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

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1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. The St Aubyn Centre The St Aubyn Centre, Severalls Hospital, Colchester, CO4 5HG Tel: Date of Inspection: 25 January 2013 Date of Publication: March 2013 We inspected the following standards as part of a routine inspection. This is what we found: Respecting and involving people who use services Consent to care and treatment Care and welfare of people who use services Safeguarding people who use services from abuse Staffing Supporting workers Assessing and monitoring the quality of service provision Records Inspection Report The St Aubyn Centre March

2 Details about this location Registered Provider Overview of the service North Essex Partnership NHS Foundation Trust The St. Aubyn Centre is a Children and Adolescent Mental Health Service (CAMHS) managed by North Essex Partnership NHS Foundation Trust. It provides acute, intensive and secure care and treatment to young people between the age of 11 and 18 who are experiencing acute, complex and/or severe mental health, emotional and psychological problems. An education facility is also on site providing education and vocational opportunities within the national curriculum. Type of services Regulated activities Diagnostic and/or screening service Hospital services for people with mental health needs, learning disabilities and problems with substance misuse Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Treatment of disease, disorder or injury Inspection Report The St Aubyn Centre March

3 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'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 5 Our judgements for each standard inspected: Respecting and involving people who use services 6 Consent to care and treatment 8 Care and welfare of people who use services 9 Safeguarding people who use services from abuse 11 Staffing 13 Supporting workers 14 Assessing and monitoring the quality of service provision 15 Records 17 About CQC Inspections 18 How we define our judgements 19 Glossary of terms we use in this report 21 Contact us 23 Inspection Report The St Aubyn Centre March

4 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. 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 25 January 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and reviewed information we asked the provider to send to us. We were accompanied by a Mental Health Act commissioner who met with patients who are detained or receiving supervised community treatment under the Mental Health Act What people told us and what we found Our inspection on 25 January 2013 was in response to concerns raised about the Centre. The St Aubyn Centre provided care and treatment to young people on an informal (voluntary) basis as well as those detained under the Mental Health Act The Centre was found to be warm, bright, spacious and welcoming. Young people were involved in their care and treatment and most had agreed to their care pathway. They were given choices and supported to make decisions. Care plans, risk assessments, daily notes, observations, safeguarding and restraint records were comprehensive and clear which provided all staff and the young people with an understanding of their treatment and care pathway. Staff had the necessary skills and training to provide care and treatment to the young people. They were provided with appropriate clinical supervision and support in order to carry out their duties effectively. The young people told us they felt supported by the staff. They listened and gave them advice when they needed it. One young person said, "I am really supported here and it's the best place I have been." Another young person said, "Eventually I was listened to and my views were acknowledged." There were effective systems in place to assess and monitor the quality of the service. You can see our judgements on the front page of this report. Inspection Report The St Aubyn Centre March

5 More information about the provider Please see our website 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. Inspection Report The St Aubyn Centre March

6 Our judgements for each standard inspected Respecting and involving people who use services People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run Our judgement The provider was meeting this standard. People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. Reasons for our judgement The Centre provided care and treatment to young people on an informal (voluntary) basis as well as those detained under the Mental Health Act The Centre was found to be warm, bright, spacious and welcoming. There were two units and allocated areas for young people to participate in therapeutic treatments and activities. An education facility was also on site that provided education and vocational opportunities within the national curriculum. We saw on each unit that young people were offered choices and opportunities, such as what to do with their leisure time, phoning their parents and going home for a visit and meals. The young people told us they felt supported by the staff. They told us staff listened and gave them advice when they needed it. One young person said, "I am really supported here and it's the best place I have been". Another young person said,"eventually I was listened to and my views were acknowledged." They had opportunities to express their opinions and feelings at the community meetings every morning and at the monthly young person's forum which was run by an independent advocate. This meant that young people using the service were involved in discussions about their care and treatment and able to influence how the service was run. The manager told us that a group of young people with experience of being detained had helped to develop the new Centre, including the art work and interior design. Young people were also involved in the recruitment of staff which included meeting and greeting them and they had developed a number of questions for the interview. We saw that staff interacted well with the young people on each unit. They were friendly, supportive and respectful in the way they communicated and responded to them. Inspection Report The St Aubyn Centre March

