Care Home: The Elms

What the care home does well People have lived at the home for a longtime and they know each other and their support workers very well. There was a relaxed and friendly atmosphere and people said they were happy living at the home. In the what does the home do well section of the survey people commented that support workers, "Listen to your problems and there when you need them." And, "They look after us." And also, "Everything" People were able to make choices and decisions and are encouraged to be as independent as possible. They take part in community activities that help them live fulfilling and valued lifestyles. For example people had planned to see the Chinese circus at a Manchester theatre and then they were going out for a meal afterwards. The registered managers` advocate strongly on behalf of people living at the home to ensure that they get the best healthcare treatment that they need. The home is in a residential area and blends in with neighbouring properties. People living at the home said that they knew who to speak with if they were unhappy about anything. Support workers gave positive feedback about working at the home. One support worker commented that the home, "Supports service users who therefore feel safe in their home environment and are able to confide worries or problems to staff." Support workers said that they received good support from the managers` at the home. What has improved since the last inspection? This is the first inspection of a new service. What the care home could do better: Some record keeping needed to be improved, not only to be developed so that there are more user friendly and person centred formats in place, but also to be kept up to date if people`s needs change. Support workers would benefit from up to date training in safeguarding people as well as Mental Capacity Act training that includes deprivation of liberty and also equality and diversity training. The home is comfortable and homely but there is a need for continuing improvement in decoration to ensure that satisfactory standards are maintained for the comfort of the people who live there. The shortfalls in health and safety training must be addressed to ensure that support workers have the knowledge and skills that they need to support people safely and effectively. Key inspection report Care homes for adults (18-65 years) Name: Address: The Elms 230 Walmersley Road Bury Lancs BL9 6NH     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: Julie Bodell     Date: 2 8 0 1 2 0 1 0 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: The Elms 230 Walmersley Road Bury Lancs BL9 6NH 01617633855 01204887038 parkviewbury@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Miss Dawn Charlesworth and Mrs Cheryl Ince Name of registered manager (if applicable) Mrs Dawn Charlesworth Type of registration: Number of places registered: care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The registered person may provide the following categories of service only: Care home only - code PC, to people of either gender whose primary care needs on admission to the home are in the following category: Learning Disabilities Code LD The maximum number of people who can be accommodated is 6. Date of last inspection Brief description of the care home 6 Over 65 0 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 included an unannounced visit to the home. We (the commission) spent four hours at the home. We watched what went on and talked briefly with two people who live at the home as well as the registered provider/manager and a support worker. We also looked round parts of the home and at paperwork. Information requested from the service called an annual quality assurance assessment (AQAA) was received before the visit. Two people living at the home and two support workers returned a completed survey to us, which were positive. However, this is a change of ownership within the same family who have supported the people who have lived at The Elms for a very long time. Some of the information in this report was taken from recent visits to the organisations two other homes, Park View and The Ferns. Care Homes for Adults (18-65 years) Page 5 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 Care Homes for Adults (18-65 years) Page 6 of 27 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. Before a person moves into the home they are assessed to ensure that their individual needs can be met and that the person will get on well with the existing group. Evidence: Although there had been a recent change of ownership of the home it had stayed within the same family and this had ensured continuity for the people living their. The new registered providers had updated the statement of purpose, service user guide and issued new contracts to people. The people living at the home were very settled and most had lived at the home for many years. One person had recently passed away. The person concerned was a very popular resident and his death had been very upsetting for everyone. Should a new person come to live at the home an up to date community care assessment would be obtained from a qualified social worker before a person moved into the home. The managers would spend time getting to know the person to make sure that they would be able to meet their individual needs and ensure that they Care Homes for Adults (18-65 years) Page 9 of 27 Evidence: would get on well with the existing group. From a brief discussion with two people living at the home and observation it was clear that people got on well together. No concerns were raised about the homes ability to meet peoples individual needs. There was a relaxed and friendly atmosphere at the home. 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. People are encouraged to be as independent as possible and are able to make choices and decisions about their individual lifestyles. Evidence: We looked at the care plan and risk assessments for one person. Records included details about the persons needs and wishes and what action was required by support workers to meet them. The new registered provider/manager intends to review the current care plan and risk assessment formats in the coming year to make them more person centred and user friendly and to ensure that people were involved in developing them. Daily records about people were very detailed. Records could be better organised so that they would be easier for support workers to use for example having a working file. The registered provider/manager was very knowledgeable about the needs of people living at the home. The needs of most people were kept under review by the social workers and minutes Care Homes for Adults (18-65 years) Page 11 of 27 Evidence: of review meetings were kept on the files. Risk management plans for the person had been completed. From observation of people living at the home it was clear that they had the opportunity to do things for themselves if they were able. They could decide what they did each day and who they spent time with. 