Inspection on 07/04/09 for Gresham Care Home

This is the latest available inspection report for this service, carried out on 7th April 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gresham Care Home 07/11/06

Gresham Care Home 13/02/06

Gresham Care Home 13/06/05

Gresham Care Home 18/01/05

Gresham Care Home 19/08/04

Gresham Care Home 03/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Gresham Care Home 49 John Road Gorleston Norfolk NR31 6LJ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jane Craig     Date: 0 8 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 03000 616161 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Gresham Care Home 49 John Road Gorleston Norfolk NR31 6LJ 01493661670 01493658735 greshamcarehome@internet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr. Naim Mohammud Ruhomutally,Mrs. Vidia Ruhomutally care home 28 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 11 28 dementia old age, not falling within any other category Additional conditions: 0 0 Eleven (11) service users may be accommodated within the categories of DE(E) or DE. From time to time the home may accommodate up to two service users under the age of 65 years. Total number not to exceed twenty-eight (28). Twenty eight (28) Older People may be accommodated. Date of last inspection Brief description of the care home Gresham Care Home provides nursing or personal care to a maximum of 28 people. Accommodation is situated on the ground and first floor in single and double rooms. There is a large lounge with a dining room attached and a small quieter lounge for those that prefer it. The home is situated close to Gorleston seafront and to the high street with shops and other facilities available within walking distance. Information about the home was sent out to people making enquiries about the home. The latest Care Homes for Older People Page 4 of 29 Brief description of the care home inspection report was available from the manager. The fees range from 358 to 538 pounds per week. There are extra charges for toiletries, hairdressing, chiropody and newspapers. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection on this service was completed on 27th April 2007. This key (main) inspection includes information gathered since the last inspection and an unannounced visit to the home. The visit was carried out on 7th and 8th April 2009 and took a total of nine hours. The visit was conducted by one regulatory inspector. At the time of the visit there were twenty four residents in the home. We met with some of them and asked about their views of Gresham Care Home. We spent time observing daily routines in the home and how staff interacted with residents. Three residents were case tracked. This meant that we looked at their care plans and other records and talked to staff about their care needs. Care Homes for Older People Page 6 of 29 We talked to the both of the owners, one of whom manages the home. We also talked to staff and visitors. We looked around the home and viewed a number of documents and records. This report also includes information from the annual quality assurance assessment (AQAA), which is a self-assessment report that the manager has to fill in and send to the Commission every year. What the care home does well: What has improved since the last inspection? What they could do better: To make sure that residents are supported in the way they wish, care plans should be more detailed and the instructions for staff should take into account the residents individual preferences. Improvements must be made to the records and administration of medicines to make them safer and to make sure that residents receive the correct medication as it is prescribed. Care Homes for Older People Page 8 of 29 The procedure for reporting poor or abusive practice should be made clearer so that staff know exactly what action they should take if they suspect an incident may have occurred. In order to protect the residents, the manager must ensure that thorough background checks are carried out for all new staff before they start work at the home. The systems for measuring and improving the quality of the service should be developed further. Residents and other people with an interest in the service should be consulted and have more opportunities to influence the development of the service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –03000 616161. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff received sufficient information about new residents to enable them to understand their needs. Evidence: Prospective residents and their families were encouraged to visit the home and speak with residents and staff, which helped them to make a decision about whether the home was right for them. A family carer said the manager made him feel very welcome and he did not feel any pressure had been put on him to choose the home. Residents were assessed prior to being offered a place at the home. This practice helped to ensure that their needs were understood and could be met by the service. The manager discussed a case where extra training had been arranged for the staff before they admitted a resident who had needs they were not familiar with. Care Homes for Older People Page 11 of 29 Evidence: The pre-admission assessment document comprised a tick list which highlighted the prospective residents level of independence or dependence in various activities of living. There was room for staff to add comments but those we saw provided little extra information about the individual. A further assessment, which contained more information about the resident, was carried out on admission. The staff we spoke to said they received enough information about new residents to be able to carry out the right care. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care met the assessed needs of people who use the service and was provided in a personal and dignified manner. Evidence: We looked at three sets of care records as part of the case tracking process and others were looked at to check specific issues. The standard of care plans varied. Some were clear and gave staff specific directions. Others were not detailed enough to ensure that staff provided a consistent level of care. For example, some care plans to assist with personal care were vague and did not inform staff how the resident wished to be supported. However, discussions with residents indicated that they were happy with the care they received. Staff told us that they found the care plans useful and they also received good verbal handovers where they were kept informed about any changes in the residents health or care. During discussions with staff it was apparent that they knew the residents and their individual preferences very well. Care Homes for Older People Page 13 of 29 Evidence: There were assessments to identify potential risks to residents health. These were not always reviewed frequently enough and plans were not always detailed enough to help reduce the risks. Care plans were reviewed every month and residents or their families had opportunities to be involved in care planning and reviews if they wished. A family carer told us that staff always kept them up to date with anything to do with the care of their relative. Shortfalls in care plans were discussed with the manager. She took immediate action to ensure that the risk assessments and care plans we had looked at were re-written to provide detailed directions that also included residents preferences for support. The manager said she was planning to audit care plans on a regular basis to make sure that they were kept up to date. There was evidence on care files that residents were referred to health care professionals as needed. Residents told us they were well cared for and staff called the doctor if they were not well. A visitor told us that the medical care was good and staff had sorted out some of their relatives health problems. Another said that their relative was looked after better than they had been in hospital. The manager told us she sought up to date advice on tissue viability, and care plans to manage wounds were very clear. The staff were undertaking training to help them to implement an end of life care pathway. The manager had spoken with residents and relatives about this and had started to assist people to draw up advance care plans. All medication was administered by registered nurses, who worked to the homes policies and procedures. The manager had recently introduced a monitored dose system for managing medication and the stocks and records we checked relating to this system were accurate. The records of other medicines received into the home, or carried forward from the previous month, were not complete. This meant there was not a full audit trail, which could increase the risk of mishandling. Before the end of the visit all medication in the home had been counted and the manager arranged for a full audit to take place, which she planned to repeat on a regular basis. There were no gaps on any of the medication administration records (MAR) charts we saw. There were complete records of medicines to be disposed of. Medicines, including those awaiting disposal, were stored safely. Storage temperatures were monitored to ensure that they were within the range recommended by the manufacturer. Care Homes for Older People Page 14 of 29 Evidence: Controlled drugs were stored safely and records of administration were complete. However, we found an error in the timing of medication administered to one resident, which meant that they were not receiving their painkillers at the time they were prescribed. Staff received training on core values during their induction and NVQ training and during the course of the inspection we observed staff speaking to residents politely and with respect. The staff we spoke to described how they promoted residents privacy during their day to day work. Residents and visitors said that staff were polite and caring. One family carer told us that staff made sure their relative was always clean and well dressed. Another relative said, They talk to her and treat her with dignity. Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents had lifestyles which generally matched their expectations. Evidence: The AQAA told us that there had been an increase in the level of activities available to residents who were not able to occupy themselves. The residents we asked said there were some activities such as bingo, music and cards. One told us, Theres something going on if you want to do it but there is no obligation. Another resident said that staff would take him out when the weather was suitable. A family member told us that staff spent one to one time with their relative. Residents had choices in most aspects of their daily lives. Some information about residents preferred routines was recorded on their care plans and staff were able to describe how individual residents chose to spend their days. Residents we spoke to said they were able to get up and go to bed when they wished and were happy with the daily routines in the home. One said, I like to have my own routine. A number of residents told us that they were generally happy living at the home. One said, Ive no qualms about this place. Another said, I have no regrets about coming here whatsoever. Care Homes for Older People Page 16 of 29 Evidence: The AQAA told us that the service was good at respecting residents cultural and religious beliefs. The manager discussed how one resident was assisted to attend church each week. Staff also accompanied a resident to a community group which helped to address their cultural needs. The manager told us that the chef had experience in providing special