7 One young person told us that his legal rights had been explained and they understood that they could appeal against the section in which they were detained. On all the files we looked at, the young people had their legal rights read and explained to them on a regular basis in line with the code of practice of the Mental Health Act 1983 (as amended 2007). They also had section 17 leave (a detained patient may only leave hospital when granted leave under Section 17 of the Mental Health Act by their Responsible Clinician) which clearly stated if this was unescorted or escorted and the frequency was noted. This meant that young people using the service were aware of their rights. The provider may find it useful to note that for some of those young people detained under the Mental Health Act 1983, their views about treatment and detention were not recorded in their care documentation. This made it unclear if the person had participated in and had an understanding of their treatment planning and care pathway. Information about the St Aubyn Centre was provided to the young people and their families in the form of a welcome pack. This enabled everyone to have an understanding of the therapeutic services available. We saw that there was information available for people detained about their rights and the Mental Health Act. This was also available in easy words and pictures for those who may require it. General advocacy and Independent Mental Health Advocate (IMHA) services were established at the Centre. However, detained patients with whom we spoke were not clear about their right to access an IMHA. We were told that information about advocacy services was given to the young people on admission and leaflets were available. However information and advocacy contact details were not on general display in each unit for easy access to people who used the service. The provider was asked to note that details of the IMHA who visited the ward, the times and dates and how they can access them outside of these times, was made available. Young people were able to have visitors during certain times of the day although there was flexibility if families were travelling a distance away. The manager told us that the staff on each unit kept in touch with family members on a regular basis and usually knew when they were visiting. Young people were also able to spend periods of time at home when appropriate. Inspection Report The St Aubyn Centre March

8 Consent to care and treatment Before people are given any examination, care, treatment or support, they should be asked if they agree to it Our judgement The provider was meeting this standard. Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. Reasons for our judgement We saw that there were systems in place to obtain and act on the young people's consent to their care and treatment. The young people were all on a structured programme of therapeutic treatment and most had been involved in the development of this. We reviewed five sets of care records and interviewed four young people who were detained under the Mental Health Act 1983 (as amended 2007). We saw in the care records that we looked at that most of the young people had signed their agreement to their treatment and care plan. However, where a person had refused, this had been noted. Consent forms had also been completed by them and their guardians. We reviewed five sets of care records and interviewed four young people who were detained under the Mental Health Act 1983 (as amended 2007). All of the detention papers examined were in order and lawful. On examining consent to treatment, we were satisfied that section 58 of the Mental Health Act was complied with and the required forms for consent for treatment were completed. The required forms had been verified by the approved clinician that the patient was capable of understanding the nature, purpose and likely effects of treatment. However, there was one file where the young person was prescribed for rapid tranquillisation by intramuscular injection. We noted that the required level of detention was not recorded appropriately for the administration of this injection. We made the manager aware of this and this was to be looked into. The provider may wish to note that accurate records of consent and treatment provided assured young people using the service that their treatment would be provided in line with their agreement. Inspection Report The St Aubyn Centre March

9 Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. People experienced care, treatment and support that met their needs and protected their rights. Reasons for our judgement There were two units at the St Aubyn Centre. One unit provided admission, assessment and treatment and the other provided a more secure environment where young people were detained under the Mental Health Act Treatments provided at the Centre included psychiatric assessment and medication, family therapy, individual therapy, occupational therapy, group work and education. We looked at care records for seven people currently staying at the Centre. These were for young people who were detained as well as those who were being treated at the Centre 'informally'. Assessments were in place for each person's needs to ensure that these could be met effectively before they were admitted. The young people had physical health checks on admission which were followed up by the doctor in charge. The Centre admitted young people in crisis and provided them with a place of safety. This was either for their own protection or for the protection of others, so that their immediate needs could be properly assessed. The Centre provided a dedicated area for this purpose, away from the main units. We saw that once a person's immediate needs and risks were taken care of, a care pathway was put in place to ensure the Centre could meet their needs. The care plans and risk assessments we saw were comprehensive and provided clear and concise information for staff in caring for the young people. Activities during the day included following their school timetable, therapeutic care pathway and hobbies such as arts and crafts, music and watching films. Care plans included an assessment and diagnosis of their mental, psychological, emotional and physical health needs. A structured care pathway of therapeutic activities and the agreed level of observation required to keep the person safe was documented. Physical health checks were undertaken regularly including weight and fluid intake monitoring where necessary, and the young people had access to a General Practitioner (GP). Inspection Report The St Aubyn Centre March