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. People living at the home are very independent and they take part in community activities that help them to have fulfilling and valued lifestyles. Evidence: The Elms is a very busy household. All the people living at the home were able to travel independently and were observed coming and going from the home as they wanted. People talked about some of the activities they took part in, for example, going out on buses, shopping in Bury town centre, meeting friends, going to pubs and group outings with support workers. One person had a job helping out at another home in the area. At home, people liked to pursue their own interests, such as watching television. Everyone was able to access community leisure activities unaccompanied although they said that they sometimes went out as a group with staff, perhaps to the cinema Care Homes for Adults (18-65 years) Page 13 of 27 Evidence: or for meals out and they really enjoyed these occasions. People talked about the contact they had with their families and friends. It was clear from these discussions that they were encouraged to maintain contact with family and friends if they wanted to. People said that they could choose how they spent their time. They said that they got up at the time they wanted to. They said that they took responsibility for some household tasks such as washing up and tidying their rooms. People said that their privacy was respected and no one entered their bedroom without knocking on the door. People living at the home said that staff were friendly and treated them with respect. We received four surveys from people living at the home. In the what does the home do well section of the survey people commented that support workers, Listen to your problems and there when you need them. And, They look after us. And also, Everything 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. Peoples personal support and healthcare needs were met. Evidence: People living at the home were very independent in respect of personal care needs and only needed reminding and encouragement from support workers. They said that they chose their own daily routines, for example what time they got up. They said that they liked the staff and a good rapport and friendly atmosphere between the people who live at the home and the staff members was observed throughout our visit. People have a health care file, which covered health checks and medication. Records were kept of individual health appointments as well as BMI, weight, blood pressure, and information about the affects of medication, behavioural assessment, physical health, personal care and mental health. Records confirmed that people had contact with GPs, dentists and hospital consultants. They used local healthcare services and a staff member would always go with them to appointments, usually the registered manager. We looked at the healthcare assessment for one person and found that it had recently been reviewed and updated. Care Homes for Adults (18-65 years) Page 15 of 27 Evidence: We talked at length about the experiences of the person who recently passed away in hospital. We recommended that the Traffic Light system that gives information to hospital staff about the persons needs and wishes at the point of admission, be adopted by the home. We looked at the medication system and no major concerns were found. However the old medication administration (MAR) forms need to be archived. 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 living at the home know who to complain to and that they would be listened to and action would be taken to address the matter and ensure their protection. Evidence: The home had a written complaints procedure and we were given a copy of it. We had received no complaints about the service and the AQAA showed that there had been no internal complaints. People we spoke with said that they knew who to complain too and were confident that action would be taken to address the matter. There have been no allegations of abuse at the home. The home had a copy of the local authority safeguarding procedures. The registered provider/manager said that there had been problems accessing safeguarding training through the Bury Adult Care Training Partnership because of changes to the training course. It was intended that support workers would undertake updated training when the course becomes available. To ensure their continued professional development support workers also need to undertake Mental Capacity Act training that includes deprivation of liberty as well as equality and diversity training. Care Homes for Adults (18-65 years) 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, 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a homely and comfortable environment for people who live there but there is a need to continue making improvements to ensure that standards are maintained. Evidence: The home is situated in a residential area of Bury on a main road leading to the town centre. It is close to bus routes, local shops and other local amenities. There is a park close by. The house is a three storey terraced property and is similar to other properties in the area and it does not stand out as a care home. Outside there was a small garden at the front and a pleasant yard at the back, with seating so that people who live at the home could sit out in nice weather. There is no passenger lift so access to upper floors was by stairs and the home would not be able to meet the needs of a physically disabled person. The home has a homely and comfortable lounge and a dining room/kitchen. The laundry room is on the first floor. Furnishings were homely and domestic in style. There were three single bedrooms on the first floor and a single and a double on the second floor. Bedrooms were personalised with peoples own belongings. We looked at one persons bedroom that had recently been refurbished and they were very pleased with how their room had turned out. The hall and stairways were in need of Care Homes for Adults (18-65 years) Page 18 of 27 Evidence: redecoration and a new carpet. There is a bathroom with toilet on the first floor and a toilet just off the laundry room. They are lockable to ensure privacy. People we spoke with said that they were happy with their rooms and with the home in general. However, there remains a need for ongoing redecoration and refurbishment in order to maintain standards and a maintenance and renewal schedule that gives evidence of plans for the coming year is required. Cleanliness in the home was generally satisfactory. Care Homes for Adults (18-65 years) 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, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Support workers are safely recruited and know people well but they need to receive all the training they need to support people safely and effectively. Evidence: During our visit we observed that there was a relaxed, friendly atmosphere between people, the registered managers and the support worker. No outside agency staff were being used. Staff rotas showed that there is normally only one staff member on duty, with extra cover provided, for example to accompany people to attend