Care Home: Ridgemede Care Limited

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What the care home does well Prospective residents` needs are assessed before they are offered a place at the home. Information is provided by the home to prospective residents giving details of the service. Care plans are of a good standard and staff and residents report that care needs are met. A resident`s reltive made the following comment, `I have been completely satisfied with the support and care my mother/father has received.` Staff and relatives reported that the home communicates well with relatives. There is a programme of activities for the residents including regular entertainment and outings. Residents are able to suggest activities that would like to take part in. Nutritious meals are provided and support is given to those who need help with eating. The home is well maintained and clean. Residents have been able to personalise their bedrooms. Each room has its ow telephone line. Staff recruitment procedures protect residents. What has improved since the last inspection? Specific procedures have been introduced regarding nutritional assessments, living wills, health and safety and continence care. A system of auditing care plans has been introduced. The activities programme has been developed with more outings for the residents. There is a monthly newsletter which gives details of activities. Relatives` meetings have been introduced. A process of installing cable television channels for each bedroom is in progress. Catering equipment has been purchased. The environment has been maintained and refurbished including paint work and flooring. Additional staff have been employed including an Operations Manager and a Personal Assistant. A senior staff member has started a Leadership and Management course. Staff training has been developed and 3 staff have attained National Vocational Qualification level 3 in care. The home is part of the Hampshire County Council partnership in care training, which qualifies staff to train other staff in moving and handling. Staff now have name badges. What the care home could do better: Residents reported restrictions on times they can say in the lounge. This was refuted by the manager. Residents may need reminding that they do not have to go to their room at 9pm. A controlled drug cupboard needs to be installed. There is a lack of clarity regarding the provision of `sleep in` night staff. Staffing levels need to be reviewed for the period immediately before 8am when 2 staff are getting residents up and preparing the breakfast. Key inspection report Care homes for older people Name: Address: Ridgemede Care Limited Ridgemede Care Limited Rareridge Lane Bishops Waltham Southampton Hampshire SO32 1DX     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: Ian Craig     Date: 2 5 0 8 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: Ridgemede Care Limited Ridgemede Care Limited Rareridge Lane Bishops Waltham Southampton Hampshire SO32 1DX 01489892511 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ridgemede Care Limited care home 36 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 36 The registered person may provide the following category of service only; Care home only (PC) to service users of the following gender; Either whose primary care needs on admission to the home are with the following category: Dementia (DE) Physical disability (PD) Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Ridgemede is located in a quiet residential area of Bishops Waltham, with local amenities close by. The home is set in pleasant well maintained grounds and accommodation is arranged on two levels, in twenty-eight single and four shared rooms, all with en suite facilities. Communal areas include a large entrance foyer with Care Homes for Older People Page 4 of 27 Over 65 0 36 0 36 0 36 Brief description of the care home comfortable seating, a quiet lounge overlooking the rear gardens, a comfortable sitting room, and separate dining room overlooking the gardens. Additional seating is provided in the grounds. The home is registered to accommodate 36 older people, including those experiencing dementia and those with a physical disability. 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: An unannounced visit was made to the home which lasted for approximately 7 hours. Four residents and 3 staff were involved in the inspection. Discussions took place with the manager. 15 resident surveys, 5 health care professional surveys and 12 staff surveys were sent to the home with pre paid envelopes so that they could be returned directly to the Commission by those completing them. The Commission received information from 2 sources that the surveys were given out by the homes management without the pre paid envelopes with instructions that they must be returned to the manager. Surveys were received from 6 staff and 12 residents or their relative. Communal areas and a number of bedrooms were seen. Records, documents, policies and procedures were looked at. Care Homes for Older People Page 6 of 27 Care services are required to complete an Annual Quality Assurance Assessment (AQAA). This was completed by the home and returned to the Commission. Information contained in the AQAA has been used for this report. 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: Residents reported restrictions on times they can say in the lounge. This was refuted by the manager. Residents may need reminding that they do not have to go to their room at 9pm. Care Homes for Older People Page 8 of 27 A controlled drug cupboard needs to be installed. There is a lack of clarity regarding the provision of sleep in night staff. Staffing levels need to be reviewed for the period immediately before 8am when 2 staff are getting residents up and preparing the breakfast. 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 are able to make an informed choice about whether or not to move into the home. The home takes steps to ensure that it accommodates only those whose needs it can meet. Evidence: The home has a Service Users Guide, which has the Statement of Purpose incorporated into it. This gives details about the home including the facilities and the complaints procedure. A copy of this document is given to residents. The home also has a brochure which can be given to those making enquiries about moving in. Residents said that they moved into the home after recommendation, or, after a relative had looked round on their behalf. Those residents or their relatives who returned a survey said that the received enough information about the home so that Care Homes for Older People Page 11 of 27 Evidence: they could make a decision about moving in or not. Records show that the home carries out an assessment of need for those referred for possible admission. This pre admission assessment includes the following needs: mobility, dexterity, diet, oral health, bowel and bladder control, speech, hearing, sight, foot care, plus other assessments of mental health needs. Following admission another assessment is carried out including a nutritional assessment, risk assessments, pressure area assessments, and falls risk assessments as well as the preferred routines for each person. Records of multi agency planning assessments were available for one person. A staff member described the relevance of this to planning care for the individual. Where residents are referred for admission by the local authority it was noted that copies of referring care managers assessments and care plans were not obtained. The importance of obtaining relevant information from referring agencies was discussed with the manager. 