10 People's cultural, religious and communication needs had also been identified and recorded. The manager assured us that young people's sexual orientation was also recorded within the care plans as and when identified. This meant that people experienced care, treatment and support which protected their rights. Risks to people's health, safety and wellbeing were assessed, recorded and reviewed on a regular basis. The risk assessments were written in a respectful and person centred way. The multidisciplinary team of professionals including consultant psychiatrists, charge nurses, therapists and teachers met together on a regular basis with the young person and as a team to review progress and plan next steps. Regular reviews of young people's care were undertaken and signed and dated. This ensured their changing needs were identified and met in the most appropriate way. Staff completed a daily handover to ensure that important information about the wellbeing of the young people was relayed and acted upon effectively. Care plans and risk assessments were also maintained on a computerised system. This ensured that records were able to be reviewed and accessed quickly by a range of professionals involved in the young person's care. We saw that effective links with accident and emergency services and paediatric services at Colchester General Hospital were maintained. This meant that the young people received the appropriate emergency support and care when they needed it. Staff were very knowledgeable about the young people's needs and circumstances which provided a continual clear focus on an individual young person's care pathway and kept within the boundaries of the agreed treatment plan. Inspection Report The St Aubyn Centre March

11 Safeguarding people who use services from abuse People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Reasons for our judgement The Centre had a comprehensive range of policies, procedures and practices in place in relation to safeguarding young people in their care. Safeguarding alerts and concerns were reported via the Trust's internal mechanisms as well as to Essex County Council's children safeguarding services. All staff caring for young people at the Centre had undertaken training in safeguarding children. All the staff had undertaken safeguarding training in early 2012 and also received an intensive four week programme of training which had included safeguarding children and restraint training in June 2012 prior to the Centre opening in July We were told that further safeguarding children training was planned and booked for February, March and April The Centre had reported four serious untoward incidents since the Centre opened in July These had been reported, recorded and investigated appropriately. We looked at the recording of where physical intervention and the administration of medication had been used. We asked the manager to provide records that showed where intramuscular injections had been used when oral sedation had been refused. The information they provided to us showed that the recording of incidents requiring the administration of intramuscular injections was detailed in the computerised system. The recordings were succinct and captured the reasons, the action and the outcome for the young person. The manager told us that this was also evidenced in the nursing notes and medication chart. We were assured that correct procedures were in place for the care and welfare of young people using the service. Each unit within the Centre had an area for seclusion for the purpose of reducing agitation and the short term management of disturbed/violent behaviour. We saw that there was a clear protocol for staff to follow in these circumstances to ensure the person's safety. Records showed that the need for, duration and monitoring of people's seclusion was recorded. This meant that people using the service were suitably protected from abuse and their rights were upheld. Inspection Report The St Aubyn Centre March

12 The building had been designed so that there was a clear segregation of male and female bedrooms. This helped to ensure that young people were kept safe during personal times in their bedrooms. We saw that clear procedures and arrangements were in place to protect young people against the risk of unlawful or excessive control or restraint. Inspection Report The St Aubyn Centre March

13 Staffing There should be enough members of staff to keep people safe and meet their health and welfare needs Our judgement The provider was meeting this standard. There were enough qualified, skilled and experienced staff to meet people's needs. Reasons for our judgement The manager told us that they had experienced some turn over of staff. There were a minimum of eight nursing staff on each unit which included a manager, charge nurses, qualified nurses and healthcare assistants. On one unit an additional shift between four and eleven pm had been implemented providing an additional staff member on duty for support to young people during the evenings. There was also a system in place for staff support to be available should one unit require extra assistance at any particular time. The manager told us that they had a pool of bank staff but that agency staff were used where necessary to ensure that there was a full staff team on duty at all times. Staff told us that staff do come and go and sickness absence was quite high. However, there was regular bank staff so it was not seen as a problem. We were shown the staff rotas for the current week of the inspection. We saw that there was sufficient staff on duty to meet the needs of the young people. Inspection Report The St Aubyn Centre March

