inspection report - cqc.org.uk fileregistered provider s jiwa registered manager mrs maria varnava...

| Inspection Report | Firtree House Nursing Home | June 2014 www.cqc.org.uk 1

Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Firtree House Nursing Home

Firtree House, 2 Firtree Road, Banstead, SM7 1NG

Tel: 01737350584

Date of Inspection: 11 February 2014 Date of Publication: June 2014

We inspected the following standards in response to concerns that standards weren'tbeing met. This is what we found:

Care and welfare of people who use services Action needed

Management of medicines Action needed

Staffing Action needed

Notification of death of a person who uses services

Action needed


Details about this location

Registered Provider S Jiwa

Registered Manager Mrs Maria Varnava

Overview of the service

Firtree Nursing Home is registered to provide accommodation for people who require nursing or personal care. The home provides care for up to 35 older people, some of whom have dementia. Accommodation is arranged over two floors.

Type of service Care home service with nursing

Regulated activity Accommodation for persons who require nursing or personalcare


Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page

Summary of this inspection:

Why we carried out this inspection 4

How we carried out this inspection 4

What people told us and what we found 4

What we have told the provider to do 5

More information about the provider 5

Our judgements for each standard inspected:

Care and welfare of people who use services 6

Management of medicines 9

Staffing 11

Notification of death of a person who uses services 13

Information primarily for the provider:

Action we have told the provider to take 14

About CQC Inspections 16

How we define our judgements 17

Glossary of terms we use in this report 19

Contact us 21


Summary of this inspection

Why we carried out this inspection

We carried out this inspection in response to concerns that one or more of the essential standards of quality and safety were not being met.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, carried out a visit on 11 February 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members, talked with staff and reviewed information given to us by the provider.

What people told us and what we found

We carried out this responsive inspection because we had received anonymous information regarding a number of practices at the home which potentially placed people atrisk of harm and receiving care and treatment that was unsafe. During our visit we met theassistant manager, the provider, three care workers and the administrative officer.

People who used the service told us that. "Staff are nice and kind but there are not enoughof them as they are always busy".

Relatives that we spoke with told us" Staff are kind and caring ". However, some relatives told us that the standard of care had got worst over the past three to four months due to staff shortages. Two relatives told us that they were disappointed with the poor care their relative received when health deteriorated and they felt there had been significant failure inrelation to medical treatment and taking appropriate action.

Care and treatment was not always planned or delivered in a way that was intended to ensure people's safety and welfare and people's care and treatment did not always reflect relevant research and guidance.

People were not always protected against the risks associated with medicines because theprovider did not have appropriate arrangements in place to manage medicines.

Peoples needs were not always met because the provider failed to take appropriate steps to ensure that there were sufficient numbers of suitable qualified, skilled and experienced staff to support people.

The provider did not notify the Care Quality Commission about a number of deaths of people who used the service. .

You can see our judgements on the front page of this report.


What we have told the provider to do

We have asked the provider to send us a report by 02 May 2014, setting out the action they will take to meet the standards. We will check to make sure that this action is taken.

Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service(and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions.

There is a glossary at the back of this report which has definitions for words and phrases we use in the report.


Our judgements for each standard inspected

Care and welfare of people who use services Action needed

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement

The provider was not meeting this standard.

Care and treatment was not always planned nor delivered in a way that was intended to ensure people's safety and welfare and people's care and treatment did not always reflect relevant research and guidance.

We have judged that this has a moderate impact on people who use the service, and havetold the provider to take action. Please see the 'Action' section within this report.

Reasons for our judgement

Care and treatment was not always planned or delivered in a way that was intended to ensure people's safety and welfare. People's care and treatment did not always reflect relevant research and guidance.

We reviewed the care records for four people as part of this inspection to determine whether the care people received was consistent with their assessed and actual care needs. We spoke with the most senior nurse in charge to identify those people whose needs had been assessed as higher than others using the service; this included people with diabetes, pressure ulcers or people who were acutely unwell on the day of inspection.

We were told that one person had a grade two pressure ulcer which was being actively managed with dressings and frequent repositioning. We reviewed this person's care plan and found that a tissue viability care plan was in place. The care plan summarised the degree of pressure ulcer as well as including information such as the necessary interventions which needed to be implemented to achieve the set goal of "Promoting healing". We saw that staff had carried out an assessment of needs at the time the person was admitted to Firtree House Nursing Home. On admission, staff had detailed the condition in which the person had been admitted; there was no reference to any areas of skin damage. However, approximately four days following admission, and on seven furtheroccasions staff recorded in the daily care records that they had noted "Sacrum area red. Sudocrem applied". It was reported that on 11 September 2013 "Skin intact to pressure areas" which indicated that the area of damage to the sacrum had been treated.

