Care Home: Willow Tree Lodge

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What the care home does well When asked this question relatives said: "The programme around my sons needs eg outings, and staffing during the day are excellent." "As well as looking after "x`s" daily needs it provides stimulating and varied activities which helps with his happiness and behaviour problems". "Rooms specially adapted to meet safety and security needs. Staff are very caring." Staff said: "The home has got high hygiene standards. It always puts the service users at the centre of all planning. The working atmosphere is very relaxed and team work is encouraged and also practiced". The service has been very effective in gathering information about the people that they support and so staff are gaining a good understanding of peoples needs, preferences and wishes. There are good systems in place to monitor and evaluate how well the service is meeting the needs of each individual in their care. These are implemented effectively. As a consequence, staff are given up to date and accurate guidelines to help them to work consistently with service users. The complex needs of service users mean that at times some restrictions to their choices may be necessary to keep them safe and well. The service ensures that any such restrictions are only made after a great deal of consultation, consideration and when all other avenues have been explored fully. There are always enough staff on duty to ensure that peoples individual needs are met. The service has done well in ensuring that there are enough experienced staff on duty to guide and to help to train the newer, less experienced members of the care team. The service is well managed and there has been consistent support from senior managers who help to review policies, procedures and practices within the home. What has improved since the last inspection? This is the first inspection to this service. What the care home could do better: No areas of improvement have been identified as a result of this inspection and the service is judged to be meeting all key National Minimum Standards. The manager has identified a number of ways in which she plans to make further improvements, for example, by ensuring that service users have access to Speech and Language therapy and by employing a cook and a cleaner. Key inspection report Care homes for adults (18-65 years) Name: Address: Willow Tree Lodge 189 Kempshott Lane Basingstoke Hants RG22 5NA     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: Kathryn Kirk     Date: 2 0 1 0 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 28 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 28 Information about the care home Name of care home: Address: Willow Tree Lodge 189 Kempshott Lane Basingstoke Hants RG22 5NA 08450949295 08450949296 c.wyatt@liaise.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Liaise Loddon Limited Name of registered manager (if applicable) Miss Michelle Payne Type of registration: Number of places registered: care home 4 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home Willow Tree Lodge was registered as a new service in April 2009. It is located in Kempshott, Basingstoke and can accommodate up to four adults with a learning disability. The providers are Liaise Loddon who have a number of other homes in the area. The home is a large detached house with three bedrooms. One bedroom has an en suite bathroom. There is also one shared bathroom. There is also one self contained bedsit with lounge, bedroom and en suite. Communal areas include two lounges, two kitchens and a dining area. There is a large walled garden and a separate laundry and office. 4 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 28 Brief description of the care home Each person has their own bedroom which is spacious and personalsised according to their individual preferences and needs. Care Homes for Adults (18-65 years) Page 5 of 28 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 is our first key inspection of Willow Tree Lodge. A key inspection focuses on the National Minimum Standards that most affect the quality of life experienced by service users. We gathered evidence for this report in a number of ways. These include: A visit to the home. This took place on 20 October 2009 and lasted for five hours. We spent time in the company of service users and staff and spoke with the manager and two senior managers in the organisation. We looked at some records relating to two service users and regarding some practices and procedures in the home, for example the complaints log and medication records. We also saw two bedrooms and the communal areas of the home. Two surveys were returned by relatives of people using the service .Three staff Care Homes for Adults (18-65 years) Page 6 of 28 members also completed a survey. An Annual Quality Assurance Assessment (AQAA) was returned to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met. It also gave us some numerical information about the service. The AQAA contained accurate information which was fully supported by other evidence obtained. We looked at the information that we had gathered about the service as part of the registration process and also at the information that the service had sent to us about significant events. Care Homes for Adults (18-65 years) Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: No areas of improvement have been identified as a result of this inspection and the service is judged to be meeting all key National Minimum Standards. The manager has identified a number of ways in which she plans to make further improvements, for example, by ensuring that service users have access to Speech and Language therapy and by employing a cook and a cleaner. Care Homes for Adults (18-65 years) Page 8 of 28 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 Adults (18-65 years) Page 9 of 28 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 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admissions to the home are not made until a full needs assessment has been undertaken and it has been established that the service can meet the assessed needs of the prospective resident Evidence: The AQAA says We have a thorough and comprehensive pre-placement process which includes visits to the individuals in their familiar surroundings; completing a thorough needs assessment with the persons key people; inviting the individual and family to visit the home, if appropriate. We found that this information was accurate through looking at records and talking to staff. A lot of information had been gathered about peoples needs and preferences whilst a move to the home was being considered. Some residents have moved from another Liaise Loddon home and so their needs were already known. Their transition process was facilitated as some key staff who knew them very well moved with them. Files contained other information which is used to help new residents to settle in. This includes photographs of staff and