Care Home: Quinton House

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What the care home does well Service users have their needs assessed before they move into the home to make sure they can be met. Service users are able to attend day placements, which one person said he enjoyed. Service users can choose whether they wish to go out in the evenings and weekends, and one said he liked to go to the local town, and had recently been on holiday. Service users can remain in contact with their families and friends through visits and phone calls. Thy can choose their own routines and are able to do things for themselves that they are able, for example make their own breakfast. One person said, "I wash the pots". Service users do as much of their personal care as they are able, one said, "I have a shave every morning". Service users are able to have their healthcare needs attended to, including routine healthcare checks. One service user had a health action plan he had compiled with a member of staff. There is a complaints procedure in place. This has not been used, and one service user said, "I am happy with everything". The building is suitable for service users, kept in good repair and clean and tidy. A service user said, "The home is nice and staff keep it clean, I don`t do it". What has improved since the last inspection? There have been some improvements made following our last visit, however there is still more work required for some of these and further requirements have been set. What the care home could do better: All care plans and risk assessments must be kept up to date and regularly reviewed and need to include details of people`s future aspirations. The menus seen did not show a lot of variety in the food people have to eat. Staff must be aware that all allegations of abuse must be followed through. There must be staff available to support people at all times, and all staff who work in the home must have completed the recruitment checks to show they are suitable to work with service users in the home. Staff must have the training they require to be able to meet the needs of the service users at the home. There is not a manager in post and there are not suitable arrangements made for managing the home. There are not opportunities for service users to express their views on the home and there are limited opportunities for staff to discuss the running of the home. Key inspection report Care homes for adults (18-65 years) Name: Address: Quinton House 2 The Hill Kirkby In Ashfield Mansfield Nottinghamshire NG17 8JR     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Stephen Benson     Date: 3 0 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 Adults (18-65 years) Page 2 of 29 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 Adults (18-65 years) 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 Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Quinton House 2 The Hill Kirkby In Ashfield Mansfield Nottinghamshire NG17 8JR 01623723321 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Freres Ltd care home 4 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is 4 The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD Date of last inspection Brief description of the care home Quinton House is a service for people who have a learning disability. It provides accomodation in a large house for up to four people, each with their own large room and three have an ensuite bathroom. The building is large with a lounge, dining room and big kitchen. Quinton House is located in Kirkby-in-Ashfield, close to the town centre with its shops and local amenities. There was no manager in post at the time of this inspection, with the manager from Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 4 3 0 0 1 2 0 0 9 Brief description of the care home another home taking responsibility for the day to day running of the service. The responsible individual said the fees for the service are £750 per week. A copy of the last inspection report was displayed in the entrance hall. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people accommodated and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This was our first visit to the home since 1st April 2009. This inspection involved one inspector; it was unannounced and took place in the daytime. Prior to the visit an analysis of the home was undertaken from information gathered over the last year including that from the Annual Quality Assurance Assessment they completed. The main method of inspection used is called case tracking which involves looking at the quality of the care received by people living at the home. We also use evidence Care Homes for Adults (18-65 years) Page 6 of 29 from our observations; we speak with them about their experience of living at the home; we look at records and talk with staff about their understanding of the peoples needs who they support. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. Care Homes for Adults (18-65 years) Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: All care plans and risk assessments must be kept up to date and regularly reviewed and need to include details of peoples future aspirations. The menus seen did not show a lot of variety in the food people have to eat. Staff must be aware that all allegations of abuse must be followed through. There must be staff available to support people at all times, and all staff who work in the home must have completed the recruitment checks to show they are suitable to work with service users in the home. Staff must have the training they require to be able to meet the needs of the service users at the home. There is not a manager in post and there are not suitable arrangements made for managing the home. There are not opportunities for service users to express their views on the home and Care Homes for Adults (18-65 years) Page 8 of 29 there are limited opportunities for staff to discuss the running of the home. 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 Adults (18-65 years) Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 29 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person 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 coming to live at the home will know that the home has already decided they can meet their needs. Evidence: The responsible individual showed the Statement of Purpose that had been updated. There were some further amendments that could also be included discussed. A service user showed a service user guide he had in his bedroom. There have not been any new long term admissions to the home since our last visit, however one person came for a period of respite care and a full pre admission assessment was completed. We were told in the assessment they completed that, We thoroughly assess the needs of the individual prior to admission. this assessment is carried out by a suitable and experienced member of staff. A service user showed a file in his room which had a pre admission assessment in it. Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: A member of staff said she had taken part in the assessment and met the service users before they moved in. There was a letter seen on one service users file that said that all seems to be going well and that the service user is happy in his new home. Care Homes for Adults (18-65 years) Page 12 of 29 Individual needs and choices 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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. 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. Staff are usually aware of how to meet service users needs and help them to make the decisions they are able to and to take responsible risks, although sometimes this information may be out of date. Evidence: We were told in the assessment they completed that, We believe that choice is a fundamental right of any individual at Quinton House and as such at the core of our person centred plans. Service users had care files prepared, which showed what their need are and how these should be met. The files were indexed and easy to follow. One plan was mainly made up of care plans from the service users previous placement, however new plans for this placement are currently being prepared. One care file had been reviewed monthly and updated where this was needed, but another had not. There was a risk assessment for one service user that highlighted some risks. This Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: was due to have been updated in February 2009, but had not been done so. It was noted that the care file for one service user did not contain any evidence of their future goals or aspirations and the section called My future plans was not completed. There was information seen in care files about the Mental Capacity Act. Staff said they felt service users had a free choice about everything, and gave examples of making hot drinks, preparing food and one service user able to go out into the local town on his own. Staff said the service user makes all his own decisions, but will sometimes need advice. There was reference seen in one care file to a service user on occasions not wanting to continue to attend his day placement. Staff said they were liaising with his social worker and the day services officer to look for an alternative. Care Homes for Adults (18-65 years) Page 14 of 29 Lifestyle 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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. 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. Service users have a lifestyle that suits them, but their opportunities to have a varied diet are limited. Evidence: Service users have day placements they attend, including a catering project and working on a small holding. One service user had already left when I arrived and another, who was getting ready to go, told me I go to Full Bloom and when I asked him if he enjoyed going there replied, Yes. Staff said they were looking for alternatives for one service user as he has a long journey each way, and is tired out at the end of the day. One service user is able to go out on his own and can use public transport. Service users tend to spend their evenings in the home and go out at weekends. One service Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: user said, I go into Kirkby. It was recorded in one service users care file that he would like to attend church, however staff said when this is offered to him he does not want to go. It was also recorded that the service user would like to go on holiday and he has been on holiday to Sherwood Pines. Service users remain in contact with their relatives through visits and phone calls. Staff said that service users get themselves up, get their own breakfast and are able to decide their own routines, but in fact they tend to follow the same pattern of what and when they do things, with weekends being more relaxed. One service user said, I wash the pots when asked if he helps around the house. Service users have a lunch when out on their day placements and a lighter meal at tea time. There is a menu book to record the meals served in. This was not always completed, but the entries that were made did not show much variety. Food is collected from another nearby care home, and although staff said the service users can make choices there was no evidence seen to support this. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support 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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to 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. Service users know they will be supported in their personal and healthcare when needed. Evidence: Service users are able to mange their own personal care with minimal intervention from staff. Staff said they sometimes need to remind them about hygiene and assist with shaving and hair washing. One service user said, I have a shave every morning. We were told in the assessment they completed that,where necessary healthcare professionals are involved so we get the best possible advice needed for each individual. There were records seen in the care files of healthcare appointment had with a dentist, doctor and clinical psychologist. Staff said they take service users to well person checks. There was a section for health and well being in the care files. One service user had a Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: health action plan he had compiled with a member of staff. Staff were seen administering one service user with some eye drops and the Medicine Administration Records were completed. One service user requires regular insulin injections. Staff were administering these, but although they had received some training in diabetic awareness, they had not been assessed as to their competency in doing so. Following a discussion with the Responsible Individual he decided that the district nurse service would be asked to take responsibility for this from now on. Care Homes for Adults (18-65 years) Page 18 of 29 Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. 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. Service users would be listened to if they made a complaint and are protected from abuse. Evidence: There is complaints procedure in the home and a pictorial complaints form for people to complete if needed. There have not been any complaints made. We were told in the assessment they completed that, We have not received any complaints since opening and feedback from clients and families has been very positive. Staff were aware of the complaints procedure and a service user said, I am happy with everything. Staff were aware of the Safeguarding Adults procedures and knew how to respond to any allegation made. There was a comment on one care plan about staff being able to determine between false and genuine allegations, that staff thought was not an appropriate comment to be in a care plan. A service user said, Staff treat me nicely. Care Homes for Adults (18-65 years) Page 19 of 29 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. 