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 needs of the residents are met. Residents privacy and dignity is promoted. Evidence: Following admission to the home a further assessment is carried out and recorded, as well as a clinical risk assessment. Care plans are completed for each person under the following headings: needs identified, aims and objectives of care, plus the care actions for staff to follow and the persons strengths in this area. For the 6 care records looked at the care plans had details of continence and catheter care, how to deal with mobility needs and the risk of falls and mental health needs. It was noted that whilst the home has procedures for catheter care, that care plans should give clear guidance so that staff know the times and frequency of providing support. Moving and handling assessments are completed with corresponding guidance for staff Care Homes for Older People Page 13 of 27 Evidence: to follow when transferring residents. Nutritional assessments are carried out and recorded. Records show that the home liaises with health care professionals, including district nursing services and general practitioners. Residents confirmed that the service provides the care and support they need and that arrangements are made for medical care. One person said how the home had assisted in improving his/her mobility. Two people said that the response to call point being answered at night could be improved. Staff report that the residents receive a good standard of personal care. Staff were observed to interact with residents in a calm and kind manner. One staff member said that the night time staffing levels are not adequate to meet residents needs when they get up as there are only 2 staff on duty before 8 am. A social history is recorded for residents. These vary in the amount of detail recorded. The homes medication procedures were looked at. Staff receive instruction from the manager for the safe handling of medication as well as observations of staff to check that they are following the correct procedures. A record is kept of any incoming medication delivered to the home as well as a record of any unused medication which is returned to the pharmacist. Staff record a signature each time medication is administered. Controlled medication procedures were looked at. Records are kept by the two staff who administer and count the remaining medication. The home does not use a controlled drug cupboard but stores controlled medication within 3 lockable units. This was discussed with the manager. The manager stated that residents are able to have a key to their bedroom door and that one person has made use of this facility. One person described how he/she uses the door lock for privacy at night. Each room has its own telephone so that residents can make a private call. 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. Residents benefit from a range of activities and community contact. Varied and nutritious diets are provided. Evidence: Each of the surveys returned by a resident states that activities are provided. This was also confirmed from residents on the day of the visit. The home has a monthly newsletter which is given to each resident. This includes details of the months activity programme. For the month of August 2009, the activities include trips out to the seaside,musical entertainment, talks on subjects such as transport in the 1960s and a local zoo from outside speakers, and religious services. One person said how residents are able to suggest activities and that the home has a staff member who coordinates the activities. Some stated that they prefer not to join in with the activities and that this choice is respected. One person said how he/she takes part in all the activities and that there are occassional outings to the theatre or to places of interest. Care Homes for Older People Page 15 of 27 Evidence: Two people said that they are not able to stay in the lounge after 9pm when they are told to go to their bedroom. One person said that he/she would like to stay up longer talking to other residents. This was raised with the manager who maintained that there is no restriction on the times the residents have to go their bedrooms in the evening. Residents were observed using their rooms to read books or a daily newspaper. One person said that a mobile library visits the home on regular basis. Residents were observed receiving visitors. Two residents said that relatives are able to visit on a regular basis. Minutes are available of meetings of the Residents Committee. A resident confirmed that these take place on a regular basis. Each person who completed a survey said that he or she likes the meals. Those spoken to on the day of the visit said the food was good, very good or ok. Two people said that there are plenty of fresh fruit and vegetables. The midday meal consisted of home made cottage pie with swede, cabbage and mixed vegetables. Dessert was bread and butter pudding. Dining tables were set with napkins and table mats. Staff gave help to those residents who needed help with eating. The days menu plan is displayed in the hall. The AQAA states that specialist diets can be catered for such as vegetarian or Halal meat. 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. The home has an effective complaints procedure and steps are taken to protect residents from possible harm. Evidence: The homes complaints procedure is contained in the Service Users Guide, which is given to each resident. Each resident who returned a survey said that there is someone available to speak to if they are not happy. Surveys from residents or their relatives say that they know how to make a complaint with the exception of one person. The AQAA states that there have not been any complaints in the last 12 months. Training is provided to staff in protecting vulnerable adults according to the staff training records and from discussions with the manager. Staff said that training in safeguarding vulnerable adults is included in their National Vocational Qualification coursework, but that more specific training would be beneficial. There has been one referral to social services regarding safeguarding of vulnerable adults in the last 12 months. 