Care Home: Ventana

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What the care home does well The home is working hard to implement person centred planning processes within the service. They want people to be treated as individuals and are making significant efforts to promote an individualised approach to activities and the delivery of care. The home acknowedges that people have rights and that their needs differ from one another. Care workers treat people who use the service in a respectful way that values their privacy and dignity. The home works hard to communicate with families of people who use the service and establish positive links with them. This is valued by relatives and enables them to feel part of their son or daughter`s life. The home responds well to the personal care needs of people who use the service. Health care professionals are involved in people`s care when this is appropriate. The procedures in place for administering medication are generally sound and people are given the medication they are prescribed. The home communicates positively with families and professionals and is responsive to any concerns or issues raised. Procedures to protect people from harm are in place. The provider has made some positive improvements to the home environment including redecoration and refurbishment of some areas. The home presents as clean and spacious and provides a pleasant place for people to live in. The home enables care staff to access induction training when they commence work in the home and study towards nationally-recognised qualifications. People we had contact with felt that staff usually had the skills and knowledge to meet service users` needs. Relatives of people who use the service appeared to have confidence in the management of the home. They felt communication was good between themselves and the management team and that their family members were well-cared for. What has improved since the last inspection? The home has taken action to address the outstanding requirement made at the last inspection. Recruitment procedures in the home are now more robust and they have ensured that checks with the Criminal Records Bureau and written references are obtained for new care workers. We also saw that the home is working to implement a more person-centred approach to care planning. This will help ensure that the care they deliver meets people`s needs and preferences. What the care home could do better: As a result of this inspection we have made two statutory requirements and thirteen recommendations. Requirements are law and therefore action must be taken by the provider to address them within the stated timescales. Recommendations are based on good practice and should be given serious consideration by the provider in improving the service and ensuring systems fully protect the people who live in the home. We acknowledge that person-centred planning processes in the home are a `work in progress` and this will develop over time. However, there are clear ways in which care planning can be improved and we have made some recommendations that the home continues to review how they write plans to ensure they contain sufficient detail about how people`s needs are to be met and that there is evidence that people have involvement in their own plans as far as practicable. In particular, risk assessment processes need to be developed further. Information about risks in care plans is currently basic and the home needs to consider not just risks associated with things that do happen in the home but also things that may happen. This will help ensure that people are protected while leading ordinary lives. Although we saw evidence of people being offered some positive social and leisure opportunities, we felt that there is still room for some development to ensure that everyone has opportunities on a daily basis to engage in meaningful activity. The home generally has good processes in place to ensure that people have the health care and medication they need. However, we have made some recommendations in relation to this which will help ensure all aspects of their procedures are robust and based on best practice. As indicated in the previous section of the report, the home has taken action to ensure new care workers have appropriate checks undertaken with the Criminal Records Bureau (CRB) and written references are obtained before they start work. Although the home has improved their procedures, there was still one gap in paperwork identified at the inspection which must be addressed in order for the home to fully comply with the law and evidence that the home is being robust in their pre-employment procedures. There are also improvements that should be made to the home`s training programme for staff to ensure that when new care workers start in the home their orientation is carefully documented so that it is clear that they have been made aware of important health and safety procedures and are able to take appropriate action in the event of an emergency. We have also recommended that all care workers employed to work in the home have training in total communication approaches as this will help them understand and meet the needs of the people they provide care for. Management arrangements and lines of accountability within the home require clarification. At the present time the registered manager, Mr Greenwood, who has responsibility for the day-to-day management of the service is also overseeing the service as the responsible individual. There is also an acting manager in post who has many delegated responsibilities. Lines of accountability would benefit from being made clearer and formalised through the Commission`s registration process. Although systems to monitor health and safety in the home are in place these should be reviewed to ensure that documentation is clear and that the home can evidence that they are taking prompt action where issues are identified. The home needs to look at ways to strengthen their own quality assurance and audit processes so that they can demonstrate how they themselves are proactively identifying shortfalls. Key inspection report Care homes for adults (18-65 years) Name: Address: Ventana 33 Florence Road Boscombe Bournemouth Dorset BH5 1HJ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Heidi Banks     Date: 2 8 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 39 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 39 Information about the care home Name of care home: Address: Ventana 33 Florence Road Boscombe Bournemouth Dorset BH5 1HJ 01202390209 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ventana Homes Ltd care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is 8. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) Date of last inspection Brief description of the care home Ventana is registered to provide accommodation and care for up to eight adults with learning disabilities. The home provides 24 hour care. The home is owned by Ventana Homes Ltd. The Registered Manager for the service is Mr Paul Greenwood. From information provided to us by the service in November 2008, individual weekly fees at the home range from 1000 - 1700 pounds. Further information on fee levels and fair terms of contracts can be obtained from the Office of Fair Trading at www.oft.gov.uk. Care Homes for Adults (18-65 years) Page 4 of 39 0 1 1 0 2 0 0 8 8 Over 65 0 Care Homes for Adults (18-65 years) Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection of Ventana undertaken as part of our routine inspection schedule. The inspection took place over two days with a visit to the home on 21st September and then a second visit on 28th September to clarify and confirm some information and to give feedback to the management team. The aim of the inspection was to assess the home against the regulations and national minimum standards for care homes for adults. For part of the inspection the lead inspector, Heidi Banks, was accompanied by a second inspector, Tracey Cockburn. Also, as part of the inspection, the lead inspector was joined by an Expert by Experience, Hayley Hughes, from Bristol and South Gloucestershire People First and her supporter. Experts by Experience is a project that involves people who use services in the inspection of those services. Their role as part of the inspection team is to help us get a picture of the service from the viewpoint of the people who use it. Although the majority of the inspection was carried out by one Care Homes for Adults (18-65 years) Page 6 of 39 inspector, we have used the term we throughout the report to indicate that the report is the view of the Care Quality Commission. As part of this inspection we requested that surveys were distributed to people who use and have contact with the service. We received a total of twelve surveys in response; one from a person who lives in the home, one from a relative of a service user, two from health care professionals and eight surveys from care workers. We also made contact with four relatives of people who use the service by telephone to obtain their views about the home and the care given to their family members. Peoples views about the home have been included throughout this report. During the inspection we spent time talking to people who use the service and observing life in the home. We also looked at a sample of records which included information about people who use the service, recruitment and training records, health and safety records and medication records. We received the homes Annual Quality Assurance Assessment when we requested it. The Annual Quality Assurance Assessment is a self-assessment tool which gives us some written information and numerical data about the service. A total of twenty-two standards were assessed at this inspection. Care Homes for Adults (18-65 years) Page 7 of 39 What the care home does well: What has improved since the last inspection? What they could do better: As a result of this inspection we have made two statutory requirements and thirteen recommendations. Requirements are law and therefore action must be taken by the provider to address them within the stated timescales. Recommendations are based on good practice and should be given serious consideration by the provider in improving the service and ensuring systems fully protect the people who live in the home. Care Homes for Adults (18-65 years) Page 8 of 39 We acknowledge that person-centred planning processes in the home are a work in progress and this will develop over time. However, there are clear ways in which care planning can be improved and we have made some recommendations that the home continues to review how they write plans to ensure they contain sufficient detail about how peoples needs are to be met and that there is evidence that people have involvement in their own plans as far as practicable. In particular, risk assessment processes need to be developed further. Information about risks in care plans is currently basic and the home needs to consider not just risks associated with things that do happen in the home but also things that may happen. This will help ensure that people are protected while leading ordinary lives. Although we saw evidence of people being offered some positive social and leisure opportunities, we felt that there is still room for some development to ensure that everyone has opportunities on a daily basis to engage in meaningful activity. The home generally has good processes in place to ensure that people have the health care and medication they need. However, we have made some recommendations in relation to this which will help ensure all aspects of their procedures are robust and based on best practice. As indicated in the previous section of the report, the home has taken action to ensure new care workers have appropriate checks undertaken with the Criminal Records Bureau (CRB) and written references are obtained before they start work. Although the home has improved their procedures, there was still one gap in paperwork identified at the inspection which must be addressed in order for the home to fully comply with the law and evidence that the home is being robust in their pre-employment procedures. There are also improvements that should be made to the homes training programme for staff to ensure that when new care workers start in the home their orientation is carefully documented so that it is clear that they have been made aware of important health and safety procedures and are able to take appropriate action in the event of an emergency. We have also recommended that all care workers employed to work in the home have training in total communication approaches as this will help them understand and meet the needs of the people they provide care for. Management arrangements and lines of accountability within the home require clarification. At the present time the registered manager, Mr Greenwood, who has responsibility for the day-to-day management of the service is also overseeing the service as the responsible individual. There is also an acting manager in post who has many delegated responsibilities. Lines of accountability would benefit from being made clearer and formalised through the Commissions registration process. Although systems to monitor health and safety in the home are in place these should be reviewed to ensure that documentation is clear and that the home can evidence that they are taking prompt action where issues are identified. The home needs to look at ways to strengthen their own quality assurance and audit processes so that they can demonstrate how they themselves are proactively identifying shortfalls. 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. Care Homes for Adults (18-65 years) Page 9 of 39 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 10 of 39 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There have been no new admissions to the home since the last inspection. This means that we are unable to assess whether the home has improved systems to ensure that enough information is obtained about peoples needs before they are admitted. The home has expressed their commitment to ensuring that recommendations made at the last inspection are responded to when they next undertake a new admissions assessment. Evidence: At the last inspection we identified some gaps in the information that had been gathered as part of the assessment process for one person who was moving into the home. We made a recommendation that the home ensures that information obtained about peoples needs is always comprehensive so that they have a good amount of information on which to base peoples care and ensure their needs are fully met. The home has told us in their Annual Quality Assurance Assessment that they have not had any new people admitted to the home in the past twelve months, this also being confirmed at