Care Home: The Grove

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What the care home does well There was an experienced, trained and stable staff team to support people. People and their representatives spoke highly of the staff team. They said, "the staff are very good although they are run off their feet and very overworked", "there is a good rapport between different relatives and the staff", "staff are helpful, considerate and very friendly and treat my mother as if she is their own mother - they are great with her", "employs hard working staff/carers", "overall we are happy. You can talk to staff if need be", "good rapport with residents" and "staff give 110% despite being rushed off their feet and probably underpaid". In respect of the health and personal care that people received they commented, "the basic necessities of care (they do well), i.e. food, toilet, bathing, warmth, general assistance, some activities", "the team at The Grove are very caring and work hard to attend the needs of my ..." and "mum has always received good care at The Grove and there is always a friendly atmosphere". People were treated as individuals. They were assisted to make choices and decisions in their daily life. Social activities met some peoples` expectations and they were able to keep in touch with family, friends and representatives. People and their representatives commented, "gives stimulation via activities co-ordinator", "I like the fact they do day trips out and other things. They also have time outside within the grounds" and "makes it feel welcome, even for young children". People had meals that were of a good quality. The living environment was clean. There was a robust recruitment procedure so that people living at the service can be assured they are sufficiently protected. What has improved since the last inspection? After listening to the views of people the home had improved its environment by having a new shower room fitted in the dementia unit, which gave people a choice of how they bathed within their own living environment and redecorating the dining room downstairs including new chairs. They had also maintained servicing of the hoist, which should make sure it is safe for people to use. What the care home could do better: There were aspects of management and administration of the home that were lacking, which had resulted in the service not meeting the legislative requirements and National Minimum Standards of a registered care home to ensure the health, safety and welfare of people and staff. These are identified below. Everyone must have an assessment of their needs before they are admitted to the home and there must be written information about this. This would mean the person will not be placed at risk or not have their wishes adhered to, by the service having insufficient information. From this make sure a plan of care is in place, so that there is confirmation about how their needs are to be met and monitored. Records didn`t always reflect that people received the health and personal care they needed. This included keeping a record of any physical restraint that might be used on a person, so that a consistent approach is maintained by staff, that has been agreed as being in the person`s best interests and people aren`t limited in their liberty of movement, freedom of choice and power to make decisions without due process. Also, behaviour charts should detail the type of behaviour displayed and what happened and who was involved prior to the change of behaviour. This would enable the care plan to be reviewed objectively and how changes in behaviour may be managed by staff. Staff need to act on information noted in records to make sure people`s diet and nutritional needs are met, so that their health and welfare is maintained. All aspects of dealing with medication need to improve to demonstrate people are receiving the medication they are prescribed. Improve the dining experience for people on the dementia unit, including that the meal on offer is the same for everyone in the home and the dining room in the dementia unit is welcoming, including the decor and sufficient space. All complaints must be investigated, to inform the person who made the complaint of the outcome of their complaint. This will give complainants reassurance that their complaints are acted on. Refer staff to the appropriate registers when their conduct has identified they may not be safe to work in a care environment. This will mean people aren`t placed at risk of harm or abuse. People, their relatives and staff felt the environment could be improved for people. They said, "Guardian Care should ensure that maintenance matters, i.e. replacement windows should be a priority" and "maintenance problems never seem to take priority in time or money". We found this ourselves and therefore the service must take action, including replacing windows that are not fit for purpose and take steps to fit window restictors where this is needed or repair them where necessary, provide suitable lighting and heating, make part of the lounge in the dementia unit able to be used by people and provide hot water from taps on the dementia unit. Everyone thought staffing levels were insufficient, therefore, the home must use a recognised dependency tool to ensure they have sufficient staff on duty to meet people`s needs, including their social needs. Comments included, "there is definitely not enough staff. The legal limit for The Grove apparently is two per shift, which is ridiculous especially when it takes two staff to bathe or toilet someone. That often leaves no-one else looking after others. Relatives can quite often never find a member of staff, through no fault of theirs, as they are usually with a resident in the bathroom. There have been times when a member of staff has phoned in sick and it has left only one on duty for a few hours until a replacement has been found. This is not fair to the residents, the relatives or the member of staff on his/her own", "staff would stay longer in the past. Also, be more willing to work at short notice if they were treated better and received more pay", "in my opinion there should be at least three staff per shift. My mother is quite independent, but other residents are not. Also, my mother tries to do as much as she can for herself as possible as she thinks she is bothering them. This is ok, but there might come a time when she tries to be too independent and hurts herself. The Grove overall is a very nice care home and it`s a shame that the staff are so overworked that they feel they haven`t the time to mingle with both residents and their relatives", "staffing when I need it", "increase the number of carers and hourly rate of pay, even though the relevant guidelines on staff numbers are `adequate`. Allow paid time to staff on cross over shift time. This will enable them to converse on residents` problems, in addition to the daily diary", "as a matter of health and safety, there are 2 staff on 2 floors. When a resident is being bathed/showered the remaining residents are alone, as it takes both carers to complete the task. In this alone anything, i.e. accidents