14 Supporting workers Staff should be properly trained and supervised, and have the chance to develop and improve their skills Our judgement The provider was meeting this standard. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Reasons for our judgement The Centre had a range of staff who worked closely as part of a multidisciplinary team. Professionals included teachers and teaching assistants, consultant psychiatrists, clinical psychologists, therapists, a social worker and access to dieticians. This team provided care and treatment to the young people as part of their planned care pathway. We saw from the three staff files we looked at that staff had undertaken training appropriate to the needs of the service. This training included three year refresher training in safeguarding and restraint. Other training included medication, fire safety, conflict resolution, infection control, Mental Capacity Act 2008, food hygiene, management of self harm, learning disability awareness, incident reporting and Carebase training (computerised patient records system). The training programme included both on-line and specialist group training sessions. This showed us that training and clinical support sessions were planned in advance and monitored to ensure that all staff undertook training and updates in relevant areas, when necessary. Staff told us that there was good communication within the team and the team were well managed and supported. Staff said that support and debrief sessions were very useful after incidents had occurred and helped to provide some reassurance for them in how they dealt with the situation. Staff had received regular supervision sessions and annual appraisals. This showed us that suitable arrangements were in place to train and support staff in caring and supporting for the young people at the St Aubyn Centre. Inspection Report The St Aubyn Centre March

15 Assessing and monitoring the quality of service provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. Reasons for our judgement There were a number of ways in which the Centre monitored and assessed the quality of the service. Young people were encouraged to give their views about the service through attendance at community meetings each day, a monthly young people's forum and their therapeutic meetings. They were encouraged to be involved in staff recruitment and to make choices about meals, group activities and improvements to the environment. Reviews of young people's care pathways took place weekly. Some young people completed part of the review themselves. The review of their plan of care and any risk assessments were updated as appropriate so as to monitor their progress and make decisions about future discharge. Meetings and agreements with families ensured that they were involved in the planning and delivery of care in the best interests of the individual concerned. Effective strategic planning and communication took place between the different staff disciplines. These included senior handover and clinical supervision sessions to reflect on negative and positive behaviours. Staff meetings, clinical board meetings and lessons learnt sessions which all fed into the overall development plan for the Centre. The manager told us that the computerised system used for recording all information about young people's behaviour and the use of intervention and restraint. This system made it easier to look for trends and incidences and put systems in place to prevent reoccurrence. The Centre had a risk register which logged operational and clinical risks which included the environment, staffing and the reporting of faults. Criminal records bureau checks (CRB) and maintenance of appropriate qualifications, training and regular supervision of staff mitigated risk in relation to recruitment and support of staff. The reporting and investigations of incidents and safeguarding concerns internally provided a way of monitoring the safety of the service for the young people using it. The Centre monitored patient safety, clinical effectiveness and user experience which fed Inspection Report The St Aubyn Centre March

16 into North Essex Partnership NHS Foundation Trust's auditing and monitoring process called a ward quality barometer. This showed at a glance a picture of how the trust was performing on quality. The quality of the service provided by St Aubyn Centre for November 2012 was rated as good. Inspection Report The St Aubyn Centre March

17 Records People's personal records, including medical records, should be accurate and kept safe and confidential Our judgement The provider was meeting this standard. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. Reasons for our judgement The Centre had a central database system in place which was used for recording, reporting and monitoring information. Paper based records were also in place. We reviewed the records of seven young people including care plans, risk assessments, clinical notes and daily reports. Care plans, risk assessments, weight and fluid charts and physical health checks were recorded on the database as well as kept in a folder which was accessible to all staff as well as the young person. This meant that young people using the service were assured that accurate and up to date records were held in relation to their care and treatment. Details of physical restraint, incidents or events, observations and the need for 'as and when required' medication was well recorded and maintained. These records were also monitored for quality and safety auditing purposes. We were told by staff that the database system was easy to use and effective in recording people's ongoing care and treatment. The records relating to staff employment and the management of the regulated activity were accurately maintained. All records were kept securely. Inspection Report The St Aubyn Centre March

18 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 We regulate against these standards, which we sometimes describe as "government standards". 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 dentists and other services at least once every two years. 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 but we always inspect at least one standard from each of the five key areas every year. We may check fewer key areas in the case of dentists and some other services. 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 reinspect 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. Inspection Report The St Aubyn Centre March

19 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. 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 of actions 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 prosecuting a 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. Inspection Report The St Aubyn Centre March

20 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. We make a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation) from the breach. 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. Inspection Report The St Aubyn Centre March

21 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 number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations These regulations describe the essential 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. Inspection Report The St Aubyn Centre March

22 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 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. Inspection Report The St Aubyn Centre March

23 Contact us Phone: Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: 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 the title and date of publication of the document specified. Inspection Report The St Aubyn Centre March

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