cultural diets. There was an open visiting policy but staff respected residents wishes if they did not want to see visitors. A family carer said that they were always made to feel welcome and were offered refreshments. Families were encouraged to be as involved as they wished to be in their relatives care. There were facilities for family members who may wish to stay over at the home if their relative was very poorly. Some residents went out with family and occasionally with staff. The AQAA indicated that the manager was hoping to improve links with the local community. The service did not have a pre-planned, rotating menu. The records of meals served were incomplete and showed that some meals were served every week. It was not possible to confirm, from the records, that residents were offered a varied and nutritionally balanced diet. However, most of the residents we asked said the food was good. One said the dinners were excellent but there were too many sandwiches at teatime. Others said they were happy with the food and the variety. One said, We have a very good chef and the food is cooked properly. A relative said the meals were, Very tasty. Residents had a choice at each mealtime and the manager said that they could always have something else if they wished. There was a file in the kitchen which listed residents likes and dislikes and any special help or equipment they needed. On the day of the visit the midday meal looked appetising. Pureed diets were served in an attractive way. Care Homes for Older People Page 17 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints were dealt with appropriately and systems were in place to help to ensure that people were safeguarded from abuse. Evidence: There was a concise complaints procedure, which explained how to complaints would be dealt with and when the complainant could expect a response. There was a procedure on display in the home and we were told that new residents were given a copy in their information pack. Residents and family members we spoke to said that they would feel able to approach the manager if they had any complaints. One resident said they would not be afraid to ask for anything. A relative told us, If I have concerns I ask the manager, shes always answered them openly and honestly. The service had received two complaints since the last inspection, both were investigated. One was unsubstantiated. The other, which was relating to infection control practices, had been found to be true. The manager had put in more staff training to ensure that the incident was not repeated. Staff had received training in safeguarding. There was a policy for staff to refer to but the action to be taken by senior staff in response to an incident of abuse was not Care Homes for Older People Page 18 of 29 Evidence: completely clear. In the absence of the manager, this could result in staff not understanding their role and limitations. The staff we spoke to said they were confident that they would be able to recognise poor practice or abuse. They knew how to report an suspected incident in the home and they understood the whistle blowing policy. There had been no safeguarding referrals in the last year. A number of staff had received training to help them to understand the implications of the Mental Capacity Act 2005 with regard to residents at the home. Care Homes for Older People Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and well maintained and the standard of decor and furnishings provided people with a comfortable and homely place to live. Evidence: From looking around the building the home appeared to be well maintained. The manager told us there was a continual programme of renewal and redecoration. Rooms were redecorated as they became vacant and several rooms had new carpets and curtains. The communal spaces were decorated and furnished in a homely and comfortable way. The main lounge was used as a storage area for some moving and handling equipment, which detracted a little from the homely feel. The manager said she would try to find an alternative. The second lounge was used as a quiet area and one of its occupants said they liked that the room was bright for reading. The garden was attractive and well maintained. There was a ramp to ensure that anyone using a wheelchair could gain access. Some rooms had en-suite facilities and there were sufficient bathrooms and toilets near communal areas. A new wet room had been installed since the last inspection, which gave residents more of a choice of bathing facilities. Two of the bathrooms were Care Homes for Older People Page 20 of 29 Evidence: in need of redecoration and the manager told us this was to be done very soon. Many people personalised their bedrooms with pictures and ornaments and they could bring in some of their own furniture if they wished. Those residents who were asked said they were satisfied with their rooms. One person described their bedroom as, spacious and light. The laundry was adequately equipped for the size of the home. There were no complaints about the laundry and we observed that residents clothing looked well cared for. On the day of the visit the home was clean and free from unpleasant odours. One family member said the lack of smell was one of the reasons they had chosen the home for their relative. Staff had received training to help them to reduce risks of cross infection. Care Homes for Older People Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were supported by a consistent and qualified staff team but recruitment practices were not thorough enough to provide safeguards. Evidence: Staff told us there were always enough staff on duty to meet the basic needs of the residents and there were usually enough to be able to spend a bit of extra time with them. The manager said the staffing levels never fell below the minimum and she would increase the numbers