Care Home: The Elms

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What the care home does well Management is clear and effective and supports the staff team in providing ever improving outcomes for service users. Provides a high standard of individualised care for service users. The service is committed to achieving positive outcomes for service users. Provides a safe and homely environment for service users. Supports and encourages service users to lead an independent life according to their needs and strengths. Benefits from a competent and committed staff team that ensures consistency of care for service users. Provides good staff training opportunities that benefits service users. What has improved since the last inspection? The consistency of approach to service users has improved across the staff team. There was sound evidence that overall outcomes for service users had improved and was continuing to improve. A range of adaptations and aids have been implemented to support some identified service users. What the care home could do better: Replace the current kitchen as part of ongoing refurbishment but replace the cooker as a matter of some urgency. The manager wishes to improve access to plans of care for service users to facilitate their involvement as far as possible. The manager wants to explore the possibility of some service users self-medicating but is mindful that this must be undertaken with caution and with individual needs at the forefront of planning. Key inspection report Care homes for adults (18-65 years) Name: Address: The Elms Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ     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: Sally Newman     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 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 Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ 01344755575 01344773174 theelms@norwood.org.uk bucketsandspades@norwood.org.uk Norwood Ravenswood Ltd T/A Norwood care home 11 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 11 The registered person may provide the following category/ies 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 within the following categories: Learning disability (LD) Date of last inspection Brief description of the care home The Elms is part of the Norwood organisation based at Ravenswood Village. The home is registered to provide accommodation and care for up to 11 service users, aged between 18 and 65 years of age. All service users have a learning disability. The range of care needs within the home is diverse and complex. Several of the service users have needs which can challenge the service. All service users have full mobility and are able to communicate their needs and wishes. Fees range from £55,592 per annum to £103,030 per annum and does not included the cost of toiletries or Care Homes for Adults (18-65 years) Page 4 of 27 Over 65 0 11 Brief description of the care home hairdressing. Care Homes for Adults (18-65 years) 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: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and health care support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection that was conducted over the course of three days and included a visit to the service of six hours duration. Time was spent observing practise in the service and talking to staff and the manager. Three staff members were spoken to in private and a visiting Psychologist was seen in private. A range of documentation was seen and a tour of the premises was undertaken. There was considerable evidence that the outcomes for all service users have improved since the appointment of the current manager. Information held about the service by the Commission and information provided by the home prior to the inspection was used in the formulation of this report. All outcome areas were good with three areas being judged as excellent. No requirements or recommendations were made as a result of this inspection. Care Homes for Adults (18-65 years) Page 6 of 27 The provider has a range of policies and procedures relating to equality and diversity. From the evidence seen the inspector considers that this service would be able to provide a service that meets the needs of individuals of various religious, racial or cultural needs. No complaints have been received about this service by the Commission since the last key inspection. Care Homes for Adults (18-65 years) Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Care Homes for Adults (18-65 years) Page 8 of 27 order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 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 health care support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 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. Prospective service users are provided with appropriate information, have their needs assessed and are introduced to the service according to their needs. Evidence: Evidence was obtained from information provided by the service prior to the inspection, from documentation seen during the visit and from discussions with the manager and staff. Discussion with the manager, the key worker and documentation seen in respect of a service user who moved into the home since the last key inspection provided evidence that an appropriate assessment was made prior to a place being offered. An individual transition plan ensured that the needs of the service user were paramount throughout the process of them moving into the home. Care Homes for Adults (18-65 years) Page 11 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users assessed and changing needs are appropriately reflected in their individual plan of care. Service users are encouraged and supported to make decisions about their lives and to take managed risks where appropriate. Evidence: All service users have their needs regularly assessed and a key worker system ensures that all paperwork in relation to service users is reviewed and updated regularly. Plans of care were seen in respect of three service users. They were detailed and followed a uniform format ensuring that all important information was easy to access. A daily diary for each service user is used to indicate and record their needs, wishes and choices. This information feeds into a monthly then quarterly report outlining how these aspirations have been fulfilled. The manager is planning to obtain a laptop to be used by staff together with service users in a setting comfortable for the individual service user in order to involve them as fully as possible in the completion of documentation about them. Formal reviews involving relatives and other professionals are arranged at least annually. Care Homes for Adults (18-65 years) Page 12 of 27 Evidence: The home has undertaken work to ascertain individual service users capacity to consent and evidence was available within plans of care. It was evident from discussion with staff members and from interactions observed with service users that decision-making is actively encouraged and supported. Guidance and assistance is provided to service