the time of the inspection. They have told us that they will ensure Care Homes for Adults (18-65 years) Page 12 of 39 Evidence: that in future they have all the necessary documentation in place to support peoples admission and ensure that a more thorough moving in assessment has been carried out. As there have been no new admissions to the home we have not been able to assess whether the service has been able to put this into practice and fully respond to the recommendations made at the last inspection. We will therefore carry forward these recommendations to the next inspection. During the course of our inspection we spoke to the relative of one person who lives in the home who told us that in their view Ventana was not a suitable placement for their family member; X is not in the right place. This was because they felt that the needs of their relative were different to others who lived in the home. A care worker employed at the home also told us in a survey that, in their view, the home was not particularly suited to the needs of one resident. We have made a recommendation that the home liaises with the placing authority to ensure that a full review is undertaken of the persons needs and, if appropriate, that alternatives are explored with the person concerned. At the time of our inspection Mr Greenwood informed us that a care review had recently been carried out for the individual concerned but he would liaise with the persons care manager to make them aware of the issue raised. Care Homes for Adults (18-65 years) Page 13 of 39 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is making positive efforts to implement an individualised approach to care based on person-centred planning and communication. Further work is needed, however, to develop this process and ensure that all risks associated with delivering care are fully assessed. Evidence: We looked at the care plans for two people who use the service. We found that there was some good detail about individuals needs in both documents which would be helpful to care workers in delivering support. This included information about peoples routines, likes and dislikes and their communication needs. The acting manager for the service told us that she and one other member of staff had attended training in person-centred planning in the last year and they were aiming to apply this knowledge in reviewing peoples plans. The Expert by Experience who visited the home as part of our inspection told us that they felt there had been some good work on PersonCentred Plans in the home. Care Homes for Adults (18-65 years) Page 14 of 39 Evidence: Care workers responding to our survey told us that they were always given up-to-date information about the needs of the people they support or care for. Comments we received from staff indicated that they felt this enabled them to deliver care that was person-centred and took into account peoples needs and preferences; There is personalised care for the service users; It is a home which encourages individuality; Ensure each individual is treated as such. The survey we received from one relative indicated that in their view the home usually responded to their family members diverse needs, this also being echoed by a care professional. While we acknowledge the progress that has been made in relation to implementing a person-centred approach to care planning and are aware that this is a work in progress we have identified clear ways in which the process could be improved. We identified instances where statements had been made about individuals needs without there being information for the reader on how to meet them. For example, the care plan for one person stated; I should be encouraged to vary my range of activities and I should find ways to occupy my own time. There was no additional information on how staff could support the service user in this. There was also limited evidence in this persons plan that they had been fully involved in the process or that the plan had been explained to them and they had agreed with the content. A relative we had contact with as part of the inspection told us that they felt improvements could be made to person-centred planning processes which could lead to support for people becoming even more individualised. Discussion with the registered manager and the acting manager indicated that they are making an effort to engage service users in making choices. It was noted that the majority of people who live in the home communicate non-verbally. Therefore we have concluded that knowledge and skills in total communication approaches will be important for staff in engaging people who use the service. The sample of staff training records we looked at did not show evidence of total communication training being an integral part of the homes training programme. In spite of this we observed staff working hard to communicate with the people they support and have positive interactions with them. The Expert by Experience also observed this and told us that they saw staff interacting with service users in a respectful way. The Expert by Experience also noted that the home were using photographs to help people make Care Homes for Adults (18-65 years) Page 15 of 39 Evidence: choices and that one resident uses cards. The home did not have communication passports in place for individuals as a way of informing staff about peoples needs but staff told the Expert by Experience that information about communication is contained within individuals Person Centred Plans. Relatives we had contact with during the inspection confirmed that, in their experience, staff were sensitive to their family members methods of communication. The manager of the home told us that they are intending to roll out total communication training within the team. We have made this a recommendation under Standard 35 as it is important staff have the necessary knowledge and skills to be able to understand and respond to people in a way that is meaningful to them and feel confident in using a variety of communication approaches. We looked at a sample of risk assessments for three individuals who use the service. We had been notified by the home that one person had recently had an epileptic seizure in a swimming pool. We looked to see that the home had assessed the risks and found that an appropriate framework was in place with the action that needed to be taken in the event of this occurring. There was also a risk assessment in place regarding the risk of a seizure occurring during the night. However, there was no risk assessment about how staff should respond if the person has a seizure when they are in the homes vehicle and we have recommended that this is given consideration so that safety issues are addressed and risks minimised. Although the Expert by Experience was told that all the people who use the service have bus passes to help them in accessing the community we did not see evidence of specific risk assessments being in place regarding individuls use of public transport. We saw in one persons care plan evidence of an incident where they had engaged in inappropriate behaviour. Their care plan stated that they must be monitored in relation to this. There was no specific risk assessment in place to support this or information on how staff should support the service user in managing their behaviour in a positive way. All the plans we looked at showed some consideration of risks in