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Inspection on 11/09/08 for 290 Dyke Road

Also see our care home review for 290 Dyke Road for more information

This inspection was carried out on 11th September 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 290 Dyke Road 290 Dyke Road Brighton East Sussex BN1 5BA two star good service The quality rating for this care home is: 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: Nigel Thompson Date: 1 1 0 9 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. They reflect the things that people have said are important to them: 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. 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 Information about the care home Name of care home: Address: 290 Dyke Road 290 Dyke Road Brighton East Sussex BN1 5BA 01273 552069 F/P 01273 552069 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Care Management Group Ltd Mr Daniel John Dunman care home 5 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 0 0 learning disability Additional conditions: The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disabilities (LD) The maximum number of service users to be accommodated is 5. Date of last inspection 1 1 0 9 2 0 0 8 A bit about the care home 290 Dyke Road is a care home, which provides personal care and accommodation for up to five residents with profound physical and learning disabilities. The home is owned and run by Care Management Group (CMG) who are a large organisation that provides care for people with learning disabilities. The home is a converted bungalow with a wheelchair accessible garden to the rear of the property. All bedrooms are for single occupancy. There are suitable bathing facilities at the home to meet the assessed needs of residents. The home is located on a main road on the outskirts of Brighton, with nearby access to some local amenities and public transport. There is some parking available at the home, however free parking is permitted on the street. Residents are provided with an opportunity to attend a day centre provided through the use of the organisations development centre. The home provides personal care and support to residents who are funded by Social Services. The home?s fees as of 3rd October 2006 range between #1150 - #2000 per person per week. Additional costs are charged for chiropody (#10). Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. The home?s most recent inspection report is available on request at the home. 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 How we did our inspection: This is what the inspector did when they were at the care home The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The last inspection on this service was completed on 17 November 2006. This key unannounced inspection took place over five and a half hours in September 2008. It found that the majority of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Residents relatvies spoken with as part of the inspection process expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were four residents living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with two members of staff and the appointed manager. The focus of the inspection was on the quality of life for people who live at the home. What the care home does well What has got better from the last inspection Specialist input, including guidelines regarding postural management, has been provided by the in-house physiotherapist in relation to moving and handling of residents during the night. Medication policies and procedures, including epilepsy management guidelines, have been reviewed and improved, as reuired, since the last inspection. The kitchen has been totally refurbished, with new cupboards, appliances and floor covering. What the care home could do better If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Nigel Thompson The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 01622724950 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.southeast@csci.gsi.gov.uk or by telephoning our order line - 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 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 improved admission policy and procedure ensures that residents are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective residents know that the home is able to meet their individual care and support needs. Evidence: Comprehensive and detailed information regarding the home has been produced and is made available to all prospective residents. The quality and accessibility of the ‘Statement of Purpose ‘ and ‘Service User Guide’ is enhanced by the imaginative and effective use of photographs and diagrams. The manger confirmed that the home maintains a good working relationship with the local Community Learning Disability Team (CLDT), who consequently have a sound understanding and awareness of the suitability of the home and the range and quality of the services provided. CMG continues to employ a team of centrally based assessment and referral officers, who are responsible for considering and assessing all initial referrals for each of the care homes across the South East region. Most of the residents accommodated have lived together for a number of years in other establishments prior to moving in to 290 Dyke Road. The compatibility of residents is at this time good. There have been no new admissions to the home since the last inspection. Over recent months the manager has evidently been far more involved in the homes admission procedure. As the person best placed to know exactly what the service is able to provide and understand the need for compatibility with existing residents, this is welcome and significant development. In line with other services within the organisation, the manager confirmed that she is now directly involved in the assessment process, to establish the care and support needs of the individual. This was evident from discussion with residents relatives and examination of documentation relating to a prospective resident, who is expected to move into the home within the next few weeks. As well as being invited to visit the home to look around and meet with existing residents and staff, prospective residents have the opportunity to stop overnight or occasionally for a weekend stay before moving in. The manager confirmed that new residents undergo a flexible trial period at the home, followed by a thorough placement review, during which time their suitability and compatibility are fully assessed and it is established whether their identified care and support needs are able to be met. 