the home. Staff said that one person brought some Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: personal possessions each time they visited and their relatives decorated their room to be as similar as possible to their room at home. Staff described how transitions vary according to what is suitable to each individual , some people have slow introductions to the home with a number of visits, others may not visit the home at all if this would increase their anxieties. Where this is the case, staff spend time getting to know and understand peoples needs in other settings. Care Homes for Adults (18-65 years) Page 12 of 28 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. Good care planning helps to ensure that individual needs and preferences are understood and respected. Peoples rights to make decisions and take responsible risks are considered thoroughly and managed sensitively. Evidence: We saw two peoples care plans. These provided staff with details about how to support people in their preferred daily routines and included information about the best ways to communicate with them, for example whether using words, signs or objects of reference would be most effective. There is also a behaviour support plan which gives staff detailed guidance on how to work with people consistently and effectively. It was clear through talking with staff and through looking records that involved professionals and relatives are closely involved in the care planning process. Care plans are written in such a way as to support independence and maintain skills. Staff surveyed said that always given up to date information about the needs of people they support or care for. They also said that generally the ways in which information is shared within the staff team works well. Care Homes for Adults (18-65 years) Page 13 of 28 Evidence: The complex needs of service users mean that at times, some restrictions need to be put in place to protect peoples wellbeing. A process has been developed to ensure that any such limitations are very carefully considered, in consultation with relatives. This helps to ensure that the least restrictive method of intervention is used. These are reviewed very regularly. This means that the service is very clear as to what restrictions are in place and why they are there. Staff said that they also consider whether restrictions impinge upon other service users. Relatives confirmed in surveys that they receive enough information from the service to help them to make decisions. The AQAA says that risk assessments are in place to support service users to take reasonable risks without endangering the safety of themselves, staff or others. We saw that this was the case through looking at records. Each activity undertaken is assessed for risk, and in addition the home uses a traffic light system to ascertain whether the proposed activity schedule is appropriate for that day. This means that the routine is flexible and can be tailored to meet peoples moods and preferences. Care Homes for Adults (18-65 years) Page 14 of 28 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. Residents are involved in meaningful activities and are supported to maintain personal and family relationships. They are provided with a range of nutritious food in line with their preferences and needs. Evidence: Records show that peoples likes and dislikes are included as part of the care planning process. Each person has a daily schedule drawn up to reflect their preferences and interests and staff complete an hourly report which helps to evaluate how successful each activity has been. Staff spoke about a range of activities which they support service users to access, including horse riding, swimming and sensory clubs. They also ensure people visit local shops and facilities. Staff were observed to provide people with choice of leisure activities within the home, for example, they helped one service user to make a choice between puzzles and supported another to spend time in the garden. There were sufficient staff on duty to support each person effectively in their Care Homes for Adults (18-65 years) Page 15 of 28 Evidence: chosen activity. Relatives surveyed generally felt that the service responds appropriately to peoples different needs. Relatives also said that the service always helps them to keep in touch and that they are always aware of any important issues. When we spoke with staff it was clear that they appreciated the importance of service users maintaining family links. Staff also discussed how they try to make the journeys between the family home and the service as stress free as possible for service users, particularly pertinent as people are getting used to their new surroundings. Individuals have had locks fitted to their bedroom doors which enables them, subject to risk assessment, to have privacy away from other service users and staff members. There are two kitchens in the home. Staff said that service users have access to both, but are encouraged to use the first kitchen for drinks or snack preparation. When we visited the fridge in the first kitchen contained a range of healthy snacks. A menu is drawn up from what is known about peoples likes and dislikes. The manager said that she is looking into meaningful ways to increase choices at mealtimes. The service is going to employ a cook soon which will help with this process. Care Homes for Adults (18-65 years) Page 16 of 28 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 receive personal and healthcare support in line with their individual needs and preferences. Good Medication systems protect service users Evidence: The AQAA says All individuals have a comprehensive Supporting X document which outlines their preferred methods of support from staff during personal care tasks. This document is based on assessment and observation to ensure a high level of care is provided promoting independence and self control as far as safely possible. We saw these documents as described in peoples files. Staff spoke about how they respect peoples privacy and dignity. They described how, for example, they help with personal care in as discrete a way as possible even when the individual concerned needs two people to support them. The management team described how they analyse all information available about peoples reactions to the support and care provided. This is partly done so that they can modify guidance for staff when necessary to ensure that care is provided in a consistent and effective way. Relatives surveyed said that the service provides the Care Homes for Adults (18-65 years) Page 17 of 28 Evidence: support and care that they expect or agreed. Records we saw show that each person has a Health Action Plan which outlines health needs and ensures continuous monitoring and promotion of health and wellbeing. Staff confirmed that since moving into the home all individuals have been registered with a GP, psychiatrist, dentist and optician. Medication reviews and eye tests have also been carried