relation to money management, key holding and accessing the community with basic information on service users needs in this area. Care Homes for Adults (18-65 years) Page 16 of 39 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Ventana have their rights respected and are treated as individuals. Peoples contact with their families is positively encouraged and relatives are welcomed into the home. Although there is evidence of individuals participating in activities that meet their needs there is some room for improvement in this area to ensure people are being offered sufficient stimulation on days when there is no structured activity. Evidence: We received one survey from a person who uses the service. They told us that they could do what they wanted to do during the day but could only do what they wanted to do sometimes in the evenings and at weekends. The feedback we received from relatives of people who use the service indicated that they were satisfied with the range of activities offered to their family member. The manager of the service told us that all residents had recently gone on holiday, three to Majorca, one to France, one Care Homes for Adults (18-65 years) Page 17 of 39 Evidence: to Rhodes with residents of another home and three to a holiday park by the coast. This was reflected in comments we received from relatives who told us they were pleased their family members had been offered this opportunity which, for some, was their first experience of travelling abroad. From the surveys we received from care workers, most indicated that they felt the home works hard to provide people with activities that are meaningful; Staff always try to ensure service users are occupied in worthwhile enterprise throughout their day; The service users get to go out regularly. However, some care workers noted that improvements could be made to the provision of activities; Maybe to have more activities available when the service users are at home?; Have more day trips. At the time of our inspection the new college term had just recommenced and therefore there was evidence of some people who use the service accessing college courses including cookery and communication. Other service users regularly attend local day services as part of their programme. We looked at a sample of daily records which showed that since the new term had started peoples programmes were busier and more structured. One persons records we looked at showed evidence of them accessing a range of activities including college, playing on the computer, trips to local towns, a visit to a museum, a game of crazy golf, a pub visit and to see a concert. We also saw evidence of individuals attending church and visiting the library. For other people whose records we looked at there was less evidence of them being engaged in meaningful activities. For example, for one person, we found that over a period of five days activities they had engaged in were reported as two walks in the local area, baking a cake with support and listening to music in the conservatory or their bedroom. A lack of structure or evidence of people being offered opportunities were also evident in other records we sampled with several references to people staying in the house or wandering around the house without there being evidence of individuals being offered a real alternative. One service user told us its dead here and really boring. The home has told us in their Annual Quality Assurance Assessment that they could provide more structure for service users during the holiday period. Care Homes for Adults (18-65 years) Page 18 of 39 Evidence: This was something that was raised with the service at the last inspection. We discussed with the acting manager the current barriers to this. The home has purchased a seven-seater vehicle in the past year which could be a useful aid to supporting people with community access. However, we heard that few of the people who are employed to work in the service are able to drive and therefore this potentially restricts peoples use of the vehicle and access to places further afield. Although we were told that people who use the service have bus passes we did not see evidence in records of people accessing public transport on a regular basis. Instead, many of the activities offered to people during the summer involved walks to the clifftop or the local shopping area. One person told us that they enjoyed labouring type work and that working made them feel valued. It was evident from discussion with them and observation that the home are making efforts to give them opportunities to work alongside their maintenance person in doing gardening and other tasks. However, the home needs to continue to be proactive in this area and identify ways in which the individual can explore potential work opportunities. We continue to recommend that the home looks at the range of opportunities offered to people who use the service to ensure that they are offered real choice and opportunities to engage in activity and occupation both inside and outside the home. We have discussed these issues with Mr Greenwood who has told us that people who live in the home are offered plentiful opportunities to access their community and engage in activities. He reported that, in his view, the shortfall lay with record-keeping around these activities rather than the activities not taking place. Observation of life in the home indicated that care workers are respectful of individuals rights and promote their dignity. A health care professional who completed a survey indicated that in their experience the home always promoted the privacy and dignity of service users, this also being echoed by a relative of a person who uses the service. We saw that people have access to their bedrooms as they wish and are given the freedom to access communal areas of the home. All relatives we had contact with during the inspection told us they had regular contact with their family member and felt welcomed in the home. We were told that the home had a positive atmosphere when they visited. The home has told us in their Annual Quality Assurance Assessment that there are no restrictions on when people can visit their relatives. It was clear from discussion with the acting manager that the home is making a significant effort to engage with families, to consult with them about the welfare of their family member and to keep them updated on events in the home so they feel part of their son or daughters life. The home sends out a regular newsletter to families as part of this process. While we recognise the value of this we have advised the home to be careful about putting the names of service users in the Care Homes for Adults (18-65 years) Page 19 of 39 Evidence: newsletter in order to respect individuals right to confidentiality. On the day of the inspection we saw staff preparing meals for people who use the service. Meals were healthy and demonstrated a good balance of the different food groups including vegetables. It was observed that the evening meal was taken as a group in the kitchen with staff eating alongside service users - the Expert by Experience commented that they thought this was very positive. Some of the comments we received from staff in surveys indicated that the home has a positive family-type atmosphere. We saw that frameworks are in place to record meals eaten by service users and there was information in peoples plans about the