can happen to the remaining residents and there is nobody to attend Key inspection report Care homes for older people Name: Address: The Grove Thurnscoe Bridge Lane Thurnscoe Rotherham South Yorkshire S63 0SN     The quality rating for this care home is:   one star adequate 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: Jayne White     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 40 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 40 Information about the care home Name of care home: Address: The Grove Thurnscoe Bridge Lane Thurnscoe Rotherham South Yorkshire S63 0SN 01709895424 01709897948 admin@grovethurnscoeplus.co.uk www.guardiancarehomes.co.uk Guardian Care Homes (UK) Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Karen Willoughby Type of registration: Number of places registered: care home 28 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Persons accommodated shall be aged 60 years and above. The manager will work 40 hours per week supernumerary. Date of last inspection Brief description of the care home The Grove is a 28-bed Home providing 13 beds for older people with dementia and 15 beds for older people needing personal care. It is situated in the village of Thurnscoe, eight miles from Barnsley town centre close to the A635 Barnsley to Doncaster Road, with easy access by bus and train. The home is within walking distance of all local amenities, which includes a variety of shops, supermarkets, chemist, post office, hairdressers, community centre, bowling green, pubs clubs, local village churches and Care Homes for Older People Page 4 of 40 0 0 Over 65 13 15 Brief description of the care home the health centre. The home stands in its own extensive gardens with mature trees and shrubs. The gardens are landscaped and well maintained providing ample sitting areas for people and their families. Car parking is available at the side and front of the home. Care Homes for Older People Page 5 of 40 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: one star adequate 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: This was a key inspection. We visited without giving the service any notice from 09:00 until 17:15. Mrs Karen Willoughby, manager was present during some of the visit. She has left the home since our visit. The manager completed an Annual Quality Assurance Assessment before the site visit. This gives the service the opportunity to tell the CQC how well they think they are meeting the needs of people using the service and what they are working on to improve. Various aspects of the service were then checked during the site visit including inspection of parts of the environment, records relating to the running of the home, observing care practices and inspecting a sample of policies and procedures. We sent surveys to: Ten people living at the home, asking them about their Care Homes for Older People Page 6 of 40 experiences of living there. Eight surveys were returned (80 ). Some of these had been completed by their representatives (either a relative or someone they had asked to act on their behalf). Ten to the representatives of people living at the home (this included family and friends), asking them about their experiences of their contact with the home. Seven were returned (70 ). Five to health professionals and three to care managers, asking them about their experiences of working with the home. One was returned from a health care professional (20 ). Five to staff, asking them about their experience of working at the home. One was returned (20 ). The majority of people living at the home were seen throughout the visit and several were spoken with about the care they received, as were some of their representatives. The care provided for four people was checked against their records to determine if their individual needs identified in their plan of care were being met. We also spoke with staff and the manager about their knowledge, skills and experiences of working at the home. We checked all the key standards and previous requirement. The manager was provided with initial feedback from the inspection during and at the end of the visit. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? What they could do better: There were aspects of management and administration of the home that were lacking, which had resulted in the service not meeting the legislative requirements and National Minimum Standards of a registered care home to ensure the health, safety and welfare of people and staff. These are identified below. Everyone must have an assessment of their needs before they are admitted to the home and there must be written information about this. This would mean the person will not be placed at risk or not have their wishes adhered to, by the service having insufficient information. From this make sure a plan of care is in place, so that there is Care Homes for Older People Page 8 of 40 confirmation about how their needs are to be met and monitored. Records didnt always reflect that people received the health and personal care they needed. This included keeping a record of any physical restraint that might be used on a person, so that a consistent approach is maintained by staff, that has been agreed as being in the persons best interests and people arent limited in their liberty of movement, freedom of choice and power to make decisions without due process. Also, behaviour charts should detail the type of behaviour displayed and what happened and who was involved prior to the change of behaviour. This would enable the care plan to be reviewed objectively and how changes in behaviour may be managed by staff. Staff need to act on information noted in records to make sure peoples diet and nutritional needs are met, so that their health and welfare is maintained. All aspects of dealing with medication need to improve to demonstrate people are receiving the medication they are prescribed. Improve the dining experience for people on the dementia unit, including that the meal on offer is the same for everyone in the home and the dining room in the dementia unit is welcoming, including the decor and sufficient space. All complaints must be investigated, to inform the person who made the complaint of the outcome of their complaint. This will give complainants reassurance that their complaints are acted on. Refer staff to the appropriate registers when their conduct has identified they may not be safe to work in a care environment. This will mean people arent placed at risk of harm or abuse. People, their relatives and staff felt the environment could be improved for people. They said, Guardian Care should ensure that maintenance matters, i.e. replacement windows should be a priority and maintenance problems never seem to take priority in time or money. We found this ourselves and therefore the service must take action, including replacing windows that are not fit for purpose and take steps to fit window restictors where this is needed or repair them where necessary, provide suitable lighting and heating, make part of the lounge in the dementia unit able to be used by people and provide hot water from taps on the dementia