We saw that the tissue viability care plan for this person had been developed on 23 October 2013 as a grade two pressure ulcer had been identified on the person's sacrum.


Interventions to help manage the pressure area included "Dressing" but this information was non-specific. However, we saw that staff were recording on a separate chart the type of dressing they used when dressing the pressure area.

We noted that the person suffered chronic long-term illnesses which reduced their ability tomobilise independently. The assistant manager told us that the person required assistancewith re-positioning; there was no reference to the frequency with which the person should be repositioned to help prevent further skin damage. Guidance from the National Institute of Clinical Excellence titled "Pressure Ulcers - prevention and treatment" states that "If youhave a pressure ulcer you should change your position or be repositioned regularly to allow the ulcer to heal and avoid further damage". We found within the person's care plan a "6 hourly turn chart" which was commenced on 23 October 2013. There were records present for a period of 23 October 2013 through to 3 November 2013. We asked the assistant manager for the additional records at the time of inspection but these were not provided to us. We noted that of the 12 days of records that were present, on 9 days, it appeared as though the person had not been repositioned on a frequent basis; on 25 and 26 October and also on and 3 November, it was documented that the person had only been repositioned three times during the course of the day. This meant it was not possible for the Provider to assure them-self that staff had taken the necessary action to prevent further skin damage. We noted that staff had changed the grading of the pressure ulcer from a grade two to grade three on one occasion which indicated that despite the wound being treated, further damage had occurred.

The assistant manager informed us that at the time of the inspection there was only one person with a pressure ulcer who has been discussed above. However, we were told that one additional person was receiving treatment for a wound which had not been caused by pressure damage. The assistant manager detailed the treatment the person was receiving which included anti-biotics and additional nursing measures. The assistant manager assured us that the wound was not a pressure ulcer. However, following our inspection wespent time contacting relatives of people who used the service. We spoke with the relative of this person who informed us that immediately following our inspection, their relative had been admitted to hospital. The person said that they had been told by staff at Firtree House Nursing Home that the person had a pressure ulcer; the relative said the hospital had informed them that their relative had a grade three pressure ulcer. We were not confident that all staff at Firtree House were fully aware of the person's condition as they had previously assured us that the person was not suffering from a pressure ulcer.

The assistant manager informed us that two people had been diagnosed with type one Insulin Dependent Diabetes Mellitus (IDDM). Diabetes is a condition where the amount of glucose in the blood is too high because the body cannot use it properly. Diabetes can have both short and long term effects on the body. High blood glucose levels have a negative impact on the body and over time can cause significant damage to vessels, tissue and organs. The assistant manager told us that one person was having consistently high blood sugars (above 15mmol) whilst another person was experiencing low blood sugars (below 4mmol). We asked one nurse the action they would take when someone experienced low blood sugar. They told us they would continue to administer the prescribed dose of insulin but would encourage the person to eat breakfast and would thenre-check their blood glucose level to ensure it was within an acceptable range. We found that on one occasion a person had a blood glucose level of 4.2 at 17:00; the person received a dose of insulin and their blood glucose level was re-checked a short time after they had been offered a sweetened milk based drink. The provider sent us a copy of the person's blood glucose monitoring chart following the inspection which demonstrated that


the blood glucose level had decreased to 3.0mmol when it had been rechecked at 20:00. A note was entered into the blood glucose monitoring chart which indicated the person was offered another "Sweeting milk". There were no further entries into the blood glucose monitoring chart until 10/02 when the blood glucose had raised to 5.9mmol. However, guidance from the NHS and the National Institute for Health and Care Excellence (NICE) recommend that blood glucose levels are checked 10-15 minutes after having had a sugary food or drink to ensure the blood glucose had returned to a normal level. There was no evidence that staff had re-checked the blood glucose level when it had been re-tested at 20:00 and was recorded as 3.0mmol. There was a potential risk that because staff had not followed guidance in responding to, and managing hypoglycaemia, people with diabetes were at potential risk of harm.

Furthermore, one member of staff told us that urine was not routinely checked when people had persistently high blood sugar levels. Where high blood sugars are not appropriately managed, one associated risk is diabetes ketoacidosis (DKA) which occurs when the body is unable to use glucose because there is not enough insulin. Instead, it breaks down fat as an alternative source of fuel which causes a build-up of a by-product called ketones. This is a potentially serious condition if it is not managed early. Diagnosis of DKA can be through blood sampling and urine analysis. Although there was information available to staff regarding the management of low and high blood sugars, we were concerned that the knowledge of some staff may have compromised the safety of people with diabetes as they were not routinely following the guidance provided. Following the inspection, we asked the provider to send us further information regarding one person. As this information was not sent to us we were unable to establish whether staff were routinely checking people's urine to determine whether ketones were present, especially when their blood sugars were persistently above 15mmol.