users in relation to appropriate decisions such as choice of food, activities and bedtimes. A range of comprehensive risk assessments is in place that are individual to each service user and links to clear practise guidelines where appropriate. There was evidence that these are reviewed on a regular basis and adjusted according to changing needs. Care Homes for Adults (18-65 years) Page 13 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. Service users take part in valued occupational and leisure activities with their peer group and within the local community. They are supported with appropriate relationships and to maintain links with family and friends. Service users are enabled to choose from a healthy diet. Evidence: Service users are encouraged and supported to lead fulfilling lives appropriate to their needs, wishes and preferences. Each service user has a full programme of activities including a wide range of leisure pursuits, aromatherapy sessions, computing, gardening, music, sports, and art sessions, shopping and restaurant trips and employment commitments. Activities are also conducted within the home and form part of the plans for individuals. The manager intends to introduce an activity timetable for each service user which utilises symbols, pictures or other communication aids relevant to the individual that provides information about the Care Homes for Adults (18-65 years) Page 14 of 27 Evidence: activities to be undertaken each day. Community access is actively supported and encouraged and evidence seen within activity plans and care plans confirmed that service users access the doctors, dentist, discos, restaurants and cafes. An activity board is displayed in the communal area and details the timetable of activities planned for each service user each week. Service users meetings are held regularly and staff support and encourage their participation in these events. All service users have a holiday according to their individual needs and preferences. This may take the form of day trips if this is more suited to the needs of the individual. The home has a dedicated vehicle but does use other forms of transport on occasions. Evaluations are made about whether each trip is appropriate for individual service users. Each service user file contains details of family, friends and advocates. The manager confirmed that of the ten current service users five have a designated befriender who visits them regularly. The home actively encourages contact with family and supports service users to visit their relatives where appropriate. It was clear from discussion with staff members that the philosophy of the home promotes the rights of the service users and recognises their responsibilities. Care plans seen contain information about daily tasks and routines for individual service users. The arrangements for the provision of food is overseen by the staff team as a whole. The menu planner was seen and it provided evidence that a wide range of healthy foods are provided in the home based upon individual choice, preference and needs. Menus are formulated each week together with service users and results in a more flexible but immediate response to individuals wishes. The manager stated that since the closure of the communal dining room earlier this year vegetables have formed an integral part of meal planning and has resulted in several service users appropriately losing weight. Indirect observation conducted during the course of the lunch confirmed that staff encourage and support service users to make choices using their preferred communication methods. Care Homes for Adults (18-65 years) Page 15 of 27 Personal and health care 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users receive personal support in the way they prefer and their physical and emotional health care needs are very well met. Service users are protected by the homes policies and procedures on dealing with medicines. Evidence: The plans of care seen provided comprehensive information about the personal and health care needs of individual service users. Preferences in relation to personal care was clearly recorded and enabled staff to ensure that they undertook tasks with individual service users that focused upon their needs and reduced potential anxiety and frustration. The manager and the staff spoken to had sound and detailed knowledge of individual needs and preferences. Daily routines are flexible and bedtimes and mealtimes are not rigidly enforced but take account of individual timetables. All service users have a range of health checks undertaken on a regular basis. Their general health and well being is closely monitored by staff. It was evident from the three plans of care seen that a wide range of health care professionals are called upon according to individual service users needs. For example Physiotherapy, Speech Care Homes for Adults (18-65 years) Page 16 of 27 Evidence: Therapy, Chiropody, Dentist, General Practitioners, Psychiatrist and various hospital departments have been utilised and were evident within plans of care seen. All appointments and outcomes are recorded. A visiting Psychologist employed within the Community Team for People with Learning Disability was seen in private. She had known the manager for several years and was familiar with the service. She was complementary about the professionalism of the manager and staff and the high standard of care provided to service users. There was considerable evidence that confirmed that the staff team under the guidance of the current manager had enhanced the lives of the service users currently living in the service. Through the persistence of the manager, with health care colleagues, one service user was now walking outside the home having once been confined to a wheelchair for external trips. Another was increasing their mobility following a broken wrist due to the manager advocating on their behalf with health care providers. There are no service users who currently administer their own medication. The home is in the process of changing its medication provider and positive outcomes from this change are anticipated by the manager. All staff who administer medication have received appropriate training with regular refresher training being provided. The manager undertook to implement a recording tool to evidence the periodic audit of the medication systems that she undertakes. The medication prescribed for individual service users is reviewed regularly as needs change and at least on an annual basis. A Pharmacist from the Primary Care Trust reviewed the medication procedures within the home on 13.1.09 and considered that all the standards were met. Care Homes for Adults (18-65 years) Page 17 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. Service users have their views listened to and are protected from abuse, neglect and self-harm. Evidence: There is a robust and comprehensive complaints procedure in place that is provided by the organisation. Information provided by the service prior to the visit confirmed that no complaints had been received by the