Care Home: Reevy Road Resource Centre

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What the care home does well The home provides people with a comfortable environment. People said they were happy living at the home, they also told us "I can talk to staff if I am not happy." From our observation people are treated with respect and staff show good awareness of their changing needs. Staff and people have a good relationship with each other without been overly friendly. People are well supported to attend social recreational activities in house and in the community. Families and friends are encouraged to have input in their relatives and friends care if thats` what people want. People`s likes and dislikes in their everyday care and support needs are taken into consideration. Every effort is made to ensure that people`s choice and rights are given all due consideration. What has improved since the last inspection? Since the last key inspection the problem with the hot water supply to one of the units water outlets has been repaired. This means that people can now access bathing and washing facilities in all areas of the home. Staff have had training in first aid and basic life support, to make sure people are not put at risk. The radiator in the medication room has been permanently turned off. A record of the temperature in this room kept, to make sure that the temperature in this room is suitable at all times for the storage of medication. What the care home could do better: Feedback from the quality audit of the service should be available to people who use the service and their relatives and anyone who has taken part in the process. This would ensure that they know the outcome of the audit and they know their views are taken into account. Some consideration should be given to carrying out nutritional risk assessments for each person living in the home, this would ensure that they are not at risk of malnutrition. Key inspection report Care homes for adults (18-65 years) Name: Address: Reevy Road Resource Centre 60 Reevy Road West Buttershaw Bradford BD6 3LH     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: Valerie Francis     Date: 1 5 1 2 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 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 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 27 Information about the care home Name of care home: Address: Reevy Road Resource Centre 60 Reevy Road West Buttershaw Bradford BD6 3LH 01274691035 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Bradford District NHS Trust Name of registered manager (if applicable) Type of registration: Number of places registered: care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home Reevy Road is a Bradford Care Trust unit for people with learning difficulties. There are 24 places available and all of the bedrooms are singles. Bedrooms are located on the ground and first floor. The unit can accommodate people with a variety of differing needs including complex health needs and support independence. The home is not a nursing home, however they are very well supported by the nursing services. A good range of facilities is provided within the premises including a Jacuzzi and sensory area. Previous inspection reports and service information is made available on request. 2 8 0 1 2 0 0 9 24 Over 65 6 Care Homes for Adults (18-65 years) Page 4 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 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: This key inspection was carried out over one day by an inspector who assessed the homes performance against the key National Standard for Adults. The evidence was drawn from a number of sources and included tracking the care of three people who live in the home. This involved looking at their records and outcomes, by observing practice, discussions with the manager and staff. Some people were able to communicate their opinions about the care and support they receive at the home. The home sent us the completed (AQAA) Annual Quality Assurance Assessment, which is a self assessment form telling us what the service does well, how they have improved since the last key inspection and what they could do better. We sent surveys to the home to get the views of people and staff about the home. The current scale of weekly charges at the home ranges from one hundred and eight pounds and eight pence to four hundred and thirty five pounds and sixty eight pence Care Homes for Adults (18-65 years) Page 5 of 27 per person. The fees do not include personal items such as toiletries. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use the service are not being put to significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Adults (18-65 years) Page 6 of 27 What the care home does well: What has improved since the last inspection? What they could do better: 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 7 of 27 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 8 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, 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 who want to use the service and their representatives are given good information about the home, that is sufficient to allow them to decide if the home can meet their care and support needs. People wanting to use the service have a full assessment. Evidence: We looked at the statement of purpose, we found this gives people good information about the home and the service provided. We saw that people have a comprehensive assessment carried out by the Community Team for Learning and Disability ( CTLD). It was obvious from the information seen that people, their relatives and others involved in their care had taken part in the assessment process. The home has improved their assessment process so that it incorporate the Mental Capacity Act 2005 Deprivation of Liberty. This helps them make sure that they consider the capacity and protection of rights and choice of people moving into the home. The home uses Independent Mental Capacity Advocate (IMCA) from the NHS, who Care Homes for Adults (18-65 years) Page 9 of 27 Evidence: support vulnerable people to make decisions. Care Homes for Adults (18-65 years) Page 10 of 27 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. Peoples changing needs are recorded in sufficient detail in their personal care and support plan. This means that people will get the right care to meet their changing needs. Evidence: We were told and saw that each person has an exclusive person centered needs led care plan which includes holistic assessments and subsequent planned intervention from other agencies. Plans of care include all personal, social and health related information. All potential risks are also assessed and measures put in place to minimise any risks identified. We saw that people and their representatives are involved in the care and support plan process. We saw that all individual care plans are evaluated monthly and reviewed at a minimum of once every 12 months. There was evidence of the involvement of the person and their representatives and multi-disciplinary agencies involved in the person care. There are also regular reviews to make sure that people Care Homes for Adults (18-65 years) Page 