Care Home: The Willows Care Centre

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What the care home does well The staff give good care with dignity, privacy and they relate well to the residents. ` The staff have a good understanding of the residents needs` ` Takes care well` ` Looks after me well` ` Its like my own home, I like it here` ` I think the staff are really good` The residents live in a clean, pleasant and well - maintained home with bedrooms that are personalised and suit their needs. The home gives the residents a good and nutritious diet and they have choices in what they have to eat. The residents are confident that if they need to complain it will investigated thoroughly. What has improved since the last inspection? The requirements and recommendations made at the last inspections have been put in place. The care plans are beginning to be improved to reflect the residents up to date needs. What the care home could do better: They should make sure that the resident and/or their families should be involved in planning and reviewing the care and signing to agree with the plan. Where any form of restraint is to be used, such as bed rails a consent form should be in place. Care plans must be updated to reflect the residents current needs. Reviews of care plans could have the day that they were reviewed and not just the date to make sure that a proper period of time lapses between reviews. There should be sufficient equipment in the home to make sure that the residents can receive the right care. Drug administration must be made in a safe manner and not be predispensed.The complaints policy should be updated to give the correct address for the CQC. The home should make sure that the unpleasant odour in the home is removed. The content of training programmes should be reviewed to make sure that they are relevant. Staffing levels should be kept under review to make sure that the dependency of the resident is taken into account and not just numbers of staff per resident. The manager must make sure that the home is properly supervised in her absence. The company must make sure that there is a stable and continuing management structure in the home. Regular supervision for the staff must be put in place at the frequency advised in the National Minimum Standards to make sure that staff have the opportunity to meet regularly with their line manager. Key inspection report Care homes for older people Name: Address: The Willows Care Centre 14 The Lant Shepshed Loughborough Leicestershire LE12 9PD     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: Anthea Richards     Date: 2 6 0 2 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: The Willows Care Centre 14 The Lant Shepshed Loughborough Leicestershire LE12 9PD 01509650559 01509650362 thewillowsnh@schealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Exceler Healthcare Services Limited care home 60 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability terminally ill Additional conditions: Service user numbers. No one falling within categories PD, PD(E) or TI(E) may be admitted to the home when 25 persons of these categories/combined categories are already accommodated within the home. Date of last inspection Brief description of the care home The Willows Care Centre is a purpose built home situated in the centre of Shepshed. It can provide residential and nursing care for up to sixty older people with a range of needs including physical disabilities. A registered nurse is on duty in the home at all times. Accommodation is provided on two floors, accessible by a passenger lift. There is a large sitting/dining room and activities room on the ground floor, and a number of Care Homes for Older People Page 4 of 27 0 25 0 Over 65 60 25 25 Brief description of the care home smaller sitting rooms on both the ground and first floor. There are a small number of double rooms and some rooms have en suite facilities. There are specialised bathing facilities, with aids and adaptations fitted throughout the home. The home is set in its own gardens with seating available for general use. The home is accessible by public transport and is close to a number of public amenities such as the local library, churches and the community centre. The Statement of Purpose and Residents Guide are provided for all perspective and new residents these provide information on how the home is organised and what services they provide. A copy of the Care Quality Commission Inspection report is available and is displayed in the foyer of the home. At the time of the inspection the weekly fees ranged between £336.00 and £1000.00 per week dependent upon individual care needs. There are some additional costs for individual expenditure such as hairdressing, newspapers etc. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 of a care home for older people, which ended with an unannounced visit to the service. Before the visit we [throughout the report the use of we indicates the Care Quality Commission], spent five hours reviewing information received by the Care Quality Commission [CQC] since the last Key Inspection on the 10th July 2009. The visit took place on the 25th and 26th February 2010 and lasted seven hours. During the visit we checked the key standards for Health and Personal Care, Complaints and Protection, Staffing and Management as identified in the National Minimum Standards. The remaining standards had been inspected at the Key Inspections on 1st April 2009 and 10th July 2009. Medication standards had been inspected at a random inspection on 1st May 2009. This was achieved through a method called case tracking. Case tracking means that Care Homes for Older People Page 6 of 27 we looked at the care provided to four of the residents. To achieve this we spoke with the staff supporting their care and looked at the records relating to their health and welfare. We spoke with the residents and their families. We also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. The policy for handling complaints and how the home dealt with them was checked. We checked the Annual Quality Assurance Assessment [AQAA] that the home had sent to us. This describes the services provided at the home for the residents, how the home is hoping to improve services and statistics about the residents and the staff. The comment cards that we sent out were seen and comments made were noted. On the 25th February 2010 we spoke with the Nurse who had been left in charge of the home, the staff, the residents and visitors to the home. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: They should make sure that the resident and/or their families should be involved in planning and reviewing the care and signing to agree with the plan. Where any form of restraint is to be used, such as bed rails a consent form should be in place. Care plans must be updated to reflect the residents current needs. Reviews of care plans could have the day that they were reviewed and not just the date to make sure that a proper period of time lapses between reviews. There should be sufficient equipment in the home to make sure that the residents can receive the right care. Drug administration must be made in a safe manner and not be predispensed. Care Homes for Older People Page 8 of 27 The complaints policy should be updated to give the correct address for the CQC. The home should make sure that the unpleasant odour in the home is removed. The content of training programmes should be reviewed to make sure that they are relevant. Staffing levels should be kept under review to make sure that the dependency of the resident is taken into account and not just numbers of staff per resident. The manager must make sure that the home is properly supervised in her absence. The company must make sure that there is a stable and continuing management structure in the home. Regular supervision for the staff must be put in place at the frequency advised in the National Minimum Standards to make sure that staff have the opportunity to meet regularly with their line manager. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 27 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This outcome was inspected on 1st April 2009 and it was judged that: The Willows Care Centre enables people who require care to make an informed decision as to whether the home is appropriate to their needs by providing information about the services it provides and through its assessment process. Evidence: This standard was not inspected on this occasion. The findings from the key inspection on 10th July 2009 were used. Care Homes for Older People Page 11 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite some of the shortfalls in the care plans, the staff mainly meet the care needs of the residents, with privacy, dignity and respect. Medication administration could put the residents at risk. Evidence: We undertook this inspection in response to some areas of concern that had been identified, that there was incorrect information in the care plans and care plans that had not been updated. It was also alleged that the residents were not being with the dignity that they should expect. We looked at four sets of care plans and found that they contained the information that was needed and had mainly been reviewed and updated. In two of them two areas of care need had not been updated or reviewed. This was particularly concerning where there was a change in how someone was to be moved. Whilst the care plans had not been updated, four staff were spoken with and were all aware of the changed needs and the care that was being given was correct. When the Care Homes for Older People Page 12 of 27 Evidence: care plans have been updated only the month and year have been entered and not the date. This could mean that that there is a longer than required time lapse before they are reviewed. The named nurse on one of the care plans had left the home some time previously, but we noted that a new list of named nurses had been put on the noticeboard the day before the visit. The daily records fully described the residents day and there was a good pictorial record of their likes and dislikes. On one of the care plans looked at the consent form for the use of restraint, in this case bedrails, had not been signed by the residents or the family. There had been concerns raised that the residents were not having baths or showers regularly as this had not been recorded. During the visit we spoke with the residents who all told us that they had showers or baths when they wanted them. We saw the records that the home had started and they told us that they were planning to record these in the care plans. A resident who had a fall out of bed had been provided with a low bed to keep her safe. During the visit we saw that call bells were answered quickly and those residents who were seen who were in their rooms had call bells within their reach. Six residents that we spoke with told us that the staff answered their bells most of the time but felt that they were sometimes short of staff and it took longer. Whilst we were in the home we saw that the residents were spoken with whenever staff were working with them and were treated with dignity and privacy. The surveys that were in returned were mostly positive about the care, activities and meals in the home. Some of the comments that we received both during the visit and from the surveys were: The turnover of staff is confusing and cannot always understand what they say I think that the staff are really good Care Homes for Older People Page 13 of 27 Evidence: Look after us very well Its like my own home, I like it here Could do with more staff Too many agency nurses As the home had complied with all the requirements and recommendations made at the Random medication visit in May 2009 we did not plan to inspect the medication standards during this visit. During the visit a medication round was observed and the staff involved were initially undertaking it correctly. However a member of staff was seen to be pre-dispensing tablets into pots with paper labels with the residents names in them. This is dangerous practice as the pots could be dropped or the labels could be lost resulting in the possibiity of the residents having the wrong medicines or not having them at all. The member of staff assured us that she never normally did this but was in a hurry as she had to do a medicine round that she would not usually do as there was an agency nurse coming on duty who had not worked in the home previously. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This outcome was inspected on the 1st April 2009 and it was judged that: Opportunities are available for people to engage in activities and take part in recreational events as a group. The Willows Care Centre provides a wholesome and varied diet and meets the individual and specialist needs of people. Evidence: This standard was not inspected on this occasion. The findings from the key inspection on 10th July 2009 were used. Care Homes for Older People Page 15 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to support and protect residents and staff are aware of the processes. Evidence: The complaints policy was displayed in the entrance hall of the home. It was in large print and very clear, the address for the care Quality Commission needed to be updated. The residents and their families also have this information given to them in their service User pack and Statement of Purpose. There were details for an advocacy service available for the residents or their families to use if they wished to. We looked at the complaints file and found that the home had received 6 complaints and had one safeguarding referral since the last inspection on 10th July 2009. On all these complaints and the safeguarding referral the manager had completed a thorough investigation. Four of the complaints had been resolved, two had been investigated but were still unresolved, the new manager is currently reviewing these to resolve them. The safeguarding referral is still being investigated by the Local Authority. The residents and their families spoken with during the visit were happy that they knew how to complain and felt that their complaint would be responded to. The staff spoken with were all aware of how to handle a complaint. Care Homes for Older People Page 16 of 27 Evidence: All of the staff spoken with were aware of Safeguarding of Vulnerable Adults (SOVA) and would be prepared to whistle-blow. They all told us that they had received