support they need with eating and drinking in order to make meal-times safe for them. Care Homes for Adults (18-65 years) Page 20 of 39 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from personal care and access to health care that meets their needs. Some elements of paperwork however would benefit from review to ensure that it is fully comprehensive. Systems in place to ensure the safe administration of medication are generally sound. Evidence: We spoke to relatives of people who use the service in order to obtain their views on the personal care that was given to their family members by staff at Ventana. All the relatives we spoke with told us that they were satisfied with the homes approach and felt that their relatives were looked after well by the service. This was echoed by a care professional who indicated that peoples needs were properly monitored, reviewed and met by the care service. There was some good information about peoples personal care requirements in their care plans which took into account their preferences, for example how they like to be supported in the bath. Care workers told us that they felt personal care was something the home did well. One student who had been placed within the home as part of a programme of study also told us that they felt the home provided high quality care to service users. Care Homes for Adults (18-65 years) Page 21 of 39 Evidence: The sample of records we looked at showed that people have been supported to attend appointments with various health care professionals to ensure their needs are met. These were seen to include appointments with the primary health care team, optician and dentist. The acting manager told us that the local surgery had recently visited the home to do an annual health check-up on all service users which is good practice. From discussion with the manager and relatives we are aware that individuals receive specialist support from physiotherapists and speech and language therapists. A health care professional responding to our survey told us that the home always sought advice as appropriate and acted on it to meet peoples needs. They commented that communication with professionals was something the home did well. Relatives also expressed confidence that their family members had appropriate access to health care as necessary to meet their requirements. We noted from the records for one person that their visit from a speech and language therapist had been documented in their daily diary notes and not in their appointments records. We have recommended that the home reviews their recordkeeping systems so that all appointments with health and social care professionals are recorded in one place as this will make it easier for the home to review the degree of professional input and outcomes from these interventions. The home has notified us when one service user has had epileptic seizures which have required medical intervention. These notifications indicate that a protocol is in place by which staff are instructed to call emergency services after a specific period of time. We looked at training available to staff on epilepsy. The records we sampled for staff who have been working at Ventana for some time indicated that they have received training in this subject. All care workers responding to our survey told us that they felt they had received enough training about health care to be able to meet peoples needs. One care worker told us that the home could do better at informing new staff of actions to be taken when service users have a seizure. We looked at the induction record for a member of staff who had recently commenced working at the home. This did not show evidence of them having received basic instruction on how they should respond in the event of them witnessing a seizure. It is important that new staff are able to recognise when someone is having a seizure and know what action to take. We have made a recommendation that this is made a priority when people come to work in the home. We looked at the homes procedures for the administration of medication. We saw that there is suitable lockable storage for medication in the home and at the time of the inspection medicines were being safely stored. Medication is supplied by a local pharmacy which also produces medication administration record (MAR) charts for the Care Homes for Adults (18-65 years) Page 22 of 39 Evidence: home to use. We looked at a sample of these charts and found that they had been fully completed indicating that medication had been administered as prescribed. Individuals allergies had also been indicated on the MAR chart or none known as appropriate. We looked at the medication prescribed for one person. We were informed by the manager of the service that their medication was currently under review by their doctor and the dose was being reduced. In order to respond to this the manager had halved the tablets and placed them in an envelope so that staff could administer the reduced dose directly from the envelope. We advised the manager that this was not good practice as, although the envelope had been labelled, care workers should be administering medication from a container dispensed by a pharmacist. We have recommended that the manager reviews this practice. We saw that there is documentation in place to record random audits of medication by the home. As part of our inspection, we looked at the boxed medication for one service user and checked the number of tablets it contained. The number of tablets left in the box corresponded with the MAR chart suggesting that the medication has been adminstered correctly. We found that there was no storage facility in the home appropriate for controlled drugs. Although at the time of the inspection there were no controlled drugs being stored in the home we have told the manager that he needs to make suitable arrangements for their storage so that the home is prepared in the event of a service user being prescribed them. Following the inspection the manager has told us that he has ordered an appropriate controlled drugs cupboard to be installed in the home. The acting manager told us that only staff who have been trained in the administration of medication are permitted to do so. We looked at a sample of training records for people who have worked in the home for some time. All showed evidence of having undertaken training in the administration of medication including training in the safe handling of medicines run by the local Primary Care Trust. All eight care workers responding to our survey told us they felt they had been given enough training about medication by the home. Care Homes for Adults (18-65 years) Page 23 of 39 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Suitable procedures are in place to respond to concerns and complaints about the home and ensure that people feel listened to. There are procedures in place to protect people from abuse. Evidence: The homes complaints procedure is on display in the home, this also giving the contact telephone number for the Care Quality Commission. The home has a book in which they record complaints and concerns from people who have contact with the service. Review of this documentation showed that there has been one complaint made about the service since the last inspection. We were notified of this complaint when it was received by the home with information about how they had responded to it. No complaints or