out. The manager said that a speech and language therapist will also be working with service users in the near future. No service users are able to manage their own medication. We saw that medication is stored safely and appropriately. We checked some Medication Administration records and found that they had been completed accurately. We also saw that protocols have been written up for as required medication. Records we checked confirmed that all staff that manage residents medication have completed training in this area. Care Homes for Adults (18-65 years) Page 18 of 28 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. The complaint and safeguarding procedures help to protect people living at the home. Evidence: Although service users are unable to make complaints verbally, staff are trained to observe and record peoples responses and reactions. In this way they are able to gain an understanding of peoples preferences and concerns. Relatives surveyed confirmed that they knew how to make a complaint and said that the service had responded appropriately to any concerns raised. Staff said that they would know what to do if someone expressed concerns about the service. During our visit we saw the complaints log and discussed the complaint procedure with the manager. It was evident that the service was responding to complaints made in a timely and appropriate way. The service has procedures in place to protect service users from abuse. Records we saw showed that staff are trained in safeguarding matters as part of their induction programme. All staff are also trained in PROACT SCIPr UK. This enables them to respond to and effectively manage any challenging behaviours exhibited by services users. Care Homes for Adults (18-65 years) Page 19 of 28 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. Residents live in a safe, well maintained and comfortable environment which encourages independence Evidence: We visited the service two times this year, the first visit was part of the registration process. When we registered the service in April 2009 the building was assessed as being suitable for purpose and met with all National Minimum Standards relating to the environment. Each service user has their own bedroom. Windows in bedrooms are all fitted with restrictors. All bedrooms have covered radiators. The temperature of the radiators can be controlled individually. Service users share the use of communal areas. These include two lounges, a dining room two kitchens and a large enclosed garden. There is parking for some cars at the front of the building. The laundry facility has all the relevant equipment and is a good size. As this is outside of the home a protocol has been written stating no laundry will be completed after ten at night. All areas of the service are fitted with smoke detectors, emergency lighting and fire alarm call points linked to a main system as well as having fire fighting equipment as necessary. Care Homes for Adults (18-65 years) Page 20 of 28 Evidence: During the visit that formed part of our key inspection we found that the home was clean, tidy and well maintained. Furnishings reflected peoples preferences and needs. The manager said that a cleaner will be employed soon. Care Homes for Adults (18-65 years) Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are well trained, properly recruited and are employed in sufficient numbers to support all service users effectively Evidence: Relatives surveyed said that generally staff have the skills and experience to look after people properly. The rota shows that during the day there are a minimum of five care staff on duty, the manager and deputy work in addition to this. During the night there are three waking staff on duty. As discussed in a previous section, some staff who have already worked with some of the service users have moved homes with them. As this is a new service, the organisation has also brought over experienced members of staff from other homes to help to train new staff at Willow Tree Lodge. Staff said that this is working well. The AQAA says that 56 shifts have been covered by agency workers in the past three months. The manager said that these shifts are filled by regular agency staff who may become permanent after three months, depending on their suitability. The AQAA says that all staff have completed satisfactory recruitment checks. Staff surveyed confirmed that their employer had carried out checks such as CRB and had taken up references before they started work. This was verified by looking at two staff records during our visit. Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: Staff surveyed said that their induction covered everything that they needed to know when they started. They also said that they are provided with relevant training to fulfill their role. The AQAA says that all staff have an average of 5 hours a month dedicated to their personal development. Records we saw showed that staff have received training, for example, in health and safety, adult protection , principles of learning disability, roles of the support worker and PROACT SCIP. Care Homes for Adults (18-65 years) Page 23 of 28 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. Service users benefit from a well run home Evidence: As part of the Registration process, the manager demonstrated a good working knowledge of the Care Homes Regulations and the National Minimum Standards and of the specialist needs of the service user group. She has a degree in autism and learning disabilities and is starting a Registered Managers Award Qualification in the near future. The manager is supported by a number of senior staff who spend about 10 hours a week at the home. Staff surveyed said that that the manager regularly gives them enough support and meets with them to discuss ways of working. A lot of work at Willow Tree Lodge is done to monitor and evaluate the service provided. This is done every day by staff recording how successful or not activities have been, by observing service users reactions and by gaining the opinions of people significant to each service user. A senior manager also carries out a monthly quality assurance visit which reviews how well the service is doing in meeting its aims and objectives. We saw a written report of the most recent visit which showed that this Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: process was thorough and comprehensive. The service has surveyed staff to gain their views about the quality of the service but the result of this had not been received at the time of this inspection. The AQAA says that all equipment has been regularly serviced and maintained and as part of the registration process we saw certificates for electrical testing and gas safety. Care Homes for Adults (18-65 years) Page 25 of 28 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 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 27 of 28 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. 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