Inspection on 15/10/08 for 14 Norfolk Road

This inspection was carried out on 15th October 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

14 Norfolk Road 30/09/09

14 Norfolk Road 28/02/07

14 Norfolk Road 16/06/06

14 Norfolk Road 02/02/06

14 Norfolk Road 19/09/05

14 Norfolk Road 21/03/05

14 Norfolk Road 16/08/04

14 Norfolk Road 19/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/02/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 14 Norfolk Road 14 Norfolk Road Carlisle Cumbria CA2 5PQ     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: Ray Mowat     Date: 1 5 1 0 2 0 0 8 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. the things that people have said are important to them: They reflect 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 Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The 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 Adults (18-65 years) Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) 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.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: 14 Norfolk Road 14 Norfolk Road Carlisle Cumbria CA2 5PQ 01228592515 Telephone number: Fax number: Email address: Provider web address: norfolkroad@cic.co.uk Name of registered provider(s): Name of registered manager (if applicable) Mr Stuart Leonard Dryden Type of registration: Number of places registered: Community Integrated Care care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 Date of last inspection Brief description of the care home 14 Norfolk Road is a detached three-storey property. Community Integrated Care provides the care and services. The home is registered to provide care for six people with a learning disability. Service users only use the ground and first floors, with staff accommodation on the top floor. It is situated in a residential street approximately one mile from the City of Carlisle and is indistinguishable from other properties in the area. A staircase provides access between the floors. There is a private and enclosed garden area to the rear of the building and car parking to the front. People are given information about the home before moving in which includes an informative service user guide. Previous inspection reports are also made available to people on request. Care Homes for Adults (18-65 years) Page 4 of 28 6 Over 65 0 Brief description of the care home The current scale for charging is 1,119.92 per week with additional charges for such items as toiletries, hairdressing and magazines. Care Homes for Adults (18-65 years) Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This inspection visit took place over one day. We, the Commission for Social Care Inspection, CSCI, spent time with people who live in the home and looked at records relating to their care. We spent time with the manager and met with three care staff on duty. We looked at records relating to the running of the home to make sure that people are safe and comfortable in their home. We also sent out surveys to get feedback from people living in the home, the staff who work there and other professionals involved with the home. Before the visit the manager completed an Annual Quality Assurance Assessment, AQAA, which provided information about the running of the home and the people who live and work there. It also included a self assessment stating what the home does well, what has improved and plans for the future. It also contained information about Care Homes for Adults (18-65 years) Page 6 of 28 health and safety, policies and procedures and maintenance records of the home. Fees for the home are currently 1,119 pounds per week with additional charges for personal expenses such as toiletries. What the care home does well: What has improved since the last inspection? What they could do better: The service should review their systems for the handling and storage of confidential information so that staff and people living in the home know that information is secure at all times. There is some duplication and possible confusion with the different recording systems, which should be looked at to make information easier to record and refer to. General risk assessments for the home need to be looked at to make sure they are up to date, relevant and keep people safe. Care Homes for Adults (18-65 years) Page 8 of 28 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 28 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The assessment process is effective in ensuring peoples needs can be met and the appropriate resources are available to support them. Evidence: All the referrals to the home are from the Social Work/care management team. Comprehensive assessments are completed by the relevant Social Worker, with the involvment of other health professionals for people with complex or specialist needs. This has included the Behaviour Intervention Team, Psychologist and Psychiatrist. This process enables the home to make an informed judgement about having the resources and being able to meet the assessed needs of individuals and check out their compatability with people currently living in the home. In addition it is important that the staff have the appropriate skills and knowledge to support people, which the manager will consider as part of the assessment process. The home works closely with the other agencies involved to ensure they have up to date information and to arrange any specialist or specific training that may be necessary to provide a suitable support package for the individual. Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: An important part of the assesment process is a visit to the home to enable the person to be assessed in the home environment and to be able to meet the people currently living there. There have been no new referrals to the home in the last twelve months, however the home has requested a Social Work re-assessment for one person due to their changing needs. Care Homes for Adults (18-65 years) Page 12 of 28 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Detailed person centred care plans ensure peoples individual needs and choices are being met and responded to appropriately. Evidence: The manager and staff team have developed comprehensive person centred care plans for all the people living in the home. They are easy to follow and use pictures and symbols to support the typed text making it easier for people to understand. There is an informative pen picture at the start of the plan, which is written in the first person and gives the reader a better understanding about the individual, significant relationships and significant events in their lives. These are kept under review at least monthly to make sure they are up to date and accurate. Due to the complex needs of the people living there the home work closely with a number of other professionals and agencies to develop strategies and guidance that support and guide staff in responding to individual needs including at times quite challenging behaviour. It was evident from the reduction in the number of serious Care Homes for Adults (18-65 years) Page 13 of 28 Evidence: incidents that this approach has been effective and is supporting and promoting people to lead an independent