concerns have been raised with the Commission by people who have contact with the home within the last twelve months. All care workers responding to our survey told us that they knew what to do in the event of someone raising concerns about the home. Relatives we spoke with at this inspection indicated that there was good communication between themselves and the home. One relative told us that they felt they had built up a positive working relationship with the home and they could work together in solving problems that arose. Another relative told us in a survey that they felt they had gained trust in the service in recent months. The registered manager of the home has confirmed that they have received a copy of the local authoritys safeguarding policy although the acting manager did not seem to Care Homes for Adults (18-65 years) Page 24 of 39 Evidence: be aware of this policy at the time of the inspection. The registered manager has said that he will make the policy available for staff to read. From a sample of training records we looked at we saw that all staff receive training in the protection of vulnerable adults as part of their induction training. There have been no safeguarding referrals or investigations in the past twelve months at the home. Our inspection of recruitment records for new staff indicated that robust procedures are in place to ensure that appropriate checks with the Criminal Records Bureau are carried out on staff before they come to work in the home to ensure they are safe to work with vulnerable adults. Care Homes for Adults (18-65 years) Page 25 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Ventana provides a well-maintained, clean and homely environment for people to live in. Evidence: Ventana provides accommodation for eight people. It is a detached property situated along a road of similar properties within walking distance of the centre of Boscombe. The home has a spacious entrance hall with a ramp to enable access by people who use wheelchairs. There is a lounge, conservatory, kitchen / dining room and two bedrooms with en-suite facillities on the ground floor of the home. A further six bedrooms are situated on the first floor of the home, five of which have en-suite toilet facilities and one with an en-suite toilet and shower. Communal toilets and bathroom / shower facilities are situated on both floors of the home. There is a large garden at the rear of the home which is accessible by two concrete steps. Care workers told us that the internal ramp used in the entrance hall can be moved to the garden when necessary to promote wheelchair access. From our discussion with the manager of the home and review of the homes annual development plan we saw that improvements have been made to the home environment to make it a smarter and more homely place to live. This has included redecoration of communal areas and new flooring. The areas of the home that we Care Homes for Adults (18-65 years) Page 26 of 39 Evidence: looked at during the inspection presented as fresh, clean and uncluttered. A person who uses the service told us that the home was always fresh and clean and comments we received from relatives and staff agreed with this. The manager has told us in the homes Annual Quality Assurance Assessment that there is a procedure in place for preventing infection and managing infection control within the home. We checked the communal toilet, laundry facility and kitchen of the home and found that in all three areas there was liquid soap and paper towels available for people to use. We checked the training records for five care workers employed to work in the home including the acting manager. All five showed evidence of having received training in infection control in the past two years either during their induction programme or as stand-alone training. Care Homes for Adults (18-65 years) Page 27 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has made progress in ensuring that appropriate checks have been carried out on prospective care workers to ensure they are suitable to work with vulnerable adults. There is a training programme in place for care workers which enables them to gain knowledge and skills in caring for vulnerable adults. Evidence: At the last inspection we repeated a requirement for the provider to ensure that they have full and satisfactory information on file to evidence that appropriate preemployment checks are undertaken for each care worker before they start work. We made this requirement because we found that checks with the Criminal Records Bureau and two written references had not always been obtained before people commenced employment. We told the home that enforcement action may be taken if they did not address these shortfalls. At this inspection we looked at the records for three care workers who have been employed by the service since the last inspection. All three files showed evidence of a completed application form, two written references, evidence of a check with the Criminal Records Bureau and a health declaration. There was suitable proof of identity on two out of three files which included a photograph. The third file did not contain proof of identity or a photograph. We have made a new requirement that this information is kept on file in order for the home to fully comply with the law. From the records we looked at we did not see Care Homes for Adults (18-65 years) Page 28 of 39 Evidence: evidence of a system in place to verify the authenticity of referees and we therefore suggest that this is put in place and clearly documented on records. Although the home continues to be in breach of this regulation due to a failure in relation to recordkeeping, we are satisfied that, on the whole, the homes procedures protect people who use the service. We saw that there is an induction checklist in place for people who come to work in the home. The purpose of this is for the manager to ensure people are aware of their role, important policies and procedures in the home, the philosophy of care, information about service users and their needs and risk assessments. It is intended that this will give new staff the basic information they need to know until they commence their six-day Skills for Care induction with the local authority. We looked at the checklists for two people who had started work in the home. In both documents some areas had not been ticked as having been discussed with the new care worker. The manager needs to ensure that the induction checklist is fully completed and signed with each new care worker as evidence that they have been made aware of policies and procedures in the home and are able to respond in an emergency. We looked at the training records for four care workers who are permanently employed in the home. All showed evidence of having received induction training that meets the Common Induction Standards. Six out of eight care workers who responded to the survey indicated that the induction training they had received covered what they needed to know very well. Two told us that this was mostly the case. There was also evidence of a range of other courses being accessed by staff including training in epilepsy, the Mental Capacity Act, food hygiene and moving and handling. It was clear from the records that the provider has been proactive in sourcing training that is external to the home, for example from the local health care trust, local authorities and Health Protection