Manor Care Home - Middlewich

Manor Care Home - Middlewich is a residential care home registered to provide personal care and accommodation for up to 44 people aged 65 and over. There were 42 people living at the home at the time of this inspection.

People’s experience of using this service and what we found

The management of medication had been improved and was safe. People told us that they received their medicines when they needed, and audits were robust. People felt safe living at the service, and this was reflected in the views of relatives.

Audits to measure the quality of care provided were now more robust. The new manager had sent out surveys to residents, relatives and staff in order to gain an indication of their experiences. Responses were mixed and as a result the manager and provider had started a process of meeting with people and setting timescales in order to drive improvement.

Staffing levels met the needs of people with comments indicating that staff were available when needed and that such care was provided in a timely manner. Assessments were in place reflecting personal risk as well as risks within the environment. Standards of good hygiene were maintained.

Interventions for those at risk of malnutrition and dehydration were appropriate with people having been Comments about the variety and portions of food were mixed. The manager had an action plan in place to resolve these issues. Kitchen staff were aware of the dietary needs of people.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 25 October 2021) and there were breaches of two regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced inspection of this service on 23 September 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve in areas of safety and governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Manor Middlewich on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Manor Care Home - Middlewich is a residential care home registered to provide personal care and accommodation for up to 44 people aged 65 and over. There were 40 people living at the home at the time of this inspection.

People’s experience of using this service and what we found

People did not receive their medicines safely and as prescribed. Some people had not been given their medicines because they were out of stock and one person had been given the wrong dose of a blood thinner. Medicines rounds were not always completed in a timely manner, which meant people did not receive their time-critical medicines when they needed them. The provider’s quality assurance processes to monitor the safety and quality of medicines administration were ineffective.

The provider did not have effective systems in place to monitor, assess and improve the quality and safety of service being provided. Quality assurance processes and records relating to this had not been properly maintained since our last inspection. The quality and accuracy of record keeping at the home was also inconsistent.

People said they felt there were enough staff. One person said “Always lots of staff around. I do most things for myself but they are quick when I need them.” Staff were visible around the home during our inspection and any call bells were answered promptly. Staffing levels were planned to meet people’s needs and the provider confirmed this considered the individual layout of the building. Staff were safely recruited, ensuring new staff were suitable to work with vulnerable adults.

People said they felt safe living at the home. One person said, “I do feel safe. Staff always check if I’m ok and I can say if I’m unhappy.” Staff had received safeguarding training and understood their role in recognising and reporting safeguarding concerns.

The home was clean and hygienic. Enhanced cleaning schedules were in place and cleaning products had been reviewed and amended in response to COVID-19. Staff followed the relevant guidance and best practice in relation to infection prevention and control. The home had a COVID-19 testing programme in place for people living at the home and staff. Staff and people living at the home had been supported to access COVID-19 vaccinations.

There was a caring and supportive culture amongst staff at the home. People appeared happy and comfortable. People living at the home and their relatives spoke positively about the staff. One relative commented, “Staff go above and beyond, they have a genuinely caring nature and treat people like family.” Staff were familiar with and knowledgeable about the people they were supporting.

People and their relatives said staff involved them in decisions about their care and kept them updated about any changes. One relative said, “I’m involved in all care plan reviews, staff are on top of all [Relative’s] needs.”

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 26 January 2021).

Why we inspected

We received concerns in relation to staffing levels, the management of medicines and governance. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to medicines management and governance. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Manor Care Home - Middlewich is a residential care home providing personal care to 35 people at the time of the inspection. The service can support up to 44 people across two separate floors, each of which has separate adapted facilities.

People’s experience of using this service and what we found

Improvements identified at our last inspection had been sustained and built upon. Safety, effectiveness and leadership had improved significantly. People received safe and effective care and outcomes were good.