lifestyle. All the people living in the home have communication difficulties, which makes it difficult for staff to be certain of the choices people are making. However the individual care plans contain detailed guidance based on past experiences, about how people communicate their needs and preferences and make choices other than through verbal communication. In addition staff have developed good relationships with people and they meet regularly with each other to record peoples experiences and reactions and continue to learn from them. This is reflected in the detailed daily routines that are recorded in the care plans that guide staff in ensuring people are leading their chosen lifestyle and making choices throughout each day, such as what time to get up, what to wear or how they will spend their day. Some people are enjoying a sedentry lifestyle as it has become apparent that it is very important to them to take life at their own pace. Others however are enjoying a more active lifestyle both in the home environment and in the local community. Through the development of the person centred plans positive risk taking is encouraged. The home has what they call a transition policy, which guides staff in supporting people to try new things and take positive risks. There were recent examples recorded of people going on holidays or experiencing new activities that previously would not have been attempted. Each individiual has two diaries to record significant events, activities and the personal care and support provided each day. In addition other recording systems are also used, which can be time consuming for staff to complete and also duplicate information. It is recommended recording systems are reviewed to make sure they are effective. Individual risk assessments contained within the care plan had been regularly reviewed ensuring people are safeguarded at all times, however general risk assessments for the home are now in need of review to ensure they are up to date and relevant. Based on discussions with staff they are aware of their responsibility in relation to maintaing confidentiality with peoples personal and confidential information and how it can be shared. Service user records examined were appropriately written and securely stored, however some confidential service user and staff information was left unsecured on the floor outside an office for the duration of this visit, which was pointed out to the manager. Care Homes for Adults (18-65 years) Page 14 of 28 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples lifestyles reflect their individual needs and personal preferences with staff supporting independence and choice in their everday lives. Evidence: Despite some people sometimes presenting very difficult and challenging behaviour staff are supporting and encouraging people to lead a fulfilling lifestyle both in the home and in the local community. Peoples hobbies, interests and preferences about how they spend their day are recorded in their care plan, which enables staff to work with them in acheving their goals. People are involved in day to day househod tasks appropriate to their abilities with staff supporting or prompting them as required. In addition staff support people with a good range of social and leisure activities as well as knowing when to leave people to enjoy some private leisure time. A lot of planning goes into community activities each week to ensure appropriate Care Homes for Adults (18-65 years) Page 15 of 28 Evidence: resources and staffing are available when required. Through the monthly monitoring of the daily record of activities, which are completed at the end of each shift, the manager or senior staff can ensure all the people are having opportunities to go into the local community. As staff gain a better understanding of how people communicate their needs and what they like or dislike doing, the home has enjoyed a good level of success with the incidents of challenging behaviour either being greatly reduced or ceasing completely. People have been supported with new activities in the home in addition to enjoying new experiences on day trips and annual holidays, which staff have also found to be very rewarding experiences. With the continued support of the committed group of staff, families and other professionals people living in Norfolk Rd are enjoying a very settled and fulfilling period in their lives. Care Homes for Adults (18-65 years) Page 16 of 28 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has good systems and records in place to minitor peoples personal and healthcare needs and make sure they are responded to appropriately. Evidence: The person centred care plans provide staff with very detailed information about peoples personal support needs and healthcare requirments. Daily routines are documented that explain to staff how each person likes to be supported with intimate personal care tasks, which ensures an effective and consistent service is provided. The staff work closely with other agencies to make sure each person has the aids, adaptations or othe specialist input they require. Key workers are appointed for each person who take a lead role in coordinating a personalised care package. Regular staff meetings are held to share information and learn from their practice and personal experiences. Personal and healthcare needs are kept under review to make sure changing needs are recognised and responded to. All healthcare interventions and appointments are well documented to keep all staff up to date at all times. We examined a selection of medication records and checked these against the medication held in the home. These were up to date and accurate and guided staff in Care Homes for Adults (18-65 years) Page 17 of 28 Evidence: the safe management and administration of peoples medication. The majority of medication held in the home was in a monitored dosage system with the remainder held in the prescribing pharmacists container and appropriately labelled. Sound systems were also in place to monitor the administration and stock of all PRN(as required) medications. All the medication was securely stored in wall mounted cabinets. Care Homes for Adults (18-65 years) Page 18 of 28 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good practice, policies and procedures are followed that ensure the safety and wellbeing of the people living and working in the home. Evidence: There have been no formal complaints recorded since the last inspection, although the home has introduced a suggestion book so anyone with any involvement with the home can make any suggestions for improvements. The comments are reviewed on a monthly basis by the manager enabling him to respond to the suggestions. There is a suitable policy and procedure in place to guide staff in dealing with complaints making sure they are responded to and peoples voices are heard. Since the last inspection there have been two safeguarding referrals made, which were handled appropriately by the home manager who made timely referrals to the appropriate agencies and followed good practice guidelines in dealing with the allegations. There was no further action required in one case with the other one resulting in a disciplinary