unit. Everyone thought staffing levels were insufficient, therefore, the home must use a recognised dependency tool to ensure they have sufficient staff on duty to meet peoples needs, including their social needs. Comments included, there is definitely not enough staff. The legal limit for The Grove apparently is two per shift, which is ridiculous especially when it takes two staff to bathe or toilet someone. That often leaves no-one else looking after others. Relatives can quite often never find a member of staff, through no fault of theirs, as they are usually with a resident in the bathroom. There have been times when a member of staff has phoned in sick and it has left only one on duty for a few hours until a replacement has been found. This is not fair to the residents, the relatives or the member of staff on his/her own, staff would stay longer in the past. Also, be more willing to work at short notice if they were treated better and received more pay, in my opinion there should be at least three staff per shift. My mother is quite independent, but other residents are not. Also, my mother Care Homes for Older People Page 9 of 40 tries to do as much as she can for herself as possible as she thinks she is bothering them. This is ok, but there might come a time when she tries to be too independent and hurts herself. The Grove overall is a very nice care home and its a shame that the staff are so overworked that they feel they havent the time to mingle with both residents and their relatives, staffing when I need it, increase the number of carers and hourly rate of pay, even though the relevant guidelines on staff numbers are adequate. Allow paid time to staff on cross over shift time. This will enable them to converse on residents problems, in addition to the daily diary, as a matter of health and safety, there are 2 staff on 2 floors. When a resident is being bathed/showered the remaining residents are alone, as it takes both carers to complete the task. In this alone anything, i.e. accidents can happen to the remaining residents and there is nobody to attend to them, I do not think that two carers per shift is enough. They are often run off their feet and if a resident needs two carers for bathing or toilet, there is no-one immediately on hand, needs more staff. For instance when my nan-nan had to go to hospital due to a fall which she did whilst in there, the staff werent able to go with her and give an accurate account of what went on. I know it was about 8 9ish pm. Sometimes we cant always make it (relatives) which makes it frustrating as like many older people they cant always hear and answer for themselves. When they get to hospital they are left for a long time to be fearful as well as in pain, never seems enough staff, two members of staff is not enough when it takes two to bath a resident, there is often a shortage of staff due to sickness, I think additional funding would help them provide a better service. They are always rushed off their feet and more resource is needed to help them and would like to see more staff - they are always stretched. Staff supported this. The manager should not loan money to people as this does not ensure sufficient safeguards are in place for people. 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 10 of 40 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 11 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A written assessment of peoples needs had not taken place before they moved into the home. This could mean the person may be placed at risk of not having their needs met or not having their wishes adhered to by the service having no written information about them. Evidence: Most people when we spoke to them said their family had taken the responsibility for making the decision about the choice of home. One person we spoke to told us they had come to look round the home and liked it because it was clean and the girls were working hard. Six of them told us in their surveys that they had received enough information about the home to help them decide if it was the right place for them, two hadnt. The manager in the AQAA told us all clients are visited before being admitted to The Grove to ensure their needs can be met. When we looked at three peoples files to Care Homes for Older People Page 12 of 40 Evidence: confirm the process had included a written assessment of their needs, we did not find this. In two of the files, the pre-admission assessment or admission assessment was dated after the person had become resident at the home. This is not good practice and could mean the person may be placed at risk of not having their needs met or not having their wishes adhered to by the service having no written information about them. In the other file, the admission information was blank. A summary assessment had been received from the placing authority for one of the people. A plan of care had been put together from the information. Care Homes for Older People Page 13 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. On the whole, the health and personal care that people received reflected what assistance they needed, but records didnt always support this. Overall, people were treated with respect, dignity and privacy. Evidence: Peoples surveys that were returned told us three thought they always received the care and support they needed, four that they usually did and one that they sometimes did. Five stated they always received the medical care they needed, three that they usually did. Comments in the section what they do well included, the basic necessities of care, i.e. food, toilet, bathing, warmth, general assistance, some activities and mum has always received good care at The Grove and there is always a friendly atmosphere. Similar information was provided when we spoke with people and their representatives on the day of the visit. The relatives surveys told us three felt the care service always met the needs of their representative, three that they usually did and one that they sometimes did. Three stated they felt the service always kept them up to date with important issues Care Homes for Older People Page 14 of 40 Evidence: affecting their representative, four that they usually did. Three stated the service always gave the care to their representative that they expected or agreed, four that they usually did. One commented, the team at The Grove are very caring and work hard to attend the needs of my .... The staff survey stated they were usually given up to date information about the needs of people they cared for and the way information is shared aout people with other carers and the manager usually works well. This was confirmed with staff when we spoke with them during the inspection. We looked at four care plans. Three of them contained satisfactory information that was in the main sufficient to inform staff of the action they needed to take to meet peoples needs, but there were areas for improvement (see below). The other was poor with very little information about the person, other than their social history. On three of the files the daily report identified that staff generally acted on information in