Inspection on 13/11/08 for Gargrave Road (24) - North Yorkshire County Council

This inspection was carried out on 13th November 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gargrave Road (24) - North... 15/01/07

Gargrave Road (24) - North... 06/12/05

Gargrave Road (24) - North... 17/05/05

Gargrave Road (24) - North... 18/11/04

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Gargrave Road (24) - North Yorkshire County Council 24 Gargrave Road Skipton North Yorkshire BD23 1QJ     The quality rating for this care home is:   one star adequate 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: Linda Trenouth     Date: 1 3 1 1 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 31 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 31 Information about the care home Name of care home: Address: Gargrave Road (24) - North Yorkshire County Council 24 Gargrave Road Skipton North Yorkshire BD23 1QJ 01756700720 01756795981 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Miss Catherine Simms Type of registration: Number of places registered: North Yorkshire County Council care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Service Users up to 5 LD and up to 5 LD(E) up to a maximum of 5 Service Users Date of last inspection Brief description of the care home 24 Gargrave Road is a care home owned and operated by North Yorkshire County Council and registered to provide a service for 5 adults of either gender aged over 18 years who have a learning disability. It concentrates exclusively on providing a temporary home for people living in the Craven area. The home is located in a midterrace Victorian property within walking distance of the centre of Skipton. There is a lounge, dining room, kitchen and bedroom on the ground floor and three bedrooms on the first. 5 Over 65 5 Care Homes for Adults (18-65 years) Page 4 of 31 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: one star adequate 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: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We visited the service over one day for approximately 6 hours. The inspection also included gathering information and evidence before and after the visit to decide the overall judgement. We looked at the records, watched staff working, and talked to people who use the respite service. Due to the communication needs of people living at the home mainly observations of their care was used to inform this report. Care Homes for Adults (18-65 years) Page 5 of 31 We also looked around the building to see that the home was safe and well maintained. The main purpose of this inspection is to make sure that the service provides a good standard of care. We sent comment cards to people who use the service and to staff, to give them the opportunity to comment on the service. Three comment cards were returned. The manager of the home completed a self-assessment form called an AQAA, which is information we ask for every year and is used as part of the inspection process. The returned self-assessment documentation provides information about staffing and people who use the service. The last key inspection at the home was held on the 15th January 2007. The present fee for the home is 806.82 pounds, the charge is dependent on financial assessment. The home is without a registered manager, however a new acting manager is in place, David Teague, who has applied for registration with the CSCI. Feedback was given during the inspection to the acting manager and requirements and recommendations made during this visit can be found at the end of the report. What the care home does well: What has improved since the last inspection? What they could do better: The home is a respite unit which mean that people stay for short period of time to give their families and carers a break. The quality of the service has been compromised by the admitting people long term. The service cannot fully meet the long term needs of individuals at the same time as providing respite care. The home has gone through an unsettled time in the last two years with a succession of different managers. This has meant that people have not always had the support that they should and that important areas have been overlooked. Some of the previous requirements made at the last inspection have not been completed and continue to be of concern. Important care records need to be in place to make sure that individual care needs are not overlooked. Recruitment policies and procedures have not been thorough and staff records are not complete, which could put people at risk. The environment continues to be unsuitable and limited for people with physical disabilities. The layout of the home can not adequately ensure individuals privacy and dignity. At the last inspection January 2007, it was understood that a new purpose built Care Homes for Adults (18-65 years) Page 7 of 31 building was soon to be built. Whilst land has been identified unfortunately no building work has begun, this means that people and staff still have to manage in a less than ideal environment. 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 8 of 31 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 9 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are admitted to the home when the service cannot fully meet their needs. Evidence: The manager provides a copy of the service user guide. This and other information is not always available in a format that meets the communication needs of people using the service. It is important that information is provided in a way that individuals can understand so that they are aware what the home can provide for them and what their rights are whilst staying at the home. From the care records it was evident that people had a full care assessment before they began to use the service. The staff confirmed that assessments are always undertaken and people are supported to visit and stay for tea, people then stay overnight. This is important to make sure that they are comfortable and the service is right for them. Care Homes for Adults (18-65 years) Page 10 of 31 Evidence: Peoples communication needs are assessed and are recorded within their care records. Staff have good communication and understanding of how to meet the needs of individuals. Most people using the service continued to attend their usual day service commitments, therefore they usually participate in activities during the evening and weekend. From the care records reviewed not everyone had an individual contract. This means that people may not be aware of their rights whilst living at the home. For one individual the respite unit is their home, until alternative accommodation can be found. Because of the turn over of people who use the respite service this means they share their accommodation with different