People told us they felt safe and well cared for. All relatives told us their loved ones were in safe hands. Safeguarding systems, policies and procedures ensured people were safe and protected from abuse. Risks to people’s health, safety and welfare, were identified and managed safely with the involvement of the person or their representatives.

We were assured by the additional measures in place to help prevent the spread of COVID-19. Risks relating to infection prevention and control (IPC), including in relation to the COVID-19 pandemic were assessed and managed. Staff followed good IPC practices.

Medicines were safely managed, and systems were in place for reporting accidents and incidents and learning from them.

There were sufficient numbers of suitably trained and experienced staff on duty and safe recruitment procedures were followed. Staff presented as well trained, caring professionals. Visiting professionals told us that care staff were skilled and knowledgeable about meeting people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People's nutritional and hydration needs had been assessed and were being met. One person said: “The food is excellent, compliments to the chef, two choices and if you don’t want that you can have something else.”

The registered manager and staff were clear about their roles and responsibilities and they promoted a positive, person-centred culture. Staff worked well together as a team, and there was good partnership working with others to meet people's needs.

Effective systems were in place for checking on the quality and safety of the service and making improvements where needed.

Rating at last inspection.

The last rating for this service was requires improvement (published November 2019) there were no breaches of regulation.

Why we inspected

This was a planned inspection based on the previous rating. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Manor Care Home - Middlewich on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Manor is a residential care home providing personal care to 32 people at the time of the inspection. The service can support up to 44 people across two separate floors, each of which has separate adapted facilities.

People’s experience of using this service and what we found

Overall, safety in the service had improved since our last inspection and systems in were place to ensure people were protected from the risk of abuse. Risks to people’s health and wellbeing had been assessed and care plans updated to reflect this. Care plans had improved and reflected peoples current care and support needs. People told us they felt safe living at the Manor.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. The service has implemented an electronic care planning system and we have made a recommendation regarding ensuring consent is recorded.

Staff felt supported by the registered manager and systems were in place to ensure staff were supervised. Further improvements were required however to ensure staff have the required training they need to do their job well. We have made a recommendation about staff training.

Governance systems had improved and there was an increased level of oversight by the provider and the registered manager. Some of the systems were newly introduced and need to be embedded to ensure they are effective in driving improvements and monitoring the quality of care being provided.

Medicines were managed safely and we found the service was clean and tidy. Careful consideration had been made by the registered manager to improve the environment. This included ensuring the home was adapted to assist people living with dementia and improving communal areas such as the dining area and also the dining experience.

There was a range of activities available at the home for people to engage in. we also observed people being supported by caring and attentive staff who clearly knew the needs of people living at the service very well.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 19 April 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations, however the service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Manor care home is a care home with 34 people living at the home at the time of this inspection.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home has two floors with ensuite rooms and a passenger lift. The majority of people living at the home were living with dementia.

There was no registered manager present in the home at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a new manager who had taken up their position as manager from October 2018. The new manager had applied for registration with the Care Quality Commission and was going through the registration process at the time of our inspection.

When we completed our previous inspection on 10 and 11 July 2018 we found concerns relating to staffing in the home and also governance. On this inspection we found a continued breach of the regulation in relation to good governance and we made a recommendation regarding staff deployment within the home. We also found the provider was in breach of regulations in relation to consent, safe care and treatment and the premises.

We undertook a tour of the premises and found numerous health and safety concerns not being addressed by the provider such as an uncovered hot water pipe which was 75 degrees Celsius and fire doors not all staff could open in the event of a fire.

The provider was not always following the Mental Capacity Act (MCA) 2005. A best interests process was absent in the records for one person. Staff were administering prescribed medication to manage their behaviours without evidence of lawful consent.

There was no evidence of behaviours which were challenging being analysed for triggers to always show people were being supported in the least restrictive way.

Safeguarding processes were not robust enough. There was no evidence of trends or themes being analysed by the provider.

Care plans were not up to date with accurate information. Person centred care was not being delivered.