the plan of care. In the other there were gaps in the daily records about what they had done for the person and the quality of life theyd enjoyed. Apart from one of the files, risk assessments were in place to identify any risks that might be presented by people, for example, mobility and falls. The assessment identified the action required by staff to reduce the potential risks to people, which promoted and maintained their independence. Apart from one of the files, nutritional risk assessments were in place and a record of peoples weights were maintained. However, one of the care plans we looked at identified the person had lost weight and dietary intake must be monitored. This was not taking place. The senior care in charge of the shift put dietary intake sheets in place on the day of the visit and was told to check that no further action was needed. A visit undertaken by the provider in October 2009 had also highlighted another instance where appropriate action had not been taken in regard to a persons weight loss. This identifies consistent poor monitoring of an area that may indicate the health of a person needs closer monitoring. For people in the dementia unit a mini mental score had been undertaken to assess a persons dependency level. In one instance the score was 0, but they had been identified only as having medium dependency. We also found evidence in a daily report of restraint being used, but there was nothing in the plan of care to indicate this was to be used or what the restraint might be. This can lead to inconsistent practice by staff, which can make the situation worse. Also, the behaviour chart in place was ineffective as it detailed good or bad behaviour. This is subjective and Care Homes for Older People Page 15 of 40 Evidence: does not give a true reflection of the situation, so that the care plan can be reviewed to identify how changes in behaviour may be managed by staff. Records of healthcare visits that were undertaken were maintained and demonstrated people did receive visits some visits from healthcare professionals. People confirmed this when we spoke with them. When we observed staff working, in the main there was clear and respectful communication between people and staff and staff treated people in a kind manner. People were well dressed, with no food spillages on their clothes, but their hair and nails could have received better attention. Some peoples hair looked as if it hadnt been brushed and some peoples nails were dirty. Senior care staff administered medication. The seniors on duty told us they had received training in how to deal with medication. Discussions with staff and observations of their practice told us there were inconsistencies about the procedures used at the home. For example, all staff did not sign the medication administration record (MAR) after the person had received their medication. This is not safe or good practice and can result to providing misleading information. For example, we saw that one type of tablet had been dropped on the floor. Another tablet was not offered, but because it had been signed for on the MAR it indicated they had received the medication. Medicines were securely stored. However, medication was not always properly stored. For example, we found creams stored in the fridge. We saw that when people were given their medication it was done in a respectful and dignified way. A drink was available to assist people in taking their medication. However, people were not always prompted and encouraged to take their medication properly. We noted at the lunch time meal in the downstairs unit, medication was left on tables for people to take. There were no risk assessments in place that identified this would be safe. We looked at the recording, administration and storage of medication on a sample basis. Medication received was clearly recorded on the persons medication administration record. However, handwritten entries had not always been countersigned to confirm they were correct. The record indicated people were not always receiving their medication as prescribed. Staff stated the prescription had been changed, but there was no written information to confirm this. There were lots of gaps in the MAR with no codes given to indicate why there may not be a record. For Care Homes for Older People Page 16 of 40 Evidence: medication that was given when people required it, there was no indication of when this might be. This is particularly important for people that are unable to make that decision themselves so that a consistent approach is maintained and medication given for the correct reason. The manager undertook audits of medication on a regular basis. The last one on 14 October had not highlighted any concerns. Our findings in regard to medication gave us concerns that people may not be receiving their medication as prescribed and we issued an immediate requirement to the manager to complete an audit of the medication within 2 days to confirm people were receiving their medication as prescribed. An e-mail received by the manager confirmed this had been done, but contained insufficient information. A discussion with the area manager on 23 December 2009 clarified this had been done and appropriate action taken. Care Homes for Older People Page 17 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In the main, people were assisted to make choices and decisions about their daily life and social activities, but staffing levels hampered this for some people. Evidence: Six of the surveys returned by people told us the home always arranged activities that they could take part in, 2 that they usually did. They commented, gives stimulation via activities co-ordinator, I like the fact they do day trips out and other things. They also have time outside within the grounds and makes it feel welcome, even for young children. Similar information was given by people about social activities they took part in when we spoke with them. Some said they liked spending time in their rooms and were able to do this, coming and going as they pleased. We spoke to the representatives of two people who lived there. They knew who did the activities with their representatives and were able to tell us about the activities they took part in. They told us theyd been to a show and a club at Ardsley where theres a singer and a buffet. They said daily life was good. They described this as having a Xmas Fayre, raising funds for entertainment, having an entertainer and having fireworks. They said the TV was often on, but old time music was sometimes playing. They told us in the summer the gardens were used. Care Homes for Older People Page 18 of 40 Evidence: We spoke to the activities co-ordinator who confirmed what people and their representatives had told us. They said they divided their time between both units and both one to one and group activities took place. They told us how they were due to attend training for activities that would be suitable for people with dementia. The activity book where they recorded what activities had taken place showed a variety of activities and in November this had included musical bingo, reorganising