health appointments or planned one to one activities. As well as their care tasks, support staff also carried out cooking and cleaning duties. We spoke with one support worker who had recently come to work at the home on a full time basis after five years working mainly at the weekend. She spoke positively about her role at the home and enjoyed taking people out and about. The support worker said that she was looking forward to getting more involved in training and spending time working at another home within the organisation. The support worker said that they were supported well by the managers at the home. We received two surveys from support workers which were generally positive about the home. One support worker commented that the home, Supports service users Care Homes for Adults (18-65 years) Page 20 of 27 Evidence: who therefore feel safe in their home environment and are able to confide worries or problems to staff. One support worker said that they felt that there needed to be more regular full staff meetings. We checked the recruitment documents for three support workers working for the organisation. Records held Criminal Records Bureau (CRB) checks and also included application forms with employment histories, medical declarations and proof of identity. Staff files contained induction checklists and copies of job descriptions and contracts. The new registered providers had developed an employee handbook that gave good information to support workers about their responsibilities. The manager had completed the Registered Managers Award and one of the two support worker holds an NVQ Level 3 and the other NVQ Level 2. Copies of training certificates were held on the support workers personal file. The home was an active member of Bury Adult Care Training Partnership, a group set up by the local authority to promote training opportunities in the care sector. The training list given to us for the staff team identifies that some of the health and safety mandatory training support workers had received needed to be updated. Some support workers were undertaking health and safety induction training. Training in equality and diversity and the Mental Capacity Act for all staff members is also strongly recommended. The registered provider was aware of these shortfalls in training and had indicated this on the homes AQAA. This was due to delays in recruiting new staff across the organisation and difficulties accessing courses through the partnership. Care Homes for Adults (18-65 years) Page 21 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. People living at the home benefit from a relaxed and open style of management and they are able express their views confidently. Evidence: The home had been established for many years as one of three homes within an organisation run by the same family. Four months ago there was a change of ownership of the organisation within the family. This meant that the homes had to be re-registered and is therefore being assessed by us at this key inspection as a new service. There were two new registered providers. One of the providers had worked at the homes for 15 years working directly with people. The other registered provider had worked at the homes for 13 years undertaking a mainly administrative role. The registered providers therefore knew people who live at the homes very well. It was the new registered providers intention to build on the previous owners success. There continue to be two registered managers who oversee the management of the three homes within the group. Both managers are registered with us. One of the registered managers was also the registered provider. Both registered managers hold Care Homes for Adults (18-65 years) Page 22 of 27 Evidence: the Registered Managers Award and NVQ Level 4 in Health and Social care. The registered/provider manager is an active member of the local training partnership and has regular opportunities to ensure her continuous professional development. The registered managers operate an open door policy. People living at the home were observed confidently expressing their views and opinions throughout this visit to the registered provider/manager on duty. Because one of the registered provider was working as a registered manager, Regulation 26 visits were not required. However, both job share registered managers must be identified on the rota for this home so that they can evidence that time is being spent there. We received an annual quality assurance assessment document from the registered provider/manager, which gave an honest appraisal about the current position of the homes and what needed to be done to improve the situation. It also showed that the registered providers were aware of potential changes in arrangements for funding for people. The registered providers had produced a business plan as part of our registration process. The new registered providers plan to undertake an internal quality assurance exercise in the near future that will involve surveys being sent to the people living at the home as well as general practitioners and health and social care professionals. Several safety records were checked. These included portable electric appliance tests, electrical fitting and fitments and a gas safety check, which were seen to be in order. An independent organisation carried out health and safety checks at the home and found no areas of concern. We also looked at the financial accounts of one person and no concerns were raised. Care Homes for Adults (18-65 years) Page 23 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 24 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 24 23 The registered providers 31/03/2010 must send us a copy of their maintenance and renewal plan for the home for the coming 12 months. This is so we know what work is going to be undertaken to ensure ongoing improvement for the comfort of people that live at the home. 2 35 18 The registered providers must ensure that staff receive all the health and safety training that they need. This must be done to ensure that people are supported in a safe way. 30/06/2010 Care Homes for Adults (18-65 years) Page 25 of 27 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 6 That the registered provider/manager follows through plans to review care plans and risk assessments to make them more person centred and user friendly. That the traffic light system is adopted by the home to give staff at the hospital clear information about the persons needs and wishes. Support workers need to undertake updated safeguarding training and Mental Capacity Act training that includes deprivation of liberty as well equality and diversity training, as soon as it becomes available. The registered provider/manager needs to evidence on the rota that they each spend time at this home regularly. The providers need to undertake the planned quality assurance audit by the first year of being registered to ensure that the home is being run in the best interests of the people who live there. 2 19 3 23 4 5 39 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). 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