training. We were able to confirm this from the training records. Care Homes for Older People Page 17 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This outcome was inspected on the 1st April 2009 and it was judged that: The Willows care centre provides a comfortable and homely environment which is well maintained. Evidence: This standard was not inspected on this occasion. The findings from the key inspection on 10th July 2009 were used. However it was noted that there was an unpleasant odour on arrival in the home that did not fully disappear throughout the day, it was still present on arrival on the second day of the inspection. Care Homes for Older People Page 18 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff numbers at this time meet the residents needs and protect their safety. Training for the staff does not always meet the training needs. Evidence: We were concerned that the staffing levels were not sufficient to meet the needs of the residents and had received several comments through the surveys from the residents and the staff that they needed more staff. On the day of the visit there were adequate levels of staff to meet the needs of the 36 residents who were living there. The nurse who was caring for the nursing residents was also in-charge of the home, so was having to deal with administrative queries as well as her duties for the residents. There was an administrator on duty who undertook some of the administrative tasks. There were ancillary staff for cleaning, laundry and in the kitchen. Staff rotas supported this level of staff morning and afternoon. These numbers appeared adequate for the numbers and dependency of the residents, although the nurse was having difficulty coping with having to be in charge as well as her nursing duties. Care Homes for Older People Page 19 of 27 Evidence: The staff told us that they were worried that the numbers would be reduced as the home was not full. When we discussed this with the acting manager on the day following the visit we were assured that this would not happen. The staff spoken with told us that they have plenty of training although we were told that some of the training did not give them enough knowledge, this was particularly identified in the use of care plans. The training records confirmed that training had taken place. Care Homes for Older People Page 20 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The acting manager is now providing some management stability in the home, but there remain management failings to be addressed. Evidence: On the day of the visit there was no manager present. The home had been left in the morning with a bank nurse who has worked at the home for two months on ad hoc shifts. In the afternoon an agency nurse who had never worked in the home before came on duty to take charge. There was an administrator on duty, who was undertaking all the administrative tasks. This meant that the nurse had to make administrative decisions in addition to her nursing responsibilities to the residents. We were told by the staff that there would be a new manager and deputy starting work on the 1st April. The acting manager had told us at a meeting with the Local Care Homes for Older People Page 21 of 27 Evidence: authority and the Primary Care Team that there would be a new manager starting work on the 1st April 2010. We returned on the following day to speak with the acting manager, who confirmed the information that we had been given. She is an Operations manager with Southern Cross but will be no longer following the reorganisation of their management team and told us that she had been offered the managers post at The Willows and was going to consider it over the week-end. The deputy manager is currently a senior manager for a local company and has previously worked well with us. The acting manager telephoned us after the week-end and told us that she was going to remain in the post and that she had already started the process to become registered with the Care Quality Commission. There are regular audits completed in the home and an annual questionnaire is sent to all the residents and their families. A Residents and relatives meeting has been arranged by the new manager. There are no records that Supervisions for the staff have taken place and the staff spoken with confirmed that they have not been given the opportunity of regular supervision with their line manager. Care Homes for Older People Page 22 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 23 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 14 (2)That the assessment of the persons needs are kept under review and revised as the need arises. That the resident receives the current care and has their current needs met. 31/03/2010 2 7 17 (1)(a) That records detailed in Schedule 3 of the care standards act are maintained for each resident. That if restraint of any description is to be used for a resident that the consent must be sought from the resident or the family. 19/03/2010 3 9 13 (2)that are safe and suitable 06/03/2010 practices employed for the administration of medicines. That the residents receive the correct medication. Care Homes for Older People Page 24 of 27 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 4 31 39 (a)(b)That the Commission is notified in writing of any management changes in the home. That the Commission is aware of who is in charge of the home and any changes that are proposed. 31/03/2010 5 36 18 (2) That the people working in the home receive appropriate supervision. That the staff have the opportunity of regular formal supervision with their line manager. 30/06/2010 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 7 That the actual day that the care plans have been updated should be entered to make sure that the proper period of time elapses before the care plan is reviewed. That care plans are signed by the resident or their family to make sure that they agree with the care planned. Or that it is documented that they are happy but do not wish to sign the care plans. That the complaints policy is updated to reflect the up to date address for the Care Quality Commission. That the home takes all measures to remove the unpleasant odour. Staffing levels should be regularly reviewed with the needs and the dependency of the residents taken into account. consideration should be given to having a second nurse on Page 25 of 27 2 7 3 4 5 16 26 27 Care Homes for Older People 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 duty in the absence of the manager. 6 30 The training in the home for the staff should be reviewed to make sure that it is comprehensive and fulfills the needs of the staff. That in the absence of the manager the home is left in the charge of an experienced person with knowledge of the home. That regular resident and relatives meetings are put in place to establish an effective communication process. That the management team make sure that there are safe working practices for moving and handling carried out in the home and that there is sufficient equipment to enable this to happen. 7 31 8 9 33 38 Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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. 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