the china cabinet, Christmas card making and a fashion show. Our observations during the visit and discussions with people identified for those people that were able, because they were more independent they could spend their day as they wished following their preferred routines. For people who were not as independent we saw that staff did not spend quality time with people. This was because they were otherwise engaged doing practical tasks. This meant leaving people unsupervised and just popping in to make sure everything was ok. This resulted in two people in the dementia unit constantly shouting out. When we engaged them in activity or conversation this stopped. Carers supported this observation, but said they couldnt engage them like this because there was only two staff on duty and most of the time they had other tasks to attend to. People told us their family and friends could visit at any time and that they were made to feel welcome by being offered a drink and staff being friendly. This means they were able to maintain important personal and family relationships. Two of the surveys returned by people told us they always liked the meals at the home, six that they usually did. One commented, supplies good nutritional food, which is presented and served in a correct manner. Again this was supported when we spoke to people and their representatives. A health professional survey that was returned contained the comment, the food appears plentiful and of good quality. The dining room downstairs was welcoming, being bright and clean. Someone said it had recently been decorated and the curtains dry cleaned. The upstairs dining room did not enable a pleasant meal time environment for people. The environment was cramped and the hot trolley and medication trolley in the room at the same time did not help the situation. They blocked the way for people to come and go as they pleased and made the room claustrophobic. We saw the lunchtime meal being served, both downstairs and upstairs. There was no Care Homes for Older People Page 19 of 40 Evidence: rush to the mealtime and people were given sufficient time to eat. Staff were patient and helpful and allowed people time to finish their meal. Care staff were sensitive to those people who found it difficult to eat their meal themselves and needed assistance. They helped the person at their pace, making them feel comfortable and unhurried. However, we noted that people upstairs had a variation to the sweet offered to people downstairs. There was no explanation for this. Care Homes for Older People Page 20 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to express their concerns and had access to a complaints procedure, but there was not always a record of the outcomes of those complaints. Policies and procedures were in place to keep people safe, but this didnt always protect people. Evidence: All surveys returned by people told us there was someone they could speak to informally if they werent happy. Six of them knew how to make a complaint, two had left this blank. One commented, all problems that occur are usually dealt with straight away. This was supported when we spoke to people on the visit. This indicated there was an open culture that allowed people to express their views and concerns in a safe and understanding environment. The representatives surveys told us they all knew how to make a complaint about the care provided if they needed to. Five of them stated when they had done so they always responded appropriately, two that they usually did. A health professional in their survey commented, the patients seem pleased with the home. I often ask the new arrivals if they are happy there. People could access the complaints procedure because it was displayed in the foyer and clearly described the procedure for people should they have any concerns. It was clearly written, easy to understand and explained what the procedure was. However, it Care Homes for Older People Page 21 of 40 Evidence: did not tell people how long the process might take or the correct information about the Commissions contact details, should people wish to contact them. This was brought to the managers attention. The staff survey told us they didnt know what to do if someone had concerns about the home. We saw a complaints/comments book in reception. Although this is a good idea it did not enable people to maintain their anonymity and receive feedback about their complaint or feedback. These were not transferred to the formal complaints procedure and all outcomes were not recorded as being addressed. Looking at what was recorded it told us peoples representatives were not always happy with the levels of staffing. In one instance the family had taken the person out because they couldnt find anyone to tell. This is unsafe as staff dont know peoples whereabouts. Also, there had been heaters in bedrooms that werent working. These were checked on the visit and all but one were now in working order. The actual complaints record identified four complaints had been made. This confirmed what the manager had told us in her AQAA although there was discrepancies about whether they had been upheld or not. The record told us one had been partially upheld. We discussed with the manager how the record could be improved by including more detail. The knowledge of the manager in respect of safeguarding adults was satisfactory. The service had a copy of the local adult safeguarding policy and procedure for South Yorkshire. The manager in the AQAA told us there had been two adult safeguarding referrals. The Commission were aware of four. All had resulted in investigations, which the manager knew about. A previous investigation had resulted in one member of staff being referred to a register that prevents them from working in a care environment again. However, the service had to be prompted to make the referral. Care Homes for Older People Page 22 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. On the whole, the living environment was clean but improvements were required to make all living areas a well maintained and comfortable environment for people to live and enjoy. Evidence: Surveys returned by people told us two of them felt the home was always fresh and clean, four that it usually was and one that it sometimes was. They commented in what the service did well, it has a very homely feel, relatives are able to feel that you are entering your parents home and not a care home, provides a warm, safe environment for residents, a part time gardener has been employed and now the grounds are looking well kept, since employing a gardener, the grounds and gardens are much improved and the place itself is in a beautiful setting which makes it relaxing inside and out. One of them commented in what they could do better, Guardian Care should ensure that maintenance matters, i.e. replacement windows should be a priority. Similar information was given by people when we spoke with them. They said their bedrooms were comfortable and some people said they had personalised these with pieces of their own furniture and possessions. We saw this when we looked in them on the dementia