investigation by the organisation. The way these issues were responded to ensures that people living in the home are safeguarded at all times and that allegations are dealt with in a timely and professional manner. The manager has completed a training course in Adult Protection organised by the Local Authority, which enables him to deliver relevant training to his staff team on recognising, reporting and recording allegations and concerns. Care Homes for Adults (18-65 years) Page 19 of 28 Care Homes for Adults (18-65 years) Page 20 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is decorated and maintained to a good standard and provides a homely environment that is safe and comfortable. Evidence: The home continues to provide a homely and comfortable living environment with suitable aids and adaptations in place. A new accessible bath has recently been installed in the downstairs bathroom. New furniture has been purchased in the lounge area and there is an ongoing programme of decoration. The kitchen has been recently refurbished and is well equipped. A keypad has been fitted to the kitchen door to restrict unsupervised access as a result of a risk assessment. Three of the bedrooms are on the ground floor and are fully accessible. Currently the home are experiencing problems with damp under the floor, which is being addressed to ensure it does not affect the service users. As part of a planned programme of maintenance the home is having a new roof and some remedial building work completed. The garden and grounds provide a safe and accessible outdoor area that people enjoy using when the weather permits. Care Homes for Adults (18-65 years) Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a well trained and committed staff team who provide a consistent and flexible service that responds to individuals changing needs. Evidence: The home has benefitted from having a manager and a core group of experienced care staff who have been at the home for a number of years. They are well trained and knowledgeable and have been able to develop good relationships with the people living in the home. We examined staff rotas which reflected a full compliment of staff and confirmed that staff absences were covered by regular staff, ensuring a good continuity of care is maintained. We spoke to several staff during this visit who talked positively about their experience of the organisations recruitment procedures. We examined staff personnel files and spoke to the manager, who confirmed some records were held centrally by the organisation. However all the necessary checks were completed including CRB (Criminal Record Bureau) disclosures and two references. Job descriptions and contracts are routinely issued to staff as part of the recruitment process. They had a good insight to their roles and responsibilities and the structure of the organisation and the management support available to them. Through regular staff supervision the manager is able to monitor staff training, a Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: mandatory training form is completed to ensure appropriate training is provided when required. Individual training records are also maintained on each staff members personnel file, which we sampled during this visit The organisation produces a training programme for the year that staff can access in addition to the manager planning more specific training when specialist needs are identified. Staff confirmed supervision takes place on a regular basis with a record maintained of the discussions that take place and agreed actions. New staff complete a probationary period when they meet regularly with one of the management team to review their practice. Annual appraisals have been planned for the staff team to identify individual training and development needs. Care Homes for Adults (18-65 years) Page 23 of 28 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager provides a clear sense of direction for the home and works closely with the people living there, their relatives, other professionals and staff to make sure the home is run in their best interests. Evidence: The manager Mr Dryden is suitably qualified and experienced in his role. He provides good supervision and support to the staff team and ensures the home is operating efficiently and effectively and in the best interests of the peole living there. Feedback from staff confirmed this with people saying they can raise any issues or concerns. One person said they are made to feel comfortable and can discuss what they want and they get good support and guidance from the management team. Mr Dryden explained how the staff structure had changed by removing the deputy post and introducing three senior support positions, to improve leadership on all shifts, particularly in his absence. Staff are highly motivated and feel part of the team and were all proud of their achievements in reducing the number of challenging incidents in the home and supporting people to achieve their goals and enjoy new experiences in Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: their lives. The manager and senior team work closely with key workers to ensure care plans are reveiewed and updated each month in addition to an annual review with other professionals and relevant parties. Quality assurance questionnaires are sent out each year to get feedback from people living in the home, their families, staff and other professionals who have had contact with the home. The responses are reviewed by the manager who collates them into a report that is made available to people who contributed. We examined the most recent report that had comparisons with the previous years results and showed improvements in the level of satisfaction people are experiencing. Actions taken or that are planned were also recorded to let people know how the home is responding to their views. As a result of consultation the manager has introduced a suggestions book to record peoples ideas and improve communication. This is reviewed and responded to on a monthly basis by the manager. Staff complete a daily file which has end of shift checklists for them to complete to ensure all necessary health and safety checks are recorded and relevant tasks completed, to maintain a clean and safe environment. We also examined the homes maintenance handbook which includes all relevant servicing and maintenance records, these were also up to date and accurate, making sure equipment is safe. Approriate risk assesments are in place, however they are in need of review to make sure they are relevant and up to date. Care Homes for Adults (18-65 years) Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 3 6 41 42 Recording systems should be reviewed to make sure they are effective and do not duplicate information. Individual records and home records should be securely stored at all times to maintain confidentiality. All risk assessments should be reviewed at least annually to make sure they are up to date and relevant. Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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 © (2008) 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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