service since the last inspection. No complaints or concerns about this service have been received by the Commission. Throughout the course of the inspection it was evident that the wishes and views of service users are seen as paramount in providing an individual service to them. All staff have received training in safeguarding adults and of those three staff spoken to in private all demonstrated a sound understanding of the principles of safeguarding adults. A safe guarding referral had been made since the last inspection where one service user had made an allegation about another service user. The safeguarding of vulnerable adults procedures were followed but the service user withdrew the allegation and the investigation ceased. The manager confirmed that she had attended Deprivation of Liberty Safeguards training and those staff spoken to were aware of the general principles. Care Homes for Adults (18-65 years) Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from a homely, safe and comfortable environment that is maintained in a clean and hygienic condition. Evidence: A tour of the premises was undertaken. The home is appropriately decorated and is comfortably furnished. Some individual bedrooms were seen and had clearly been decorated, furnished and personalised according the needs and preferences of the individual occupant. The communal areas were spacious and had been arranged to meet the needs of current service users. There is a garden for the use of service users that is well used during warmer weather. It was noted that the kitchen was old and in need of replacement. Staff reported that the cooker did not work properly and made the task of preparing meals for up to fifteen people each day arduous and time consuming. Repairs to the cooker had been undertaken by the organisation but had not solved the problems. The organisation must give serious consideration to replacing the current cooker and providing a timetable for replacement of the current kitchen, which is difficult to keep clean and hygienic. There is a good range of assisted bathing facilities and mobility aids were used for those service users that needed them. Maintenance issues are raised when identified and acted upon without delay. The home has a designated laundry room and Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: throughout the home was clean, tidy and fresh smelling. Staff are collectively responsible for cleaning and delegated tasks ensures that the standards of cleanliness in the home are maintained. COSHH data sheets are kept for all cleaning materials used in the home. Care Homes for Adults (18-65 years) Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are supported by competent, well-trained and qualified staff and are protected by the homes recruitment policies and practises. Evidence: The organisation provides a comprehensive staff training programme that includes National Vocational Qualification training, specialist learning disability awards and ongoing core training including moving and handling, food hygienes, fire awareness and safeguarding adults. All new staff are required to undergo induction training to Skills4care standards and guidelines. It was confirmed in discussion with staff that induction is provided and expected of all new staff. Once induction has been completed staff move to more advanced training such as NVQ. The training department is well organised and notifies services when updates or refresher training is due for individual staff. Each staff member has a training profile where copies of training certificates are maintained. The training department keeps a training profile for the home as a whole. Positive interactions between service users and staff were observed throughout the course of the inspection. Service users were supported appropriately and clearly benefited from a good rapport with staff members. Overall staff appeared confident in their roles and those spoken to indicated that they were well supported by the management within the home and by fellow team members. Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: A shift planner is posted in the hallway and includes photographs of staff on duty enabling service users to see who is working in the home. Staff meetings are held regularly and staff spoken felt that they were useful. Communication between staff was considered to be good with a range of tools being used to support this including a staff communication book and regular shift hand overs. The organisation has a robust recruitment system that is administered centrally. Evidence was accepted from information provided by the service and from knowledge of the organisation that no staff member commences employment within the home without having provided all the necessary documentation as dictated by the regulations. Care Homes for Adults (18-65 years) Page 22 of 27 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run and in a manner that reflects the views of service users. The health, safety and welfare of service users are promoted and protected. Evidence: The current manager is highly experienced and well qualified. She was described by those staff spoken to as very professional, competent and approachable. It was apparent from discussions with the manager that she is constantly looking to improve the service to service users and to develop her own learning. Staff commented that she was completely service user focused and expected the same approach and philosophy from the whole staff team. The service is monitored in various ways including the use of Regulation 26 visits and lay monitoring visits. A questionnaire is distributed to service users and their families on a periodic basis and it is the intention of the manager to include other stakeholders such as Care Managers and other health care professionals. Two questionnaires recently returned provided positive comments about the service. Feedback from service users is obtained from observations of their reactions to activities and verbal Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: comments from them about the experience. A wide range of health and safety checks are undertaken. Including the arrangements for fire safety, portable appliance tests, regular servicing of equipment such as the lift and hoists, gas safety checks and water blending valve checks. A full fire evacuation of the premises is undertaken periodically. It was noted that the fire risk assessment was overdue for review and the manager undertook to arrange a review without delay. It was also her intention to implement a management audit tool that would record when health and safety audits were undertaken by her to ensure that all checks and servicing requirements were up to date. This audit tool could be extended to include other areas of recording within the home such as plans of care. Care Homes for Adults (18-65 years) Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 25 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 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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