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. Residents benefit from a well maintained and clean building with excellent facilities. Evidence: A number of bedrooms and the communal areas were seen. Bedrooms are spacious and contain items of personal possession such as books, magazines, and pictures. Two residents said how they like their room. One person said that he/she enjoys looking out of the window at the garden and plants. All but 2 of the bedrooms have an en suite bathroom. The home has a lounge, a quiet lounge and a dining room as well as seating areas in the entrance hall. The passenger lift is capable of accommodating a bed. The home has lifting aids such as a mobile hoist and specialist bathing facilities for those with mobility needs. Ramps and rails have been used to aid those with mobility needs. The home has a hairdressing salon. Care Homes for Older People Page 18 of 27 Evidence: The home was found to be clean and free from any odours. Residents said that the home is clean and fresh. Cleaning schedules are maintained by cleaning staff throughout the day. Staff are instructed in infection control. One staff member commented that there are infection control implications as only 2 staff are on duty before 8am during which time they have to support some of the residents with personal care and prepare the breakfasts. 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. Sufficient numbers of trained staff are deployed in the day time so that residents needs are met, but there is a lack of clarity about the numbers of staff on duty at night and whether there are enough staff to get residents up. Staff recruitment procedures protect residents. Evidence: The home aims to provide the following day time staffing hours: 8am to 1pm 5 care staff, 1pm to 5pm 4 care staff, and, 5 to 8pm 3 care staff. The hours worked by the manager are additional to these hours. There was a lack of clarity regarding the night time staff hours being provided and whether or not these are sufficient to meet peoples needs. The manager stated that night time staffing from 8pm to 8am the next day consists of 2 waking and 1 sleep in staff members. The sleep in hours were not recorded on the rota. A staff member commented that there was no sleep in staff member that could be contacted and this was the reason they were not recorded on the rota. Comment was made by a staff member that the staffing numbers of 2 care staff is insufficient to meet residents needs in the period immediately before 8am when the 2 staff have to meet personal care needs to get residents up and also undertake Care Homes for Older People Page 20 of 27 Evidence: catering duties of preparing and serving the breakfast. Another staff member said that the home provides sufficient staff. Two residents also commented that there were occassional delays at night time when they ask for help. Two staff also said that the availability of the manager could be improved. 2 surveys returned by staff said that there are sometimes enough staff to meet residents needs, another said there are usually enough staff and the remainder said there are always enough staff. The home provides a cook for 7 days a week from 9am to 5pm. Cleaning staff are employed for 60 hours a week. A maintenance worker is employed for 40 hours a week and a gardener for 20 hours. Staff said that they received an induction which mostly or partly prepared them for the job. The manager stated that staff receive an induction and that this includes the nationally recognised Common Induction Standards. The AQAA states that each staff member has completed an induction using these standards. For the one person who has started work since the last inspection, there was no record of an induction only a staff supervision and assessment completed 13 days after the person started work. The AQAA states that 10 of the 19 staff have a National Vocational Qualifications (NVQ) in care at level 2 or above. Staff confirmed at the visit that they have attained, or, are studying NVQ level 3 and 4, and that other training courses are provided such as moving and handling, first aid and the Mental Capacity Act 2005. Staff who returned a survey said that training is provided with the exception of one person who said it is not. Training records are maintained to show staff receive training in fire safety, contamination of substances hazardous to health (COSHH), health and safety, moving and handling, medication, principles of care, adult protection, first aid, risk assessment and food hygiene. The manager attends local authority training courses qualifying her to instruct staff. Training for staff in dementia is due to be provided in the near future. Residents and their relatives described the staff as kind and helpful. Recruitment procedures were checked for 4 staff. These show that the required checks are carried out before staff start work at the home. Care Homes for Older People Page 21 of 27 Evidence: Staff meetings take place. This was confirmed by staff and the manager. Care Homes for Older People Page 22 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. The home is generally well managed, although there are some instances which indicate improvements could be made so that it runs in the best interests of the people who live there. The home promotes the health and safety of the residents. Evidence: The manager is both a Registered General Nurse and Registered Mental Nurse. She has qualifiactions in NVQ assessing and has a masters degree in mental health studies. 2 of the 6 surveys returned by staff said that they only sometimes receive enough support and meet their manager. The remaining surveys state that staff feel supported and that they meet with their manager. Information was also received from staff that they do not always feel supported by the homes manager. Staff said that they receive regular supervision. Care Homes for Older People Page 23 of 27 Evidence: The home uses a number of ways to monitor its own performance. This includes surveys of health care professionals, residents and their relatives. Care plans are auditted. A cleaning schedule is used and a record made of cleaning tasks being complete. Staff and residsents meetings take place. A staff member said that suggestions made by staff were sometimes ignored by the homes management. The home does not look after the monies or valuables of residents. Staff are trained in first aid, infection control, food hygiene, moving and handling, fire safety and health and safety. The AQAA confirms that the homes appliances are tested and serviced by suitably qualified persons. Care Homes for Older People 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 Older People 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 1 9 13 Medication that is classed as 25/11/2009 a controlled drug for storage must be stored in a cupboard as required by the Misuse of Drugs (Safe Custody) Regulations 1973. So that medication is safely stored. 2 27 17 An accurate copy of the duty 30/09/2009 roster must be maintained including whether or not the hours were worked. So that the home can demonstrate that adequate staffing is provided. 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 27 The staffing levels should be reviewed for the time of day before 8am when 2 staff are responsible for getting residents up and for preparing and serving the breakfast. 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. 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