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. Service users have a comfortable and clean home to live in. Evidence: We were told in the assessment they completed that, We have had some minor problems with being a new home, and given the example fo the boiler breaking down, but addressed these immediately. The responsible individual said the medicine cupboard is to be moved to a more suitable location. Staff said the building is fine and that a leak from a shower was promptly attended to. A service user said, The home is nice and staff keep it clean, I dont do it. There are suitable arrangements in place for dealing with any waste products or soiled laundry. Staff said protective clothing is available when they need it. Care Homes for Adults (18-65 years) Page 20 of 29 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. 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 arrangements made for staffing, and the training of staff, in this home are not done with the needs of the service users being paramount. Evidence: Due to the current occupancy levels the home is staffed by one member of staff when there is one or more service users present. All staff working in the home are employed at another home nearby, which is owned by another company, but has the same directors as the company that owns this home. There is only one member of staff who works full time at this home, with others doing one or two shifts a week. The responsible individual said they were working towards this home having its own staff team. The rota dos not show any managerial hours being worked, and no staff cover in the morning and during the day, although staff said the person who stayed overnight works until 9.00 when service users have gone to their day placements. The responsible individual said that if someone was not going to their day placement Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: for any reason then a member of staff would be found to cover. A service user said, Staff are always here. A sample of staff files were seen, and these were copies of staff files from the other home. The rota showed that one of the directors sometimes did a shift, but there was not a staff file for him at the home. Training and induction for staff is done through the other home. There were copies of staff training certificates in their files but there was not a training plan for this home. There are not any staff meetings held at this home, but staff said issues for this home were discussed in staff meetings at the other home. Care Homes for Adults (18-65 years) Page 22 of 29 Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. 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 home is not being managed in he best interest of the services users living there. Evidence: We were told in the assessment they completed that, We employ the services of a registered manager, RAM (Registered Managers Award) qualified with many years experience. However there is not a manager in post and the manager from the other home previously referred to has been providing management cover, however there was no record of how much managerial cover is provided, and there are considerable management demands on the manager from the other home. Staff were unaware of how much management time was spent in the home. The responsible individual said he was hoping to appoint a manager for this home shortly. There were some questionnaires completed in April but this information has not been used. The Local Authority quality assurance tool The Quality Tree is not in use. The assessment we ask the provider to complete and return to us was returned. The Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: information contained in this was brief and did not give sufficient detail about the service and the views of people living there. The responsible individual said this was because there had been a mix up with the one they had done originally and had to handwrite this one in a hurry to meet the deadline. Staff said there are not separate staff meetings held for this home, but any matters are discussed as part of the staff meeting at the other home. There were no minutes available of any meetings held in the home. We were told in the assessment they completed that equipment in the home has been serviced or tested as recommended by the manufacturer or other regulatory body. Dates provided showed this to be correct. A sample of records for the fire equipment and water temperatures were seen and these were up to date. Care Homes for Adults (18-65 years) Page 24 of 29 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 37 8 The registered provider shall 28/04/2009 appoint an individual to manage the care care. This will ensure that people receive a well managed service. Care Homes for Adults (18-65 years) Page 25 of 29 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 6 15 Ensure peoples future plans and aspirations are included in the care plans This will ensure staff know what the future wishes of service users are. 01/09/2009 2 6 15 Ensure all care plans and risk asessments are reviewed and updated when neccessary Staff will then know what service users current needs are. 01/09/2009 3 17 15 Ensure service users have opportunities to have a varied and wholesome diet. This will enable service users to make choices over the food they eat. 01/08/2009 Care Homes for Adults (18-65 years) Page 26 of 29 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 23 12 Ensure staff are aware it is not their responsibility to determine if an allegation is false or not and they must be reported. This will ensure any allegations are properly investigated, 01/08/2009 5 31 18 Current staffing 01/08/2009 arrangements must be reviewed to ensure there is suitable cover provided at all times. This will ensure service users receive appropriate support as required. 6 33 19 All staff who work in the home must have completed the required recruitment checks. This will ensure service users are supported by people who are suitable to do so 01/08/2009 7 35 17 The training needs of staff who work in this home must be identified taking into account the needs of the service users. This will ensure service users are supported by people who know how to meet their needs. 01/10/2009 Care Homes for Adults (18-65 years) Page 27 of 29 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 8 39 24 There must be effective quality monitoring in place, which provides for consultation with people living in the home as well as their representatives and form the basis of a development plan for the service. service. This will ensure service users are able to put forward views on how the home is run. 01/10/2009 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 1 Include additional information in the Statement of Purpose about services provided in the home. Care Homes for Adults (18-65 years) Page 28 of 29 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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