unit. Relatives commented in their surveys about what the service does well, rooms clean and tidy, homely atmosphere and The Grove has a homely feel about it and is Care Homes for Older People Page 23 of 40 Evidence: friendly. In what they could do better, one commented, maintenance problems never seem to take priority in time or money. The health professional commented in their survey, the home appears clean and tidy. The manager in the AQAA told us as a result of listening to people theres a new dining room layout and redecoration, new chairs have been purchased and gardens have been improved. Further plans are to improve the dementia unit through redecoration and open spaces made more user friendly. When we looked round the home, generally, the main lounges and dining area downstairs presented a pleasant and homely environment for people to live and they were well lit. There were a number of sitting areas and there were sufficient toilets for people that were appropriately located and easily accessible. This was not the case upstairs in the dementia unit, although a small lounge being used by two people was very homely, but dark. There were two sections to the main lounge in the dementia unit. One part had a centre light fitting that worked and gave off enough light, in the other part the main light was not working and staff said they relied on a standard lamp. This part of the lounge did not look inviting to use and it was unable to be used as it had only one chair in there and no table on which to place things. It looked untidy and activity equipment had been left in boxes on the floor. We were cool throughout the inspection. We checked the radiators. Most of them were aired, but clearly not warming the room sufficiently as people were sat with blankets around them and there were gaps in the windows which created cold drafts. Staff said that in the winter you feel the drafts and have to shut the curtains because windows dont fit properly. We saw some windows where putty had been put in to try and block out the drafts. They said new ones were supposed to be fitted. The manager confirmed this, but didnt know when. She was told not to use a bedroom upstairs until they had been fitted, because of this problem. Also, some of the window panes had become misted between the double glazing, which made them difficult to see out of. A new shower room had been fitted in the dementia unit, which gave people a choice of how they bathed within their own living environment. We noted that on the dementia unit new systems had been put in to provide hot water Care Homes for Older People Page 24 of 40 Evidence: to people in their rooms. Consideration had not been given to maintaining the independence of people by fitting these, as the device was not a tap, which makes how to get a wash more confusing for people as they would never have seen this system. In the future, the manager was asked to consider the needs of people first and improve things to meet their needs. Care Homes for Older People Page 25 of 40 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. There was an experienced, trained and stable staff team to support people, but they were not in sufficient numbers to meet the needs of people. The recruitment of staff was sufficient to ensure people using the service were protected. Evidence: Surveys returned by people told us two of them felt that staff were always available when they were needed, four that they usually were, one that they sometimes were and one that they never were. Two of them stated the staff did listen and act on what they said, six that they usually did. They commented in what they did well, the staff are very good although they are run off their feet and very overworked, there is a good rapport between different relatives and the staff, staff are helpful, considerate and very friendly and treat my mother as if she is their own mother - they are great with her, employs hard working staff/carers, overall we are happy. You can talk to staff if need be. In what they could do better they said, there is definitely not enough staff. The legal limit for The Grove apparently is 2 per shift, which is ridiculous especially when it takes two staff to bathe or toilet someone. That often leaves no-one else looking after others. Relatives can quite often never find a member of staff, through no fault of theirs, as they are usually with a resident in the bathroom. There have been times when a member of staff has phoned in sick and it has left only one on duty for a few hours until a replacement has been found. This is not fair to the residents, the relatives or the member of staff on his/her own, staff would stay Care Homes for Older People Page 26 of 40 Evidence: longer in the past. Also, be more willing to work at short notice if they were treated better and received more pay, in my opinion there should be at least 3 staff per shift. My mother is quite independent, but other residents are not. Also, my mother tries to do as much as she can for herself as possible as she thinks she is bothering them. This is ok, but there might come a time when she tries to be too independent and hurts herself. The Grove overall is a very nice care home and its a shame that the staff are so overworked that they feel they havent the time to mingle with both residents and their relatives, staffing when I need it, increase the number of carers and hourly rate of pay, even though the relevant guidelines on staff numbers are adequate. Allow paid time to staff on cross over shift time. This will enable them to converse on residents problems, in addition to the daily diary, as a matter of health and safety, there are 2 staff on 2 floors. When a resident is being bathed/showered the remaining residents are alone, as it takes both carers to complete the task. In this alone anything, i.e. accidents can happen to the reamining residents and there is nobody to attend to them, I do not think that 2 carers per shift is enough. They are often run off their feet and if a resident needs 2 carers for bathing or toilet, there is no-one immediately on hand and needs more staff. For instance when my nan-nan had to go to hospital due to a fall which she did whilst in there, the staff werent able to go with her and give an accurate account of what went on. I know it was about 8 9ish pm. Sometimes we cant always make it (relatives) which makes it frustrating as like many older people they cant always hear and answer for themselves. When they get to hospital they are left for a long time to be fearful as well as in pain. Similar information was given by people, their relatives and staff on the visit when we spoke with them. Comments from representatives in their surveys about what the home did well was, good rapport with residents and staff give 110 despite being rushed off their feet and probably underpaid. About what the home could do better they commented, never seems enough staff, two members of staff is not enough when it takes two to bath a resident, there is often a shortage of staff due to sickness, I think additional funding would help them provide a better service. They are always rushed off their feet