleasant garden, which people who live in the home can use. Mr and Mrs Richards ensure the building and decorations are maintained to a high standard. Recently the downstairs bathroom has been redecorated and new floor tiles have been fitted. All communal rooms are homely and comfortable. There are three lounges, and a quiet alcove area in one of the corridors. People who live in the home have their meals in the lounge/dining area at the rear of the home. Bedrooms are pleasantly furnished, well decorated, individualised and comfortable. A stair lift is provided to assist people to go upstairs. There is an assisted bath facility on the ground floor, which is good for those who are frail or have a mobility problem. The upstairs bathroom doubles as an optional sleepin bedroom for staff at night, and a shower facility. Whilst not ideal, this arrangement does provide a first floor bathing facility, and people who live in the home have a choice when and where to bathe. Care Homes for Older People Page 18 of 27 Evidence: Suitable kitchen and laundry facilities are provided, along with suitable protective equipment (e.g. red laundry sacks). Cleaning staff are employed, and the home was clean and hygienic at the time of inspection. Care Homes for Older People Page 19 of 27 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. Staffing levels are sufficient to meet peoples needs safely. Staff are qualified and competent to work with the people who use the service, though there is room for improvement. There is room for improvement with the recruitment and selection policies and practices. Evidence: There are 11 care staff including the registered manager, of which 6 have achieved NVQ Level 2 training (or equivalent) or above. Training is generally provided by an external trainer. Further training in medicine administration and infection control has been arranged in July 2009. The registered providers are aware that continuing improvement is possible and should be encouraged in respect of staff training. Training in the short-term has been arranged to include topics specified in requirements made at the last inspection. There is generally 2 care staff on at all times, with one awake and one sleeping at night. Shift patterns are generally 8am-3pm, 3pm-10pm, and 10pm-8am. Staff were seen to arrive early for their shifts. A sample of the homes recruitment records were inspected, and the sample showed some adherence to a robust recruitment procedure, though the homes application form does not get sufficient information from applicants (e.g. employment history) Care Homes for Older People Page 20 of 27 Evidence: and does not include a Rehabilitation of Offenders disclaimer. The registered providers must write for references and not accept those brought in by the applicant. The registered manager does not keep a record of interview, and the benefits of this were also discussed. The registered providers said they would seek assistance in obtaining a suitable job application form. The two staff files inspected did not have an induction training record in them, and the registered providers confirmed that this had not been completed. The registered providers were not aware of the National Training Organisation induction training available for all new care staff (www.skillsforcare.org.uk), and this was discussed with them. Care Homes for Older People Page 21 of 27 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. Residents benefit from a small, friendly service and the day-to-day involvement of the registered providers, but would be further protected by improvements in management systems at the home. The environment is well maintained and safe. Evidence: The registered providers are Mr and Mrs Richards. They appear to care for the group of people living in the home, and work hard to deliver the service to the resident group. The registered providers recognise that they are more comfortable working directly with the people that live at Penmeneth House than in dealing with records and paperwork, and that they need to give a little more attention to the content of inspection reports in order to avoid future repeated requirements. Overall though the outcome for residents is good, and therefore the rating for this section reflects this. Quality assurances systems have been introduced and we were shown a sample of survey returns. Discussion took place with the registered providers as to summarising the findings (including any action take), and publishing these. Care Homes for Older People Page 22 of 27 Evidence: Measures are in place to promote safe working practices and the equipment and services to the care home are regularly maintained and serviced. Appropriate insurance cover is in place. Some monies are looked after on behalf of people who use the service. Records maintained are kept to a good standard. One of the registered providers continues to act as an agent for one persons financial benefits. The registered providers are aware that such arrangements should be avoided where possible. Other monies of people using the service are either maintained via individual solicitors or peoples relatives via Power of Attorney arrangements. Otherwise people who use the service are responsible for their finances, and fees are paid via bank transfer. The registered persons have a satisfactory health and safety policy. The home has a fire risk assessment. Health and safety risk assessments are satisfactory. There are suitable records regarding the testing of fire equipment. Care Homes for Older People Page 23 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 27 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 29 19 Suitable pre-employment checks must be performed on all staff employed to work in a care home (e.g. a full employment history, properly obtained and addressed references). These measures will ensure people who use the service are protected. 01/07/2009 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 7 Every client should have a care plan. The care plans should be written to provide clear direction as to the care needs and intervention necessary to support the individual. The care plans should be reviewed regularly, and where possible, with the involvement of the client or their representative. Care plans should be dated. Where entries for medicines are hand written on Medicine Administration Records, there should be two initials to show the entry has been checked as correct. 2 9 Care Homes for Older People Page 25 of 27 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 3 12 Ensure that records better demonstrate the lifestyle of the people that live there and the efforts of the staff in providing a variety of social/recreational opportunities. The registered providers should continue with their commitment to providing safeguarding training to all staff, and ensure a consistent approach to allegations of abuse by developing their own safeguarding procedure (clear instruction and contact details for staff) that refers to the locally adopted procedures. The registered providers should ensure new staff receive an induction appropriate to their role (e.g. care staff or cleaner). The registered providers should implement a National Training Organisation compliant induction programme for all new staff. 4 18 5 30 Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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