Management of medicines Action needed

People should be given the medicines they need when they need them, and in a safe way

Our judgement


People were not always protected against the risks associated with medicines because theprovider did not have appropriate arrangements in place to manage medicines.

We have judged that this has a minor impact on people who use the service, and have toldthe provider to take action. Please see the 'Action' section within this report.


We received information regarding the practice of medicine in the home.

There were appropriate arrangements in place in relation to obtaining medicine. The assistant manager told us that they requested people's individual prescription for medicine each month from their GP using the 'repeat prescription' service. Prescriptions were sent from the GP to the home and the staff arranged for them to be sent to the local pharmacy to be dispensed.

Medicines were stored safely. A 'monitored dosage' (blister packed) system was in use, although some medicines were dispensed in their original packaging. There was a locked medication room, to which an allocated registered nurse held the keys.

There were medication policies and procedures and staff had received medication training.We were told that only staff that had completed this training and had been assessed as competent were responsible for the administration of medicines in the home.

The assistant manager told us that there was a system in place to monitor the number of medicines 'in stock 'in the home. We were told that medicines were delivered to the home each month and their receipt was recorded on people's individual medicines administrationrecords (MAR). Unused or excess medicines were returned to the pharmacy and recordedin a 'return book'. However, on the day of our inspection we found that the service was not recording and maintaining an accurate record of medicines "in stock". This meant that the provider was not following their own procedure in order to maintain an accurate audit trail to check on the receipt, administration and disposal of medicines.

We checked the medicines of four people by comparing the quantity in stock against the signature on the MAR charts. We found that the quantity in stock was not recorded on the MAR for two people who used the service. We asked the deputy manager who told us thatone person was admitted to the service last week and they failed to do a stock taking of their medication prior to admission. This meant that there was inconsistency in recording


of medicines when a new person was admitted to the service. This could pose a risk that aprescribed medication may have been omitted or not administered correctly.

We found that on a number of occasions (12 days in January and February 2014) one person had refused to take their medication but there had been no medical advice sought by staff. This meant that the service did not ensure that the prescribed medication was up to date or reviewed and reviewed as the needs of people changed.


Staffing Action needed

There should be enough members of staff to keep people safe and meet their health and welfare needs

Our judgement


There were not always enough qualified, skilled and experienced staff to meet people's needs

We have judged that this has a moderate impact on people who use the service, and havetold the provider to take action. Please see the 'Action' section within this report.


On the day of our inspection we saw that there were three registered nurses, two care staff, one chef and kitchen assistant. On our arrival the assistant manager told that they were short of staff and one of the staff who lived in the premises came for cover. Subsequently, around midday two more agency staff arrived to cover the shortage of staff. We spoke with four people who used the service and four relatives to ask them about the care they received.

People commented that there was not enough staff on duty to meet peoples needs. People who used the service and relatives made some positive comments which included "Staff treat me well", "Staff are nice and kind to me" "and "Very kind and caring".

People who used the service made some negative comments about the staffing levels. Comments included "Staffing not too bad, but what can I do I have to wait, poor things theyhave a lot to do", "Sometimes they are good but sometimes bad when they are busy", "Sometimes staff are busy and leave you waiting as they have lots to do", " Not enough staff" and " They haven't got enough staff."

Relatives we spoke with told us that that "Staffing level had got worst over the past three tofour months." Relatives that had visited the home regularly told us that there had been occasions when only one nurse and one or two care staff had been on duty and at that time the service had been providing care to 28 people. This was reported to the provider by the concerned relatives at the time who were told that there were staff shortages because of staff sickness. When we spoke with the provider they told us that this situation had been occurring for the past two weeks. One relative witnessed a person that had to wait for four hours for personal care to be given. We were also told that due to the lack of staff the chef and cleaner had to support people with eating. Another relative told us that "Nurse is very busy, we cannot ask for more as they got more people to look after".

Staff also told us that they felt that there were not always have enough staff on duty at times. Comments from staff were "For the past few months we struggled with staffing." "It


could be better managed." "Manager shouts at staff ." " This job is very stressful and lack of support from the provider." And " I would not recommend this service to anybody ."

We looked at the staffing rotas for the previous month; we were not able to review the rota for the period of 19 January 2014 to 25 January 2014 as this was not provided to us. We requested the timesheets on the day of the inspection to compare with the rotas but this was not available to us and we were told by staff that the clocking in system was broken. We were sent the timesheets after our inspection but we found gaps in recording as some staff did not sign in for their shifts. This meant that we were unable to accurately assess whether there were enough staff to meet peoples needs.