People’s nutritional needs were not always being met as we observed people struggling to eat and drink or sitting with food in front of them not being supported to eat. We made a recommendation about staff deployment.

The emergency call bell system was not robust. Emergency pull cords were seen tied up and some sensor mats/door alarms were unplugged/switched off.

Quality checks and audits had not identified all of the issues we found on this inspection. The provider had not demonstrated they had taken robust action since the last inspection.

The home had a 5 star rating for food and hygiene. The rating was displayed in the main entrance of the home.

Prescribed medicines were being managed safely.

Manor Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Manor Care Home provides accommodation and personal care and support for up to 44 older people. The accommodation is provided over two floors in a large listed building and a large purpose-built extension attached to the main building. The home has 44 bedrooms of varying size, 34 of which have an en-suite facility. There is a range of communal spaces including: lounges; dining rooms and sitting areas. Toilet and bathroom facilities are dispersed throughout the building. There is a car park provided for visitors and staff. The home is situated in a quiet residential area of Middlewich. At the time of our inspection 32 people were living at the service.

The home has a manager and they have applied for registration with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered provider had systems in place to monitor the quality of the service provided. Some areas needed improvements. For example, such as out of date health and safety checks had not been identified within the services own monitoring procedures. Some areas needed improvements such as environmental risk assessments, kitchen maintenance, updates needed for record keeping and repairs had not been identified within the services own monitoring procedures.

This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated activities) regulation 2014 Good Governance.

Staffing levels had been recently revised by the registered provider. On occasions staffing levels had been lower than the levels stated by the provider due to short notice of staff sickness. This puts people at risk of not being provided with appropriate support due to less staffing than would normally be in place.

This is a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated activities) regulation 2014 Staffing.

‘You can see what action we told the provider to take at the back of the full version of the report.’

Since starting in post 10 weeks earlier, the manager had introduced regular supervision sessions and training for the staff team. The manager was clear in explaining that staff had been out of date with various training when she commenced in post.

Procedures were in place to minimise the risk of harm to people using the service. Staff understood how to recognise and report abuse which helped make sure people were protected. Monitoring checks needed review to show better governance of their records in analysing and reporting events.

Risk screening tools had been developed to reflect any identified risks and these were recorded in people’s support plans. The risk screening tools gave staff instructions about what action to take in order to minimise risks e.g. for falls.

Staff were recruited following a safe process to make sure they were suitable to work with vulnerable people.

Staff had access to personal protective equipment (PPE) to help reduce the risk of cross infection for example disposable gloves and aprons.

The service had policies and procedures relating the Mental Capacity Act 2005 and deprivation of liberty safeguards. Staff had recently completed training in this topic and staff understood the needs of the people they supported who lacked capacity.

Staff had good relationships with the people they were caring for. People told us they felt comfortable and liked living at the service.

Activities had been introduced by the new manager with a programme of events organised by the staff team. The manager was recruiting to a post for an activities organiser to help develop these social events.

Since commencing in post the manager had developed everyone's support plans to show how they were meeting people’s needs. The support plans showed good overview and highlighted personal details and requests from people as to how they wanted their needs met.

People had access to healthcare services for example from the district nurse, chiropodist, optician and the GP. People were supported to attend hospital appointments as required.

We saw there was a concerns and complaint policy accessible to each person in the information leaflet supplied to people. Most of the people living at the service and visiting relatives we spoke with told us they had no concerns or complaints. We received one complaint from a relative and one from staff that we referred to the registered provider and manager to review within their complaints procedures.

We recommend the registered provider look at published guidance to consider further adaptions to the environment to meet people’s dementia needs.

We recommend that the activities programme and support plans be reviewed and developed to show how they meet people’s social needs and requests.

Manor Care Home provides accommodation and personal care and support for up to 44 older people. The accommodation is provided over two floors in a large listed building which has been converted and adapted for use as a residential care home. The home has 44 bedrooms of varying size, 34 of which have an en-suite facility. There is a range of communal spaces including: lounges; dining rooms and sitting areas. Toilet and bathroom facilities are dispersed throughout the building. There is a car park provided for visitors and staff. The home is situated in a quiet residential area of Middlewich.