11 of 27 Evidence: have an identified social worker It was clear that staff have access to comprehensive information about peoples care and support needs and how they should be met. Peoples preferences are documented, for example we saw records confirming that one person prefers not to sleep in their bedroom. Care Homes for Adults (18-65 years) Page 12 of 27 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. The home promotes and encourages the development of social and practical skills. This ensures that people have the opportunity to take part in recreational activities and live as part of the community. Peoples rights and choice are promoted through their daily living. Evidence: We found throughout the visit that staff encouraged people to access activities in the community and in the home. During our visit most people were out at day centres and places of interest. Three people was taken out to shops and in the afternoon one person was taken out by his community worker for a drive out to the local shopping centre. From discussions with the homes management team, it was obvious that they understood the importance of peoples right and choice by involving advocates to ensure peoples right and choice are protected. The home told us in the AQAA that they plan to develop an activity/visitors room where people can have dedicated time Care Homes for Adults (18-65 years) Page 13 of 27 Evidence: with families or time for activities. We were told that meals are discussed with people, for their preferences. From our discussion with the catering staff it was obvious that they knew peoples likes and dislikes. Care staff told us that they were able to assess some peoples preferences from their body language and their reaction to situations, others are given time to talk to staff about their likes and dislikes. Meals are well balanced with an emphasis on a healthy diet for people. We were told that staff work closely with dietitians who support them with anyone who they have a concern about. However, we did not see any nutritional risk assessments carrying out nutritional risk assessment would help ensure that people are not at risk of malnutrition. The home told us that within the next twelve months they plan to complete a pictorial menu to aid choice and decision making. Care Homes for Adults (18-65 years) Page 14 of 27 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. People who live in the home have their health and personal care needs met in a way that takes into account their wishes and respects their rights to privacy and dignity. The homes arrangement for administering medication makes sure that people receive their medication and they are safe. Evidence: We saw that peoples care and support plans identified their individual health and personal care needs. From discussions with the manager and staff it was confirmed that people and or their relatives are involved and consulted about their care. Some people we spoke to knew they had a support plan which told staff how they wanted their care delivered. In the AQAA the home told us that each person has a designated key worker who is responsible for overseeing their planned packages of care. The key workers liaise with a variety of multidisciplinary professionals and regularly make referrals on behalf of people to support their individual need. We were told and we saw that the home had started assessments with the input of Care Homes for Adults (18-65 years) Page 15 of 27 Evidence: advocates and families to ensure that care is delivered in the best interest of the people. We observed staff interaction with people; we found them to be friendly and patient without being overly friendly. Staff were seen to treat people with respect and dignity and were sensitive of their change in needs. In the AQAA, the home told us each person is registered with a local GP and assisted to attend health care appointments including podiatry, dentistry, optical and psychiatry as necessary. The needs of people are reviewed regularly to ensure effective response to changing conditions associated with the ageing process such as dementia screening. We saw that each person has a health plan and a care plan that identifies support needs. Key workers support people to appointments, there is a system in place to ensure peoples health is monitored. We were told by the home that they have a comprehensive network of professionals to support with monitoring health within the directorate. Key workers are currently completing individual health action plans for people and a new matrix has been developed and implemented to identify consistency of care plan reviews. We were told medications are administered by senior staff who have attended training on awareness and safe handling of medication administration. People have regular medication reviews with their individual GPs. We looked at medication arrangements in the home and found that medication administration is carried out and staff had signed to indicate that people get their medication as prescribed. However, we found that one person had excess medication from the previous months, this was brought to the attention of the manager who investigated the matter before this report was written. Medication is regularly monitored by a representaive of the organisation whose role is to carry out a monthly audit of the service. Care Homes for Adults (18-65 years) Page 16 of 27 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. People are encouraged and supported to express their views and concerns. Staff have knowledge of safeguarding adults procedures which helps to protect people. Evidence: In the AQAA the home told us they follow the no secrets policy which all staff have read and signed to indicate their awareness. During our discussion with staff it was evident from their comments that peoples wellbeing is protected. Staff told us they had no concern about whistle blowing on any practice that is not safe or not meeting peoples needs, to make sure people are safe and get the care they need. We were told that all staff have adult protection training to make sure they know what to do if this occurred. We were told and saw that peoples relatives can advocate on their behalf or an advocate would be appointed for them. Since the last key inspection there has been one safeguarding adult referral made to the adult protection unit in Bradford Social Services. An action plan was put in place to resolve the safeguarding issue. The home has a complaints procedure with copies available in the home for people and their visitors. Some consideration should be given to provide people with a procedure in words and pictures, which would help people with staff support to make their complaint. All complaints are dealt with appropriately and promptly. Most are resolved on a local level. The organisation has a robust system to deal with more serious complaints. Care Homes for Adults (18-65 years) Page 17 of 27 Evidence: All staff have pre-employment enhanced CRB (Criminal records Bureau) checks which are renewed when necessary. There are stringent monitoring systems in place to ensure peoples finances are managed efficiently. Care Homes for Adults (18-65 years) Page 18 