The provider told us that they have a minimum of two nurses and four care staff in the morning shift and one nurse and three care staff for the evening shift. At night there was one nurse and two care staff. We were told by the provider that the service operated staffing on a 1:4 ratio. We asked the provider about the tool that the service used to assess the level of dependency of each person to help determine staffing ratio's however we were told that there was no formal system in place to do this and that it was the registered managers responsibility to ensure there were enough staff. We were also told that for the previous two weeks the service had experienced staff shortages as a number of staff were on sick leave and some had left due to issues with their immigration status. The provider took action to cover some of the vacant shifts by organising agency staff to cover in the interim period but we found that the agency staff had not always arrived. This meant that the system in place for covering temporary shifts was in-effective as staff did not always arrive.

We found that the provider did not employ enough staff to meet people's needs. At the time of our inspection the provider told us that they would require a minimum of seven staffon duty at all times. We found that only six staff were working in the morning, four staff were working in the afternoon and three staff at night. The provider told us that they had carried out recruitment to increase the staff to ensure that they could meet the needs of people. This meant that the provider did ensure that the service had enough staff on each shifts.

We heard two people who used the service crying out from their rooms. We asked one of the nurses to explain why the person was crying and were told that this person always cried out. We saw that the nurse was busy and there were no staff available to assist that person or attend to their needs.


Notification of death of a person who uses services Action needed

Adult social care and independent healthcare services must tell us when somebody dies in their care. NHS services must tell us when somebody dies because they have not been given the right care

Our judgement


The provider had not notified the Care Quality Commission about the deaths of people who used the service between March 2013 and February 2014.

We have told the provider to take action. Please see the 'Action' section within this report.


The provider and registered manager had not notified the Care Quality Commission (CQC) of a number of deaths that had occurred at the service between March 2013 and February 2014.

Providers are required by law to notify the CQC of the death of a person who uses the service. We use this information to monitor the quality of the service and to identify any trends or concerns that may arise as a result.

The provider told us that the manager had notified us of these deaths however, after checking our records, we found that we had not received this information. After our inspection visit the Provider submitted the appropriate notifications which had taken place between March 2013 and February 2014.

This section is primarily information for the provider


Action we have told the provider to take

Compliance actions

The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activity Regulation

Accommodation for persons who require nursing or personal care

Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010

Care and welfare of people who use services

How the regulation was not being met:

The provider did not have a robust system in place for ensuring that the safety and welfare of people who used the service was protected because staff did not routinely follow local and nationalguidelines. Regulation 9 (1)(b)(iii)



Regulation 13 HSCA 2008 (Regulated Activities) Regulations2010

Management of medicines


The provider did not protect people who used the service againstthe risks associated with the unsafe use and management of medicine.The provider did not have appropriate arrangement for recording, handling, dispensing and safe administration of medicines .Regulation 13 .


Accommodation for persons who require

Regulation 22 HSCA 2008 (Regulated Activities) Regulations2010

This section is primarily information for the provider


nursing or personal care Staffing


The registered person failed to take appropriate steps to ensure that, at all times, there were sufficient number of suitable qualified, skilled and experiences person employed for the purposes of carrying on the regulated activity . Regulation 22.



Regulation 16 CQC (Registration) Regulations 2009

Notification of death of a person who uses services


The provider failed to notify CQC about the deaths of people who used the service. Regulation 16 1 (a), (b)

This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The provider's report should be sent to us by 02 May 2014.

CQC should be informed when compliance actions are complete.

We will check to make sure that action has been taken to meet the standards and will report on our judgements.


About CQC inspections

We are the regulator of health and social care in England.

All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.

The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "governmentstandards".

We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming.

There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times.

When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place.

We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it.

Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re-inspect a service if new concerns emerge about it before the next routine inspection.

In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers.

You can tell us about your experience of this provider on our website.


How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection.

We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action.We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement action taken

If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.


How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact.

Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.


Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17)

Consent to care and treatment - Outcome 2 (Regulation 18)

Care and welfare of people who use services - Outcome 4 (Regulation 9)

Meeting Nutritional Needs - Outcome 5 (Regulation 14)

Cooperating with other providers - Outcome 6 (Regulation 24)

Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)

Cleanliness and infection control - Outcome 8 (Regulation 12)

Management of medicines - Outcome 9 (Regulation 13)

Safety and suitability of premises - Outcome 10 (Regulation 15)

Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)

Requirements relating to workers - Outcome 12 (Regulation 21)

Staffing - Outcome 13 (Regulation 22)

Supporting Staff - Outcome 14 (Regulation 23)

Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)

Complaints - Outcome 17 (Regulation 19)

Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.


Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.


Contact us

Phone: 03000 616161

Email: [email protected]

Write to us at:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

Website: www.cqc.org.uk

Copyright Copyright © (2011) 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 thetitle and date of publication of the document specified.

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