and more resource is needed to help them and would like to see more staff - they are always stretched. The staff survey that was returned told us they also felt there was never enough staff to meet peoples needs. They commented, at the moment all staff work to the best of their ability, including laundry and the cleaners, but there just isnt enough of us, get more staff. More hours for cleaners and laundry, another staff on nights, maybe a twilight shift, as its amazing what an extra pair of hands do make. Having more staff in the right places, could give more time for the staff to interact with the residents as Care Homes for Older People Page 27 of 40 Evidence: we at the moment dont have time. I feel if staffing levels were better residents would get the right care and attention they need. We looked at the staff rota and it confirmed what everyone had told us. There were two staff on each unit during the day, one staff member on each unit during the night, with a member of staff that floated between the units. When we asked the manager for how the staffing levels were calculated she was unable to verify they were calculated using a recognised dependency tool. We observed how staff worked during the visit. This told us there were good relationships between staff and people, but that people did sometimes have to wait for assistance because staff werent immediately available. We also saw that people were left on their own for periods of time, which can be unsafe and not reassuring for some people and their representatives. The AQAA told us the dependency was high and indicated the staffing levels were not sufficient to meet their needs. Ten were doubly incontinent, with a further five incontinent of urine, fourteen needed the assistance of two or more staff to help with their care and nine needed assistance with eating. In addition, there was no time for carers to spend time with people doing meaningful activities during the day, other than when the activity co-ordinator was engaged with them. The AQAA told us training opportunities were provided that tried to deliver a programme that meets statutory requirements and National Minimum standards. It stated staff had received induction training and 95 held NVQ Level 2 in Care or above. This was confirmed by the staff member in their survey and staff when we spoke with them. They stated their induction covered everything they needed to know to do the job very well when they started and they were given training relevant to their role that helped them understand and meet the needs of people. They stated their training kept them up to date with new ways of working. Relatives in their surveys supported this because three of them told us the care workers always had the right skills and experience to look after people properly and four that they usually had. The health professional survey also stated managers and staff always had the right skills and experience to support peoples needs. When we looked at staff files it confirmed they did receive training that was relevant to their role. The AQAA stated there was a recruitment policy in place and that everyone who had Care Homes for Older People Page 28 of 40 Evidence: commenced employment in the last twelve months had satisfactory pre employment checks. This was supported when we looked at two staff files. They contained an application form, a full employment history with written verification in gaps of employment, two references and a full Criminal Records Bureau check was received before they commenced work. Care Homes for Older People Page 29 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home was not consistently in the best interests of people due to the health, safety and welfare of people and staff not always being met. Evidence: The home sent us their annual quality assurance assessment (AQAA) when we asked for it. It was brief and although all the sections of the AQAA were completed and the information gave a reasonable picture of the current situation within the service, it did not give us the detailed information we expect of a service that was rated as excellent. The registered provider had not met their responsibilities when there had been a change of manager, by letting us know about this. The manager told us they had done so, but there was no information available to support this. The current manager had many years experience within the caring profession, was appropriately qualified and registered as manager by the Commission. However, when we spoke to staff some felt Care Homes for Older People Page 30 of 40 Evidence: they were not able to voice their opinion about the quality of the service provided. On the whole, however, people were pleased with the service they received and spoke highly of the manager and staff. One person in their survey commented, could do with assistant manager, when manager not there to deal with problems out of hours. There were several quality assurance systems in place to determine the home was run in the best interests of people that lived there. The AQAA told us resident/relative meetings were held six times a year. This was confirmed by people and their representatives when we spoke with them. Visits by the area manager on the quality of the service also took place. These highlighted some of the areas that need addressing that we found on our inspection, for example, putting in place an eating and drinking plan for someone and windows in the dementia unit. This demonstrates commitment and working together with the manager to identify and put together a plan for improvement, although in some areas these were insufficient (see outcome areas health and personal care and environment). One relative in their survey commented, we personally never seem to find things out because of mum not speaking well - a regular newsletter might help. People were encouraged to maintain control over their finances unless they did not want to or lacked capacity. We checked the record of financial transactions for two people. For one person the actual monies remaining correlated with the balance on the record. For the other the person owed money to the manager. This is not good practice as it does not sufficiently safeguard peoples money. The AQAA stated maintenance of equipment was in place for premises electrical circuits, the lift, hoists and fire detection and alarm and fire fighting equipment. Certificates were out of date for portable appliance equipment, soiled waste and gas. The manager stated they had been serviced, but the certificate hadnt come through. When we looked round the building fire exits had been kept clear, which should make it easy for people and staff to leave the building in the event of a fire. A fire risk assessment had been carried out, which meant an assessment of the service had taken place to identify action that needed to take place to safeguard people in the event of a fire. When we spoke to staff, looked at their training records and the AQAA told us staff were received training in infection control, food hygiene, fire and moving and Care Homes for Older People Page 31 of 40 Evidence: handling. However, we were notified