The home has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People who lived in the home and their relatives spoke of the quality of the care delivered. They told us that the staff of the home went above and beyond to ensure they received a person centred service. Staff maintained people’s privacy and dignity ensuring that any care or discussions about people’s care were carried out in private. We saw that interactions between staff and people who used the service were caring and respectful with staff showing patience, kindness and compassion. We observed that staff knew and understood the people they cared for and ensured that people were provided with choices in all aspects of daily life. Comments made included; “The care she has received has been second to none; the staff are incredibly attentive and genuinely create relationships with the residents. Whenever issues have arisen, for example when (name) was diagnosed with pneumonia this year and was subsequently hospitalised, the staff and management alike have been quick to respond and help. Lines of communication have always been clear and open”.

Staff were well trained and used their training effectively to support people and assist them with their daily life and help them wherever possible to retain their independence. Staff told us that the provider had developed some extra training events for staff to enable them to gain knowledge and skills to enhance the lives of people who were living with dementia.

Staff understood and worked within the requirements of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards. Staff were able to demonstrate an excellent understanding and knowledge of people’s support needs so as to ensure people’s safety and protect their human rights.

Staff were recruited through a rigorous procedure. Staff went through a robust recruitment process before starting work. As part of the recruitment process the provider used value based recruitment techniques, a clearly defined culture statement and staff competency assessments.

People received their medicines as prescribed by their GP. Medicines were managed safely to ensure people received them in accordance with their health needs and the prescriber’s instructions. A GP was assigned to conduct weekly visits to the home to take a proactive approach to healthcare. Staff told us that this assisted them to discuss any issues relating to people’s health and well-being and to assist with regular health checks such as blood pressure readings ‘without fuss’.

Staff were attentive to people’s appetites and ensured that people were provided with a meal of their choice. We saw that special diets were catered for. Staff told us that menus were not provided because people were not always sure what they wished to eat prior to each meal. They said that a choice of two meals was presented to people at meal times and they were able to choose what they wanted at that time. We saw that menus were in place in the kitchen and dining areas of the home so relatives and friends of the people who lived in the home could see the meals provided. Risks to people’s nutrition were minimised because people were offered meals that were suitable for their individual dietary needs and met their preferences.

The experiences of people who lived at the home were positive. Staff had good relationships with people who lived at the home and were attentive to their needs. Activities were arranged to suit the preferences of the people who lived in the home. Staff respected people’s privacy and dignity at all times and interacted with people in a caring, respectful and professional manner.

People were protected from abuse and felt safe at the home. Staff were knowledgeable about the risks of abuse and reporting procedures. We found there were sufficient staff available to meet people’s needs and that safe and effective recruitment practices were followed.

The home was clean and staff had received training in infection prevention and control. Bedroom’s contained equipment necessary to support the person such as ceiling hoists and specialist beds.

The provider had a whistleblowing policy to inform staff how they could raise concerns, both within the organisation and with outside statutory agencies. This meant there was an alternative way of staff raising a concern if they felt unable to raise it with the registered manager.

The home had a complaints policy; details of which were provided to all the people who lived in the home and their relatives. People’s relatives told us that they had not had any reason to complain but if they did ‘they knew what to do’.

During the inspection we spoke with the home manager, the clinical lead nurse, six staff members and a director of the company. We also spoke with eight of the people who lived in the home and four of their relatives.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The home was well maintained and we noted that the security of the premises had been enhanced and a programme of refurbishment was taking place in order to ensure the home was pleasant and safe for people living and working there.

Training records highlighted that staff were up to date with all mandatory training needed to support people living at Manor Care Home. This helped to ensure people that were supported by staff who were fit to carry out their roles and responsibilities and were suitable to work with people who lived in the home.