Agency to ensure training is based on best practice. All care workers responding to our survey told us that they were being given training that kept them up-to-date and enabled them to meet the needs of people who use the service. As indicated earlier in the report, none of the records we looked at showed evidence of staff having undertaken training in total communication. Given the communication needs of people who use the service we have made this a recommendation. A health care professional who has contact with the service told us in a survey that in their experience staff at the home usually had the skills and knowledge to meet service users needs. This was echoed by a relative of a person who uses the service. The home has told us in their Annual Quality Assurance Assessment that they actively encourage people to undertake their NVQ (National Vocational Qualification) training. Care Homes for Adults (18-65 years) Page 29 of 39 Evidence: They have told us that out of a total of eight pemanent care workers, six had completed training to NVQ Level 2 or above. The home has told us in their Annual Quality Assurance Assessment that they intend to develop a training matrix which will enable them to monitor training uptake more easily and identify where updates may be needed. We agree that this will be a positive step in ensuring the homes training programme is fully robust. Care Homes for Adults (18-65 years) Page 30 of 39 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home generally operates well, communicates effectively with other agencies and is responsive to feedback from stakeholders. In order to improve further, however, the home needs to develop more effective internal monitoring and audit systems so that they can demonstrate how they are proactively identifying and responding to shortfalls. Evidence: The registered manager of the home is Mr Paul Greenwood who has a qualification in learning disability nursing and several years experience of managing services. He has been the registered manager of Ventana since November 2007. Mr Greenwood is also the responsible individual for the service. Discussion with Mr Greenwood at the last inspection indicated that the deputy manager of the service (who is now called the acting manager) is taking increasing responsibility for the day-to-day management of the home. We were told at the last inspection that it was anticipated that she would apply for registration as the manager of the home. We agreed that this should be formalised through the Commissions registration process so that management arrangements and lines of accountability are clear. To date we have not received an Care Homes for Adults (18-65 years) Page 31 of 39 Evidence: application. We discussed this with Mr Greenwood who told us that they would shortly be advertising for a manager for the home. It is anticipated that this will enable Mr Greenwood to focus on his role as the responsible individual for the service and ensure that there is clear differentiation between the role of the manager and that of the provider. Feedback we received from relatives of people who use the service indicated that in their view the home appeared to run well and they felt that the management were accessible and responsive to any issues they raised. This concurred with outcomes of surveys we saw from relatives as part of the homes quality assurance process which indicated that the home is effectively managed, communication is good and the service meets the needs of their family member. At the last inspection of the service we made a recommendation that the home nominates a person to visit the home in accordance with Regulation 26 to monitor and report on the development of the home and audit systems in place. We made this recommendation as since November 2007 Mr Greenwood has been both the responsible individual for the service as well as the registered manager and this has confused responsibilities in terms of meeting Regulation 26. We asked Mr Greenwood what progress had been made in relation to carrying out monthly visits. He told us that he was undertaking monthly visits to the home in accordance with the regulation. This means that Mr Greenwood is monitoring the service as well as being in day-today charge of it. We have advised that this is not good practice as the service should be monitored by someone who is not in day-to-day charge of it and therefore can comment objectively on its progress. Mr Greenwood told us that they had explored possibilities of an external agency undertaking Regulation 26 visits on behalf of the home. We are repeating the recommendation that, until a separate manager is appointed, the home nominates a person who does not have day-to-day responsibility for the management of the service to visit the home in accordance with the regulation. We have strongly advised Mr Greenwood to give this serious consideration. We have also recommended that the provider ensures that copies of visits made in accordance with the regulation are kept in the home and therefore accessible to both the management of the home and the Care Quality Commission. The home has a service development plan in place for this year and we saw evidence of some objectives having been met. The home has systems in place for surveying both people who use the service and their relatives on a regular basis to ascertain their views about the home. However, we noted that only three people who live in the home receive the surveys. This is because the majority of people who live in the home have non-verbal communication and therefore would experience difficulty in Care Homes for Adults (18-65 years) Page 32 of 39 Evidence: understanding and completing a survey. We recognise that this is an ongoing challenge for the service. The acting manager told us that they are making significant efforts to engage with the relatives of people who use the service who may be in a position to give feedback about the service on behalf of their family. We continue to suggest that the home expands on their quality assurance systems and surveys others who may have contact with the service including health and social care professionals and advocates in order to base their development on a larger sample of feedback. We noted that an annual development plan was also in place for the service last year. We recommend that the home ensures an evaluation takes place at the end of every year which summarises what they have achieved to date and what is still to be achieved so that the quality assurance process is based firmly on a system of planning-actionreview. We looked at a sample of health and safety records in the home to evidence that appropriate checks were being undertaken on water temperatures and refrigerator / freezer temperatures. We were told that the homes maintenance person undertakes regular checks on water temperatures. Documentation was in place to support this but the records were not always clear as they did not refer to which outlets had been checked and the temperature of each outlet. For example, one entry read Taps ok. 39-41 degrees Centigrade. The comments said 14, 9 and COSHH. It was not clear what this meant. Another entry said all ok. We have recommended that this is reviewed so it is clear to the reader which outlets have been checked on each occasion and the temperature recorded for each outlet. We were told that night staff take responsibility for recording the temperatures