of an outbreak of infection and this highlighted the home didnt have liquid soap and paper towels in peoples own rooms. The service were acting on this by ordering six dispensers each month until all rooms had them fitted. They had also ordered pedal bins for each room to further aid the control of the spread of infection. When we looked round the building we saw that a number of the windows did not have window restrictors fitted or that they were broken. No risk assessments were in place to confirm this was safe. Given that people were often left unsupervised and they had large openings this was very unsafe. In the corridor and bedroom areas upstairs on the dementia unit the storage heaters were too hot to touch, but instructions on them included do not cover. Discussion with a carer identified the storage heater system is on a different system to others. The manager was told she needed to take action with these types of heaters to make sure the environment was kept warm, but the heaters were not too hot that they would burn people if they touched them. Care Homes for Older People Page 32 of 40 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 33 of 40 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 1 9 13 An audit of all medication must be undertaken. To confirm people are receiving their medication as prescribed. 24/12/2009 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 3 14 Everyone must have an assessment before they are admitted to the service. So that the service can confirm they are able to meet their needs and staff know what their needs are. 23/01/2010 2 7 15 All people residing at the 23/01/2010 service must have a plan of care as to how their needs in respect of their health and welfare are to be met. So that information is available to the person and staff about how this is to be achieved. 3 8 17 There must be a record of any physical restraint that may be used on a person. 23/01/2010 Care Homes for Older People Page 34 of 40 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 So that a consistent approach is maintained by staff, that has been agreed as being in the persons best interests and people arent limited in their liberty of movement, freedom of choice and power to make decisions without due process. 4 8 12 Staff must act on information in a plan of care about peoples nutrition and diet. So that proper provision can be made to maintain their health. 5 9 13 When medication is 24/12/2009 prescribed as required, there must be a record of when that might be. So that people are protected by the homes procedures for dealing with medication 6 9 13 There must be a record when details of a persons prescription have been changed and that it has been made by an appropriate healthcare professional. 24/12/2009 23/01/2010 Care Homes for Older People Page 35 of 40 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 So that people receive the medication they are prescribed. 7 9 13 Medication must not be left 23/01/2010 at the dining table without supervision, unless there is a risk assessment to confirm it is safe to do so. So that people are protected by the homes procedures for dealing with medication. 8 9 13 Medication must be stored in 24/12/2009 accordance with instructions. So that the temperature it is stored at doesnt affect its use. 9 9 13 People must receive their prescribed medication. So that their health is maintained. 10 9 13 Staff must sign the 23/01/2010 medication administration record after they have administered the medication to people. So that people are protected by the homes procedures for dealing with medication. 24/12/2009 Care Homes for Older People Page 36 of 40 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 11 16 22 All complaints must be investigated and the person who made the complaint informed of the outcome of their complaint. So that complainants can be assured their complaints are acted on. 04/02/2010 12 18 13 Staff must be referred to the 04/02/2010 appropriate safeguarding authorities when their practice has identified they may be unsuitable to work in a care environment with vulnerable people. So that people arent placed at risk of harm or abuse. 13 19 23 Windows that do not fit properly or have misting between the double glazing must be replaced. So that windows are fit for purpose. 06/07/2010 14 19 23 The heating must be maintained at a suitable level for people. So that people are kept warm. 06/02/2010 15 19 23 Make part of the main lounge in the dementia unit tidy and have suitable furniture and fittings available. 06/04/2010 Care Homes for Older People Page 37 of 40 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 So that, that part of the lounge is able to be used and provide a better living environment for people. 16 19 23 Lighting that is suitable for people must be provided in all rooms used by them. So that they have sufficient lighting to meet their needs 17 27 18 The service must 06/02/2010 demonstrate there is enough staff on duty. So that peoples needs are met by the numbers of staff available. 18 38 13 The storage heaters must be 06/02/2010 kept at a temperature that is not so hot as to burn people, but keep the environment warm. So that people arent placed at unnecessary risk of burning themselves against them, but are warm. 19 38 13 Windows must be fitted with 13/01/2010 restrictors and window restrictors where fitted must be in working order unless there is a risk assessment in place that determines they are not needed. 06/04/2010 Care Homes for Older People Page 38 of 40 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 So that unnecessary risks to people are identified and as far as possible eliminated. 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 3 A written assessment of peoples needs should be in place before they are admitted to the service. This would confirm the service were able to meet the persons needs and that staff know what those needs are. The behaviour chart should detail the type of behaviour displayed and what happened and who was involved prior to the change of behaviour. This would enable the care plan to be reviewed objectively and how changes in behaviour may be managed by staff. Handwritten entries on MAR sheets should be countersigned by another person to confirm the information is correct. Staffing levels should be increased so that there is sufficient staff to engage people in meaningful activities of daily living and social activities for longer periods to improve their quality of life. The dining experience for people on the dementia unit should be improved, including that the meal on offer is the same for everyone and the dining room in the dementia unit is welcoming, including the decor and sufficient space. Hot water from sinks in the dementia unit should be delivered from taps, because in domestic settings this is normally how hot water is delivered. The manager should not loan money to people as this does not ensure sufficient safeguards are in place for people. 2 7 3 9 4 12 5 15 6 19 7 35 Care Homes for Older People Page 39 of 40 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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