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 . Residents’ care plans enable staff to meet assessed needs in a structured and consistent manner and individual plans, including risk assessments reflect changing support needs. Systems for consultation and participation remain effective and residents are treated with respect and encouraged and enabled to make decisions about their day-to-day living. Evidence: Individual person centred plans (All about me) have been thoughtfully developed for each resident and are clearly linked to their identified care and support needs. Since the previous inspection the organistion has appointed a specialist coordinator to work with individual staff teams and provide relevant guidance and training relating to person centred planning. The manager confirmed that residents and, where appropriate, a relative, advocate or representative continue to be directly involved in annual care plan reviews. It was evident from plans that were examined that, in general, reviews are appropriately recorded. In accordance with the person centred approach to care planning, it was noted that risks are assessed and appropriately recorded and provide evidence of regular and effective consultation involving the residents key workers, their relative or representative. Individuals are clearly enabled and supported to make decisions about many aspects of their life and, as far as practicable, are made aware of the reasons for specific action being taken. Independence and individuality continue to be encouraged and promoted within the home and are reflected in the personalising of residents rooms, the choice of bedclothes and colour schemes and individual preferences for menus and activities. 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 . Residents are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Residents benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. Evidence: The recreational and leisure interests of residents are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs, preferences and abilities. All residents are encouraged and enabled to make choices regarding what they prefer to do and how they spend their day, within the home or out in the community. They are supported by staff, on a 1:1 basis, with their structured day services programme. Community participation evidently remains a focus within the home and staff confirmed that, in accordance with their individual choice and preference, residents are encouraged and supported to attend day services, visit local shops, restaurants and other amenities. As previously documented, CMG owns a development centre, which is accessed by four of the residents on a daily basis, Monday to Friday. This provides opportunities for residents to engage in informative and creative activities should they wish, including sensory stimulation, art, postural movement, Speech and Language Therapy, physiotherapy, music, and IT. One person continues to attend a local day centre where he is supported on a one-to-one basis. Resident have the opportunity each year to go on a holiday and this is discussed both in reviews and team meetings. Staff confirmed that visiting to the home is largely unrestricted and relatives and friends are made welcome at any reasonable time. Residents are encouraged and supported, where appropriate, to maintain family links, however the manager confirmed that not everyone in the home enjoys regular contact. All meals are prepared within the home by care staff who have attended a Food Hygiene course. As appropriate, and in accordance with their wishes, residents are enabled to participate in food preparation and are encouraged to take turns to choose and plan the weekly menu. A list of residents’ likes, dislikes and allergies is displayed in the kitchen area as a guide for staff when preparing and cooking food. 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 . Staff have developed close and positive relationships with residents and demonstrate an awareness and sound understanding of their individual care and support needs. Residents are protected by improved, clear and comprehensive policies and procedures in place for the control and safe administration of medication. Evidence: In accordance with their personal care plan, residents are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. During the inspection, residents were observed being supported in a sensitive, professional and respectful manner by members of staff. Documentary evidence was in place to demonstrate that the complex health and emotional care needs of residents continue to be met within the home. Individual care plans that were examined were found to contain detailed information and staff guidelines, clearly developed through close consultation with and direct involvement of residents, their relatives or representatives. Comprehensive needs assessments and details of staff intervention and action to be taken, are in place to ensure a structured and consistent approach to individual care and support. The Manager confirmed that close and effective working relationships between residents and their key worker ensures that any subtle change in an individual’s mood or behaviour can be identified and addressed at an early stage. All residents are registered with local GPs and have access to other health care professionals, including physiotherapists, psychologists and occupational therapists, as required. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. Up to date and detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. Medicines are stored and recorded appropriately. The manager confirmed that all staff responsible for administering medication have received appropriate training and are individually assessed and authorised to do so. This was confirmed through discussions with staff and supported by training records examined. 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 . The home’s complaints procedure ensures that residents, staff and visitors feel able to express any concerns, confident that they will be listened to and acted upon. Residents are protected, through updated policies and procedures relating to abuse and safeguarding vulnerable adults. Evidence: A clear, comprehensive and accessible complaints procedure is in place. It is also evident from direct observation and through discussions with staff that the close working relationships, effective communication and consultation provide adequate opportunities for any concerns to be raised and discussed, before they become complaints. Residents and members of staff, spoken with during the inspection, confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. It was noted that no complaints have been received by the home since the previous inspection. The home ensures as far as is practicable that residents are safeguarded from all forms of abuse and relevant policies and procedures relating to Adult Protection, including a policy on alerting, ‘Whistle Blowing’, are in place. The manager confirmed that Safeguarding Vulnerable Adults training is mandatory and recorded for individual staff. This involves ensuring all staff are aware of the various types of abuse, and how it may present itself. During the induction process, staff are expected to read the whistle blowing policy, and have knowledge of how to report suspected abuse. This is evidently also reinforced during regular supervision and staff meetings. 