of the homes refrigerator and freezer temperatures. The sample of records we looked at had been fully completed but temperatures recorded for the refrigerators were not within the expected range. There were a number of entries indicating temperatures of 8 degrees Centigrade and above. We also identified freezer temperatures on two dates that were above the expected temperature. There was no evidence that action was being taken to check whether refrigerators, freezers or thermometers in the home were functioning properly. We informed Mr Greenwood of our concerns and by the second day of the inspection we saw that procedures had been reviewed and a memo to staff was on display instructing them of action to be taken if temperatures rose above the expected range. The temperatures recorded following the change in procedures were seen to be within a safe range. Our review of staff training records indicated that staff have access to moving and handling training to be able to meet the needs of service users. The sample of records that we checked indicated that the training people had received was still valid. We Care Homes for Adults (18-65 years) Page 33 of 39 Evidence: have suggested that the home ensures that they are aware when training certificates are due to expire so that they can provide people with prompt updates. As indicated in the last section of the report, use of a training matrix should support the home in this. The records we looked at for four care workers did not show evidence of practical first aid training. We advised the manager to undertake a risk assessment to ensure that there are always enough staff on duty with suitable training and skills to be able to respond in an emergency. The registered manager e-mailed us after the inspection to tell us that five care workers employed by the home have received training in first aid and he has booked remaining care workers onto training. This will help ensure that there is adequate first aid cover at all times. As indicated in the last section of the report the home needs to ensure that induction checklists which are intended to be completed with care workers when they start in the home are fully completed and signed by the care worker. This is to ensure that they understand the policies and procedures of the home and can respond in emergency situations. We looked at the checklists for two staff. For one member of staff the part of the form that relates to fire precautions had not been ticked or signed off. We were told that the member of staff had commenced working in the home the previous weekend and they had been shown the fire procedures but there was no written evidence to support this. We are making a recommendation that the home ensures that there is clear information on record to evidence that people are given instruction on fire procedures as soon as they start work in the home. During the inspection an officer from Dorset Fire and Rescue visited the service and has arranged to carry out an inspection of the homes procedures in the near future. Care Homes for Adults (18-65 years) Page 34 of 39 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 35 of 39 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 20 13 You must ensure that 15/12/2009 suitable arrangements are in place for the storage of controlled drugs in the home. You must do this so that if a person who uses the service is prescribed a controlled drug you have a suitable facility in place for it to be safely stored. 2 34 19 You must ensure that you obtain proof of identity and a photograph of each care worker you employ to work in the home and that this evidence is kept on file. You must do this to demonstrate that you have checked the persons identity and to ensure you recruitment processes are robust. 06/11/2009 Care Homes for Adults (18-65 years) Page 36 of 39 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 2 You should ensure that, where a person is funded by the local authority, a copy of the care management assessment of a persons needs is obtained prior to their admission. Information about a persons religious beliefs should be obtained as part of the homes assessment process. These recommendations have been carried forward from the last inspection of the service as we were unable to assess this standard fully during this inspection. 2 3 You should liaise with the placing authority for one person who lives in the home to ensure that a full review is carried out of their needs and a decision made, with the involvement of the service user concerned, as to whether the home is the most appropriate placement for them. You should ensure that, as far as practicable, people who use the service are involved in their care plans and that the content is explained to them. You should ensure that where statements are made about peoples needs in care plans there is clear guidance to staff about how they can meet these needs. 3 6 4 9 You should ensure that where incidences occur that potentially put people at risk these are fully assessed within their care plans with guidance to staff on how they should be supported. You should continue to review the way that activities are arranged for individuals to ensure that they have sufficient access to valued and fulfilling activities to meet their needs. You should continue to promote individuals access to their community and promote their access to transport. You should ensure that when new care workers are employed to work in the home they receive instruction on how to recognise epileptic seizures of people who live in the home and know how to respond. You should review the documentation of health care appointments on file so that all appointments and visits by professionals are recorded in one place. 5 12 6 7 13 19 8 20 You should ensure that all medication is administered from a container that has been dispensed and labelled by a Page 37 of 39 Care Homes for Adults (18-65 years) 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 pharmacist. 9 32 You should ensure induction checklists are completed thoroughly with each new care worker and are signed to indicate that they understand the homes policies and procedures and have been orientated to the home. You should ensure that care workers access training in total communication approaches to enable them to meet individuals communication needs. Until a separate manager is appointed the home should nominate a person who is not in day-to-day charge of the service to visit the home and undertake monthly monitoring of the service in accordance with Regulation 26. You should ensure that records of visits made in accordance with Regulation 26 are kept in the home. 12 39 You should ensure that your annual service development plan is evaluated at the end of each year so that there is a clear record of what has been achieved and what is still to be achieved. You should ensure that water temperatures within the home are clearly recorded so it is clear which outlets have been checked on each occasion and the temperature of that outlet. You should ensure you have written evidence that new care workers have been made aware of fire procedures in the home. You should ensure that prompt action is taken where recorded refrigerator temperatures are higher than expected. 10 35 11 37 13 42 Care Homes for Adults (18-65 years) Page 38 of 39 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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