if one of the residents needed extra help. Residents also said they thought there were enough staff. One told us, We might have to wait but it is only a minute or two. We heard some positive comments about the staff team. One resident said, They are a good lot and they look after everyone. There was a low turnover of staff. All the registered nurses and many of the care staff had been at the home for a number of years, which meant residents were cared for by a stable team who knew them very well. We looked at the files of two staff. One had been recruited in accordance with the procedure. All pre-employment checks had been carried out and their file contained all the required information and documents. The other person had started work before their references and CRB check had been returned, despite the POVA first advising Care Homes for Older People Page 22 of 29 Evidence: against this. This meant that the manager could not be sure that they did not have a conviction which made them unsuitable to work with vulnerable people. One person also had character references written by friends, this meant that the references might not be completely impartial. There were no risk assessments in place to show that staff who had a prior conviction were safe to work with residents. New staff went through an induction training programme. They had an initial induction to orientate them to the environment and then completed an in-depth workbook that covered each aspect of their job description. The manager told us that the programme covered all the elements of the common induction standards. At the end of each section the member of staff had a written assessment. Following their induction most staff enrolled on the NVQ programme. The AQAA indicated that over 50 of staff had achieved an NVQ level 2 in health and social care. The manager confirmed that all staff were up to date with training in the safe working practice topics. Staff said that there were good opportunities for other training relevant to the needs of the residents. For example, some staff had attended courses in palliative care and dementia care. Care Homes for Older People Page 23 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and staff benefited from a well managed home. Evidence: One of the proprietors, who had many years experience in managing services for older people, ran the home on a day to day basis. The manager is a registered nurse and also holds a relevant management qualification. She also undertakes regular training in order to keep her knowledge and skills up to date. She regularly works in a hands on capacity so leads the team by example. Two of the visitors we spoke to made positive comments about the registered person. One said, she runs the home very well and gets the results. Staff said that the manager gave them the support they needed. The manager told us that she had changed the model of staff supervision after attending further training and the new sessions were due to start in the near future. Care Homes for Older People Page 24 of 29 Evidence: There were a number of letters and cards from relatives who all made very positive comments about the staff and the service. Questionnaires were sent out to residents and relatives on an ad hoc basis. The results were not collated or published but any comments or suggestions were acted upon straight away. For example, the AQQA told us that, following a suggestion by a relative, the manager had changed the way residents belongings were given back to their family after their death. Meetings were planned if there was a specific topic to be discussed, for example, a relative meeting was held to discuss the introduction of an end of life care pathway. The manager said that residents were consulted on a day to day basis and a resident confirmed, The manager comes round to ask if I have any complaints. There were no internal audits, although the manager said that she planned to introduce regular checks of medication and care records to ensure that all staff were maintaining a good standard. Residents, who were able to, managed their own finances. Others had support from their family or appointee. The manager did not hold any money on behalf of residents but confirmed that facilities were available if needed. All staff had received fire safety training and those we asked were clear about the procedure to follow in the event of a fire. Fire alarms were tested regularly and other fire safety equipment had been serviced. The AQQA showed that the maintenance and servicing of other equipment and installations were up to date, which helped to protect the health and safety of people living and working in the home. Care Homes for Older People Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Medication must be administered in accordance with the prescribers instructions. To promote the health and safety of the residents. 30/04/2009 2 9 13 Records of medication 30/04/2009 received into the home must be accurate and complete. To begin the audit trail and to reduce the risk of mishandling. 3 29 18 Staff must not commence 30/04/2009 work at the home until satisfactory pre-employment checks have been carried out. To safeguard residents Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 27 of 29 1 7 Care plans should be more detailed and instructions for staff should take into account the residents wishes and preferences for care. Menus should be reviewed to ensure that residents receive a varied and nutritious diet. There should be complete records of meals served. The safeguarding policy should be reviewed to make sure staff are clear about the role of social services in investigating abuse. The systems for monitoring the quality of the service should be further developed. 2 15 3 18 4 33 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. 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