The manager advised us that appropriate procedures, including review were in place should anyone need to be subject to a Deprivation of Liberty Safeguard (DoLS) application or plan. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests.

Is the service effective?

We looked at six care plans and saw that people and their relatives were involved in the planning of their care. We saw that risk assessments were in place to support people's particular needs such as support with moving and handling. We saw that the care plans had been significantly improved over the past months. We saw that more robust evaluations were taking place and that care plans had been updated to reflect the changing needs of the people in the home.

Is the service caring?

We spoke with eight people who lived in the home and they all said positive things about the care that they received and the staff who supported them. Comments included; 'the staff are very nice people', 'staff are kind and helpful', 'staff are fully committed to providing good quality care and support' and 'cannot fault them'.

We observed that relationships between staff and people who lived in the home were warm and friendly and we saw that people were relaxed in the company of staff. We saw groups of people chatting to staff in a calm and friendly atmosphere. We saw that the staff were skilled in supporting people who had dementia whilst encouraging them to maintain their independence.

Is the service responsive?

The care plans looked at had been written in a person centred manner. This means that the individualised care plans focused on the person's individual assessed needs and on how they could be met. The care plans focused on providing support to an individual in different aspects of their daily life, for example how the person was to be supported with promoting their independence and any issues regarding their health so that they stayed as healthy as possible.

We saw that people were weighed on a regular basis and the results were recorded in a file in the main office as well as in people's individual care files. A recognised assessment tool was being used in the care plans and it was correctly used and recorded. We were able to see that these people were receiving the appropriate care and that people's weights were closely monitored and maintained.

Is the service well led?

We saw that quality audits were carried out by the provider. We looked at completed audits and saw that action had been taken in response to any issues raised. We looked at the manager's audit file and saw that the provider had put in place a monthly audit plan. The manager told us that they completed these each month and the information was reviewed and acted on where necessary. This showed that the provider ensured that there was an effective system to regularly assess and monitor the quality of service that people received. The staff members we spoke to said that the home was well managed and they enjoyed working there.

We carried out this inspection to follow up on actions taken by the provider to ensure people were receiving safe and appropriate care.

We found that the home had a relaxed, sociable and welcoming atmosphere. Some of the people with were able to discuss the arrangements made for their care and support. They told us that they were happy and content and we saw that they were treated with respect and enjoyed good relationships with staff.

We looked at the personal care files for four of the people who lived at the home and saw that improvements had been made in the way care plans were written. Records showed that each person's health and wellbeing was monitored closely and where appropriate staff had sought medical attention or advice and guidance from the person's health and social care professionals.

We found that improvements had been made in each of the required essential standards including the provision of suitable numbers of staff and the assessment and monitoring of the service provision by the registered person.

We observed staff carrying out their work with care, sensitivity and skill.

The directors of the company operating the home, their management team and all the staff we met with on the day of the inspection were transparent, proactive and committed to securing the positive improvements recently made in the service the home provided.

People living in the home and people visiting the home made a range of comments. Some of which were very positive others were more neutral.

Staff comments voiced some concerns about staffing levels.

One person visiting the home told us that during their visits 'staff are always kind and caring to the residents'. A relative told us 'staff always ring if my (family member) is ill or has an accident.

The relatives and other visitors told us they had no concerns or worries about the care and support offered to their family members who lived in the home. .

We saw that care plans were regularly reviewed and updated by staff. The provider may wish to note that there was little evidence to show that people who used the service and/or their relatives were involved in developing or reviewing the plans of care.

Information provided by the manager during this inspection told us there were policies and procedures in place to safeguard people who used the service from harm or possible abuse.

The manager provided us with a copy of the staff training record which showed staff had access to or had received appropriate training.

We saw records which showed that checks were carried out to ensure the health and welfare of people who lived in the home was maintained.

The provider told us that the manager would be submitting an application to the Care Quality Commission (CQC) by the end of February 2013 for the post of registered manager.