Care Home: St Vincents

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What the care home does well They ensure that people`s needs and wishes are fully assessed before they move into St Vincents. Systems were in place to ensure that people received the care and medical support they required at all times. Individual care plans were available and we saw that these documents were reviewed on a regular basis. People`s religious vocation is central to how people are supported and cared for. On going support is available for those wishing to continue their commitment to community work and in maintaining interests and past times. People told us that their religious and spiritual needs were always met. Regular Mass was held at St Vincents at least once a day in the homes chapel. The service ensures that people have the opportunity to participate in religious retreats and holidays. A good range of activities were available for people to participate in. Regular community meetings were available for people to participate in future plans for St Vincents and to raise any suggestions or concerns. People told us that the services offered at St Vincents met all of their needs. They told us that they were happy with their life. We saw that a varied nutritious menu was available. People told us that they always liked the food served at St Vincents. They told us "the food is very good", "you always have a choice" and "the food is very nice, they come around often asking people what they`d like to eat." Staff were observed addressing people in a polite, dignified manner and demonstrated a good awareness of people`s needs and wishes. We saw that good recruitment procedures were in place and that staff had access to regular training suitable for their role. We saw that the home was well decorated, clean and comfortably finished which provided a very pleasant place for people to live. People that we spoke to during our visit told us that they felt safe at St Vincents. What has improved since the last inspection? We saw that improvement had been made to ensure that individual`s had the opportunity to participate with their care planning. Risk assessments and self medication agreement forms were available to support people who administer their own medication. What the care home could do better: The medication policy and procedure should contain information regarding the management, administration and recording of medication prescribed on an as and when basis (PRN). This will help ensure that if medication is prescribed PRN it is managed appropriately. The service should obtain controlled drugs cabinet that meets current legislation storage requirements. An appropriate cabinet will help ensure that controlled drugs are stored appropriately. Key inspection report Care homes for older people Name: Address: St Vincents 33/35 Leicester Street Southport Merseyside PR9 0EX     The quality rating for this care home is:   three star excellent 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: Adele Berriman     Date: 1 0 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: St Vincents 33/35 Leicester Street Southport Merseyside PR9 0EX 01704546386 01704539257 jayjobling@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: The Daughters of Charity of St Vincent De Paul care home 13 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The registered person may provide the following category/ies 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: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 13 Date of last inspection Brief description of the care home St Vincents is a care home providing personal care and support for up to thirteen retired sisters from the Community of St Vincent de Paul and sisters from other religious communities. The home is situated in Southport town centre overlooking the marine lake and with easy access to public transport. The home has four floors served by a passenger lift and chairlifts on the back stairs. The sisters have single accommodation and a number of rooms have an ensuite facility. Bathrooms are adapted to assist those who are less able and the home also has a Jacuzzi room. Recreational areas comprise of two lounges and a dining room. All areas are very clean and well maintained. The Registered Providers are The Daughters of Charity of St Care Homes for Older People Page 4 of 28 0 Over 65 13 Brief description of the care home Vincent De Paul and the registered manager is Ms Rose Lowry. The weekly accommodation rate is 629.00 pounds. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent 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: We carried out an unannounced visit to St Vincents. The visit began at 11.45am and ended at 6.45pm. The visit formed part of a key inspection of the home in which all of the key standards were assessed. During our visit we spent time talking to people who live at St Vincents, two members of staff on duty, the director of services, and the care and administration managers. We looked around several areas of the home including communal living areas and a selection of bedrooms and bathrooms. We looked at a selection of records, policies and procedures during the visit, these included care plans, staff files, medication records and daily records. Prior to our visit the registered manager had completed an Annual Quality Assurance Assessment (AQAA). This document gave the service the opportunity to tell us what Care Homes for Older People Page 6 of 28 they thought they did well, what they thought they could do better, improvements they had made over the past 12 months and their plans for the next 12 months. The AQAA was well written and told us the information that we asked for. At the time of our visit the cost of the service is 629.00 pounds per week. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? We saw that improvement had been made to ensure that individuals had the opportunity to participate with their care planning. Risk assessments and self medication agreement forms were available to support people who administer their own medication. Care Homes for Older People Page 8 of 28 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 Older People Page 9 of 28 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs assessed before they move into St Vincents so they know their needs can be met. Evidence: We saw that a pre admission assessment was carried out prior to a person moving into the home. The purpose of this assessment was to ensure that the staff were aware of individuals needs and to ensure that the home had the facilities to meet these needs. We saw that information gained during the pre admission assessment process was recorded on a set format. The document gave the opportunity to record individuals care and health needs within their day to day life. We looked at several peoples care files and saw that they contained detailed pre admission assessments. Care Homes for Older People Page 11 of 28 Evidence: They told us that the sisters were generally familiar with the home prior to moving in as all sisters visit and the majority had stayed at the St Vincents for holidays and periods of respite prior to moving into the service. They told us in their AQAA that they plan to develop a new resident questionnaire for people moving into the service to complete and give the management feedback on peoples views on their choice of home and how they are settling in. They told us that to help people feel part of the community as soon as possible, there is continual encouragement to participate in as many activities and outings available. The sisters told us that they were given lots of information about the home and the surrounding area when they moved into St Vincents. St Vincents does not provide intermediate care facilities. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated with dignity and respect in this home. Their health, personal and social care needs are taken seriously. Evidence: We saw that each person had their own file that contained their personal information, pre admission information and their care plan. We looked at three peoples care plans and saw that they contained information about peoples day to day needs and wishes. The majority of the information contained on the care plans was detailed and well written which gave the staff team clear directions on what care and support people required. We saw that care plans were reviewed on a regular basis. People told us that they took part in their care plan reviews with their key workers. They told us in their AQAA that over the next 12 months they plan to develop a person centered approach to recording peoples needs and wishes with as much input from Care Homes for Older People Page 13 of 28 Evidence: individuals and their key workers as possible. Daily records were maintained by the staff team that recorded peoples events of the day. We saw that risk assessment specific to individuals needs formed part of peoples care plans. These assessments considered peoples deteriorating balance, moving and handling and personal evacuation plans for use in the event of an emergency. We saw that these assessments were reviewed on a regular basis. We saw one risk assessment that contained conflicting information regarding a persons mobility. We discussed during our visit the need to ensure that information detailed in risk assessments is concise to help ensure that all identified risks are considered in the care planning process. We saw records that demonstrated that people had regular access to local health care professionals including their GP, dentist and chiropodist. All six of the people that we spoke to told us that their health care needs are always met and one person told us they look after us very well. We saw that they had a policy for the receipt, recording, administration and disposal of medication. The policy did not contain guidance on the management of medication that is prescribed on an as and when required basis (PRN). Information relating to the use and recording of PRN medication should be added to the policy, this will help ensure its safe administration when it is required. At the time of our visit staff were supporting two people with the administration of their medication. We saw that all medication administered was recorded in a Medication Administration Record (MAR). We looked at the MARs in use and saw that they had been completed appropriately. We saw that a secure medication trolley was available for the safe storage of medication. It is recommended in this report that the service obtains a new cabinet for the safe storage of controlled drugs. This will help ensure that any controlled drugs prescribed for people are stored appropriately. They told us that people are encouraged to maintain as much control over their medication as possible. We saw that several people self administered their medication. Care plans contained risk assessments and self medication form agreements that were signed and dated by individuals. Throughout the visit we observed people being treated in a friendly and dignified manner by the staff team on duty. Care Homes for Older People Page 14 of 28 Evidence: Care Homes for Older People Page 15 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People received the support they needed to live their chosen lifestyle. Evidence: We saw that they had an activities programme. Activities available included a quiz, walking, shopping, keep fit, flower class and individual computer lessons. They told us in their AQAA that bi-annual day trips are arranged on a narrow boat that is accessible to all. Monthly outings are arranged using a local coach and events company. Local musical entertainers visit several times a year and people have the opportunity to attend local seasonal shows, pantomimes and religious and music events whenever they choose. We saw that people had access to computers and several people had a computer in their bedroom. They told us that they especially enjoyed getting familiar with the internet as they were able to keep in touch with friends and family. Three people told us that they really enjoyed their weekly individual computer classes. We saw that many of the people living at St Vincents were active within the local community and had activities and commitments outside of the home. For example, Care Homes for Older People Page 16 of 28 Evidence: one person told us that they attend a local church one day a week to answer the telephone. Another person told us that the attended a local homeless project on a weekly basis to assist with the preparation and serving of hot meals. Another person told us that they attended a sewing class at Liverpool Cathedral on a regular basis. The organist and choir mistress from a local church attend St Vincents on a weekly basis for choir practice sessions. St Vincents has a chapel to assist people to follow the routines of their religious life. A local priest visits the home on a daily basis to hold mass. People told is that they attend an annual retreat at a location of their choice. They told us in their AQAA that for people not able to travel a spiritual adviser holds at retreat at St Vincents. When possible, people are encouraged to take annual holidays with their families, friends or at other religious community houses. People told us that the services offered at St Vincents met all of their needs. They told us that they were happy with their life. People told us that they were able to receive visitors at anytime. One person told us that a relative had recently visited and stayed in a flat close to St Vincents owned by the service. Two small kitchen areas equipped with a microwave, kettle and toaster were available for people to prepare their breakfast, drinks and snack throughout the day and night. A selection of fresh fruit was also available for people to access whenever they wished. We saw that meals were served in a very pleasantly decorated and furnished dining rooms. The tables were set with water glasses, fresh flower, condiments and cutlery. We saw that a varied nutritious menu was available. We ate an enjoyable lunch of soup, roast ham, vegetables and cheese cake followed by cheese and biscuits. People were encouraged to serve themselves with the well presented food. All six people that we spoke to told us that they always liked the food served at St Vincents. They told us the food is very good, you always have a choice and the food is very nice, they come around often asking people what theyd like to eat. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service were protected by the complaints and safeguarding procedures. Evidence: We saw that the service had a complaints procedure that was available in the home. The procedure was also written in the residents handbook. They told us in their AQAA that all staff were aware of the residents complaints procedure. All of the people we spoke to during our visit told us that they were fully aware of the complaints procedure and that there was always somebody available to talk to if they had a concern. They told us that a weekly meeting was held and if they had any concerns they could always raise them at the meeting. No complaints had been made about the service within the last 12 months. We saw that they had a policy and procedure for the protection of vulnerable adults. In addition we saw that they had a copy of Sefton Social Services joint agency safeguarding procedures. Training records demonstrated that the majority of staff had received training in the protection of vulnerable adults within the last 12 months. All of the six people that we spoke to during our visit told us that they felt safe at St Vincents. Care Homes for Older People Page 18 of 28 Evidence: Care Homes for Older People Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. St Vincents provides a safe and comfortable home that is well maintained, decorated and furnished to an excellent standard. Evidence: St Vincents is situated near to the centre of Southport and is close to public transport links and local amenities. There is a garden area to the rear of the home and an fenced garden area to the front. A small parking area is also available at the front of the home. Stair lifts and a passenger lift are available to help people access all areas of the building. They told us that they devise an annual development and maintenance plan for the building and it decor. Over the past 12 months remedial damp proofing had taken place in some areas of the home, a new en suite facility had been installed in one of the bedrooms and a new carpet had been fitted throughout the dining room. We observed a very relaxed and comfortable environment around the home which demonstrated, along with the furnishing and decor, that St Vincents offers an excellent environment for people to live. Care Homes for Older People Page 20 of 28 Evidence: We saw that the communal areas were decorated and furnished to an excellent standard. Clean, comfortable furniture was available to meet peoples needs. We visited several communal bathrooms and saw that varied bathing and showering facilities were available to enable people to have a choice of what facilities they wished to use. We visited several peoples bedrooms. We saw that they were well furnished and people had the opportunity to individualise their rooms with the own personal effects. They told us in their AQAA that over the next 12 months their plans are to commence a redecoration programme of the internal fabric of the home. People told us that they liked living at St Vincents. Comments included it is a beautiful environment to live, there is a nice atmosphere here and its always very clean and tidy. Care Homes for Older People Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements, recruitment and training ensure that people are care for and supported safely. Evidence: We saw that three carers, the registered manager, the administrator and a cook were on duty to meet the needs of people at the time of our visit. Rotas demonstrated that a team of three carers were available throughout the day and waking night staff were available through the night to meet the needs of people. People told us good things about the staff team. Comments included staff are wonderful and the staff are very good here and we have two excellent cooks. We spoke to two staff on duty during our visit. Both staff demonstrated a good awareness of the needs of the people they supported. They told us that they received regular training for their role. We looked at the recruitment files of four staff members. We saw that the files contained the information required. We saw written references, application forms, interview evaluations and evidence of Criminal Record Bureau disclosures being obtained. Care Homes for Older People Page 22 of 28 Evidence: We looked at staff training information and saw that staff were receiving training relevant to their role. The training matrix demonstrated that the the majority of staff had received training in the last 12 months in the areas of manual handling, fire safety, basic food hygiene, health and safety, infection control and the protection of vulnerable adults. We saw that two staff had undertaken training in risk assessment and another two in the management of stress. We saw that the majority of staff had received first aid training which was updated as and when required. We saw from the training matrix that medication refresher training was planned for 2010 along with training on the Mental Capacity Act. We saw that the majority of staff had achieved an National Vocational Qualification level 2 and level 3. A further three staff were in the process of studying for their award. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. St Vincents is run in the best interests of the people living there and their welfare is protected. Evidence: The registered manager had many years experience in working in a social care environment and held the required qualifications to carry out her role. During our visit the manager demonstrated a good awareness of the needs of people living at St Vincents and had a good awareness of safeguarding and keeping people safe. It was evident during our visit that the home was run in the best interests of the people who lived there. People told us that they had weekly community meetings within the home which gave them the opportunity to ask any questions, make suggestions or raise any concerns with the management of the service. In addition to the regular community meetings we saw that peoples views on the service were asked for and documented on a regular basis by the use of satisfaction Care Homes for Older People Page 24 of 28 Evidence: surveys. We saw that the surveys in use centered on the services that people received on a day to day basis and how they viewed how their care and support was delivered. People living at St Vincents told us that they were always consulted and included in any changes planned for the service. One person told us we certainly are considered first and I am very grateful. We saw that policies and procedures were in place to safeguard peoples financial interests. They told us in their AQAA that full records are kept of residents allowances and expenditure and one residents monies are kept secure by the admin manager in a safe with written records kept of all purchases. We saw that they had policies and procedures available to promote the health, safety and wellbeing of all. They told us in their AQAA that over the last 12 months they had introduced a new walk-around health and safety check of the building that is carried out by the registered manager and the senior carer on duty. information contained in the AQAA demonstrated that regular maintenance and checks of utilities and equipment took place. On the day that we visited a full electrical mains check was taking place around the building. We saw that records were maintained of all health and safety checks carried out around the building. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 The medication policy should include information about the use of and recording of medication prescribed on an as and when required basis (PRN). An appropriate storage cabinet for controlled drugs should be obtained to help ensure that all medication is stored appropriately. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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