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, 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. The lay out of the home enables people who use the service to live in a safe, well maintained and comfortable environment. Evidence: The home is near shopping areas and offers people access to local amenities and relevant services. Within the home people have access to several communal sitting areas, which affords them enough space for wheelchairs. People have aids and adaptations available to meet their assessed needs. There is a sensory room which the manager said is being looked at for refurbishment and replacement of equipment. In the AQAA the home told us that the building is maintained to a good standard and that rooms are decorated to reflect personal taste and furnished to meet individual needs. We looked round the building and found that some areas are showing signs of wear and tear and others were in need of redecoration. We saw that most rooms were personalised reflecting the occupants interests. Generally the home is kept clean to a good standard. We did not detect any malodour when walking around the building. We were told that the home has an established team of domestic staff who maintain high standards of cleanliness throughout the home. At the last key and previous inspection an issue with the hot water system to one of the units was identified, this issue has now been resolved, which means that people Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: now have a choice of using bathing facilities in all areas of the home. We were also told the organisation has a Health and safety officer who carries out annual fire and health and safety inspections to ensure that regulatory standards are observed. At the time of our visit the fire safety officer from West Yorkshire Fire Service came to inspect the home. We were told that recommendations had been made to ensure that peoples fire safety was adhered to. We saw records that staff have attended infection control training. We did not observe any breaches of infection control and staff were adhering to guidelines and safe practices. Care Homes for Adults (18-65 years) Page 20 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, 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to staff that are trained and flexible to make sure people have the care and support they need to live the life they want. The recruitment procedure is robust to make sure staff are suitable to work with people who use their service. Evidence: From observation and from comments made by staff it was evident that staff provide people with care that meets their needs. At the time of the inspection there were six care staff and the manager on duty. We were told that the dependency levels of people and the layout of the building have been reassessed and a request had been made for the staffing levels to be increased. This will help meet the change in needs of the people living in the home. It was clear that staff knew people living at the home very well, they were able to tell us about the individual needs of people and how they were being met. There was an awareness of equality and diversity issues including peoples specialist communication needs. Staff and the people living in the home appeared to relate well to each other and there was a relaxed atmosphere in the home. From discussion with staff and from the information seen it was clear that staff training is taken seriously to make sure staff have the relevant training and knowledge Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: to meet the needs of the people in their care. We looked at three staff files. One was recently employed at the home. We found that all the required checks had been carried out, application forms completed, references taken up and all staff interviewed. This ensures that they were suitable to work with vulnerable people. Care Homes for Adults (18-65 years) Page 22 of 27 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 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 well run and the people living there are given the opportunity to be involved in all decisions made. Evidence: The manager has been in post for sometime and has not yet registered with the Care Quality Commission. She is a qualified nurse with many years experience working with people with a learning disability and managing staff. The manager was on duty part of the time the visit was made. Staff told us that she was approachable; available to them and people who live in the home when needed. Staff felt that the home was well managed. In the AQAA we were told the manager has an open atmosphere to enable people who live in the home, staff, relatives and others to raise issues and ensure inclusion. It was apparent from discussion with the manager that she was able to carry out her management duties and work closely with the team so that she was aware of the standard of care and support people was getting. Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: The home is well supported by staff from the NHS who visit to check on the service at the home. Records of these visits are kept in the home. We were told that the manager is supported by a senior manager in all matters concerning the service. Regular weekly meetings take place across residential services to ensure best practice and quality assurance systems are in place. The home told us the organisation has very stringent Health and Safety procedures which all staff are expected to follow. We saw that there are a range of health and safety policies and procedures in place. There are provisions in place to make sure that there are safe working practices, by providing staff with training, such as First aid, food hygiene, infection control and safe manual handling techniques. In the AQAA we were told records in the building are kept securely in accordance with the Data Protection Act. The manager complies with all legislative and statutory guidance to ensure that the service delivery meets the required standards. People and their relatives have the opportunity to make comment of the service at the home, through the annual quality audit questionnaires. However, there is no system in place for feedback to people about any recommendations made following the survey. This would help inform people that their views have been acted upon Care Homes for Adults (18-65 years) Page 24 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 Adults (18-65 years) Page 25 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 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 17 Some consideration should be given to carring out a nutritional risk assessment for each person living in the home. This will help staff ensure that people are not at risk of malnutrition. Consideration should be given to providing people with a complaints procedure that they could use with staff support. This will help ensure that everyone can make a complaint if they wish to. Feedback should be given to people of the outcome of surveys to ensure that they know their views have been taken into account. 2 23 3 39 Care Homes for Adults (18-65 years) 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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