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 service is accessible, safe and remains clearly suitable for it’s stated purpose. With the exception of the bathroom, residents benefit from pleasant accommodation that is comfortable, reasonably well maintained and decorated to a satisfactory standard. Evidence: During my guided tour of the building, it is evident that environmental standards at 290 Dyke Road remain largely unchanged and the premises continue to be safe, accessible and generally well maintained. As previously documented the home comprises of five single bedrooms, one bathroom, a small kitchen and a reasonably good-sized lounge. A conservatory leads from the lounge to the rear garden. Appropriate adaptations and specialist equipment, including tracking hoists, are provided as necessary, to meet the individual and collective needs of the residents. Positive comments from residents relatives, spoken with as part of the inspection process, reflected a high level of satisfaction with the home and the services provided. The manager confirmed that independence and individuality continue to be promoted within the home and this is evident from the personalising of residents rooms, which clearly reflects individual tastes and interests. However, in marked contrast to the other rooms in the home, the bathroom is neglected, with old tiles and floor covering and a worn out, chipped and rusty bath / shower facility. There is also no natural light or ventilation in the room, which results in it being humid and slightly claustrophobic. From her initial assessment of a prospective resident, due to move in to the home in the near future, the manager esatblisehd that she enjoys relaxing by soaking in the bath. It was acknowledged by the manager, however, that the new resident would not want to spend any longer than necessary in the bathroom in its current state. It was noted that infection control policies and procedures, within the home, are in place and clearly adhered to. Levels of cleanliness remain generally high throughout. 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 . Residents benefit from there always being sufficient trained and competent staff on duty to meet their assessed needs. Robust staff recruitment policies, procedures and documentation help to ensure the protection of residents. Evidence: The manager confirmed that increasingly the organisation recognises the importance of a skilled and competent workforce. All new staff receive comprehensive induction and foundation training. Specific training is provided covering such topics as learning disability and sensory impairment awareness, positive values and lifestyles and safeguarding vulnerable adults. In addition to this, the manager confirmed that appropriate core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. This was confirmed through discussions with staff and supported by training records examined: ‘There is always plenty of training here – which suits me!’ In accordance with company policy, the manager confirmed that formal supervision is provided for all care staff on a monthly basis. The manager also evidently operates an ‘open door’ policy, with staff feeling confident and able to discuss any issues at anytime. This was evidenced by supervision records examined and through discussions with staff, spoken with during the inspection, who acknowledged the benefits of effective supervision and confirmed feeling valued and supported by the manager: ‘Supervision is good. I find it very useful and the manager is always very supportive’. The manager is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of residents. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. 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 . Residents benefit from a competent management structure. They are protected by satisfactory health and safety procedures and their best interests are safeguarded by effective quality monitoring systems. Evidence: The experienced manager has worked for the organisation for 5 years and has been in her current post since July 2008. She already holds the NVQ level 4 in Management and Care and has begun studying for the Registered Manager’s Award (RMA), which she is hoping to complete by February 2009. She has wide managerial experience in different residential settings and is clearly competent to run the home. From direct observation and through discussions with residents relatives and members of staff, it is evident that the manager demonstrates a clear sense of leadership and direction. She is positive and approachable and creates an open and inclusive atmosphere within the home: ‘The manager is very approachable and supportive’. The home continues to operate effective quality monitoring systems, including satisfaction questionnaires for residents, their relativesand other stakeholders. Collated responses from the most recent survey, including comments from Care Managers and Reviewing Officers indicate a high level of satisfaction with the home and the care and support provided: ‘We are thankful that he is in such a well run and caring home. ‘I was very impressed by the staff team I met at the review. They are all highly trained individuals and I found they all spoke positively with empathy and understanding, in a refreshing manner. How good it is to receive monthly updates from the key workers - very thorough. Thank you. It was fantastic to see the bonds you all have with him and how much he cares for you all. You all do a fab job. Keep doing what you do! The manager confirmed that the health, safety and welfare of residents and staff remains of paramount importance within the home. Staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is recorded. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Temperature regulators are fitted to all hot water outlets, accessible to residents. All accidents, incidents and injuries are recorded and reported, as required. Are there any outstanding requirements from the last inspection? Yes  No  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 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 Description 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 Description Timescale for action 1 27 23 31/12/2008 Having regard to needs of the residents, all parts of the home, including the bathroom, to be kept well maintained and reasonably decorated. The bathroom is neglected, with old tiles and floor covering and a worn out, chipped and rusty bath / shower facility. There is also no natural light or ventilation in the room, which results in it being humid and slightly claustrophobic. 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 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. - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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