people every day. The service cannot meet the needs of both long term and respite users within the same home and the quality of peoples experience could be better. The acting manager and staff say they aim to offer flexible service, however placing of people permanently in the home undermines this. This has also resulted in changes to essential services for other people. Care Homes for Adults (18-65 years) Page 11 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to be involved in important decisions in their lives, but lack of care planning may mean that important needs are overlooked.. Evidence: Out of three care records reviewed it was found that two had assessments and care plans. The care records reviewed provided evidence that people had had a review in the last year and that this had involved the individuals and their families. One individuals care record however did not have a care plan and the risk assessments did not adequately address the potential risks to this individual. This was particularly important as this individual had complex needs. The acting manager agreed these documents needed completing. Other care records showed some good risk assessments in areas such as moving and Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: handling and managing epilepsy. This is important to make sure that people enjoy a fulfilling life with the minimal risk. Daily records and observations at the visits show that people are able to make many choices and decisions in their daily lives. Comment cards confirmed that relatives feel that staff keep them informed and up-to-date with important issues. Staff are able to give good examples of how they support people with their personal care and encourage them to be as independent and self-reliant as they can be. Some comments included, staff are friendly and approachable and there is a relaxed atmosphere. Care Homes for Adults (18-65 years) Page 13 of 31 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. People enjoy a wide range of activities when using the service. Evidence: Generally people who use the respite service do so for only a short period, one or two nights. People have the opportunity to engage in several activities when they use the respite service. Individuals are encouraged to continue where possible with their normal plans, hobbies and engagements. When people stay at the weekend the staff support them to enjoy the local community, to engage in events, coffee mornings, shopping, day trips, cinema, shows and go to the local pubs. Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: People were individually assessed to make sure they were involved with activities which interested them. The homes notice board in the hallway had details of forthcoming events in the community and there is a laptop computer for everyone to use in the lounge. Daily records confirm that people are well supported by staff and enjoy a range of interesting and different activities. One relative commented, the staff help my son with his independence skills There was no menu plan at the home and information regarding food was very limited. Staff say that they regularly shop for food with people if they are available and that they provide a varied wholesome diet. It was however difficult without a planned menu to see if the diet was balanced, nutritious and what choices people had. The acting manager must ensure that the provision of food is reviewed to make sure that people who use the service have their choices taken into account and that their health needs are properly supported. Care Homes for Adults (18-65 years) Page 15 of 31 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. Peoples health needs are supported and met. Evidence: Generally people only use the respite service occasionally and their main health needs are met by their families. Care records do show that the staff have a good understanding of peoples health needs and that they support people in their individual health needs whilst staying at the home. The care plans contain good information about how people should be supported, this includes transfer techniques and preferred methods of communication. Staff had a good knowledge of personal likes and dislikes of individuals in regards to their personal care and daily routine. Medication was reviewed and found to be well recorded and stored. Staff say people can self administer medication and a lockable cupboard is available in their bedroom. Risk assessments are in place if this is the case. Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: Staff said that they had training in the safe handling of medication and additional training in specialist health care support. Care Homes for Adults (18-65 years) Page 17 of 31 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. People using the service and their relatives feel confident that their concerns will be acted on properly and procedures are in place to safeguard people from harm. Evidence: The service user guide incorporates the complaints procedure. Each person has an individual link worker who supports them in maintaining regular contact with their families. People have annual service reviews where they and their families can discuss their concerns. Relatives who returned their comment cards confirmed that they know how to complain. The acting manager audits peoples monies responsibly with clear accountancy and auditing checks. Staff confirmed that they have completed training in adult protection and showed that they had a good understanding of different types of abuse and the vulnerability of people in their care. There are regular staff meetings and staff have supervision arrangements in place to discuss care practice. Care Homes for Adults (18-65 years) Page 18 of 31 Care Homes for Adults (18-65 years) Page 19 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People stay in a clean and comfortable home but the home does not meet the needs of people with physical disabilities. Evidence: This was an unannounced visit and the home was found to be reasonably decorated, well maintained and clean throughout. Lounges and the dining room are comfortable and furniture appropriate for the needs of people staying at the home. People can have a key to their room if they wish. There are long standing issues related to the suitability of the premises, which do not promote the privacy or dignity of people staying at the home. This is due to the layout of the building, poor access and lack of special mobility provision and storage. There is a shared room and three single bedrooms at the home, one single room based on the ground floor has tracking hoists and a hi low bed fitted to support people with their mobility needs. Relatives commented, The only problem is that there is only one room for wheelchair users so stays are limited Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: There isnt much room for manoeuvre and it isnt an ideal house for wheelchair users Staff say The building is inadequate for some service users The service hopes to relocate to another area of Skipton where a purpose built unit will be provided to meet the respite needs of people living in the area. The manager says that it is hoped the building will be completed by late 2009. There is some provision of mobility and disability equipment in the home, tracking hoist have been installed in the downstairs bedroom. However the storage of special equipment is limited. Most of the additional equipment is stored in the walk in shower which means that staff are constantly having to move equipment out to use the shower safely. Privacy is also difficult to maintain for people with a physical disability as the shower and ground floor toilet area are adjacent to communal areas of the home. Care Homes for Adults (18-65 years) Page 21 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by properly trained and supervised staff but unsafe recruitment may mean that people are vulnerable and at risk. Evidence: During the visit staff records were reviewed. The lack of information regarding recruitment and support raised concerns. Some staff records were not complete with some staff having no information available. Concern was also expressed that one individual had been recruited without appropriate employment checks. This meant that they may not be safe to work with vulnerable people and the service is taking unnecessary risks. There was a concern that there is inadequate auditing of training and therefore it could not be confirmed what training staff had completed and updated. Staff did however confirm that they have had induction training and said that the service supports and encourages further training. Staff also confirmed that they are undertaking NVQ level 2 (National Vocational Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: Qualification). The service has 6 out of 8 permanent staff trained to this standard. It was not clear what training other staff who work at the home ie the relief staff had completed. Staff rotas were reviewed and staffing levels appear good. Staffing hours are concentrated into the evenings and weekends with additional staffing provided through the night to meet the needs of people staying at the home. Care Homes for Adults (18-65 years) Page 23 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home could be better managed. The lack of consistency and change of management has meant that the staff and people who use the service have not had consistent support and important areas have been overlooked. Evidence: The acting manager confirmed that he has a recognised management qualification and that regular visits were undertaken by area manager to support the home. The respite service has had a long period of instability with a succession of different managers. This has been a difficult time for the staff, people who use the service and relatives. The present acting manager has applied for registration with the CSCI and has many years experience in caring for people with a learning disability. It is hope that a permanent manager will provide a better service for people working and staying at the home. Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: Comment cards received state, Their have been eight managers in two years (five permanent and three acting) so we hope that the recent appointment of an experienced manager will bring stability. Permanent staff have consistently had supervision and attend staff meetings. Concerns were expressed about the lack of information regarding relief staff. Some relief staff do a considerable amount of hours during the week and must have effective support to do their work safely. There are areas of the home that could be better managed these are, ensuring care records are complete, recruitment of staff is safe and an improvement in the auditing of staff training. The acting manager has only recently taken over the home and is anxious to improve these areas. Areas of health and safety were reviewed, including gas, electrical and water safety. Most of the certificates were updated although the gas certificate needed updating. It was raised at the previous inspection that fire doors must not be wedged open. During the visit the staff again wedged open the office door compromising fire safety in the home. The management must address make sure this practice ceases. Also of concern was the staff continuing to wedge the office door open. This is a fire risk and must be addressed. Care Homes for Adults (18-65 years) Page 25 of 31 Are there any outstanding requirements from the last inspection? Yes R 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 1 6 15 A written care plan that 01/03/2007 includes all of the service user needs must be provided. The plan must include clear guidance to staff about the support that they have to provide to meet service user needs. Consultation wherever possible should take place with the service user or their representative. The plan must be kept under review and service user or their representative made aware of any revisions. 2 24 23 The provider needs to make sure the premises are safe and well maintained and suitable for everyone. The Registered person must approve and retain a evidence of all recruitment documentation The registered person must make sure all staff have regularly attended mandatory training. Risk assessments to carried 01/03/2007 3 34 19 01/03/2007 4 35 18 (1) (c)(i) 01/03/2007 5 42 13 (4)C 01/03/2007 Care Homes for Adults (18-65 years) Page 26 of 31 out on all people who currently use bedrails to ensure they are secure and safe. 6 42 23 (4) (C) (i) The registered person must 15/01/2007 ensure that fire doors are not wedged open by unauthorised means. Care Homes for Adults (18-65 years) Page 27 of 31 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 1 4 The service user guide should be in a format that meets the communication needs of the service user and should reflect the service that is being provided. People must be able to understand the information about the home. The guide should also clearly reflect the service that is being provided for long term users. 23/01/2009 2 5 5 People must have a written contract that is signed by both parties. To make sure their rights are protected. 23/01/2009 3 6 1 Each person must have a care plan which provides clear instruction to staff about how they will meet their needs. This must be regularly reviewed. 16/01/2009 Care Homes for Adults (18-65 years) Page 28 of 31 People must have a care plan to make sure that important needs are not overlooked. 4 24 23 The home must meet the physical needs of the people who use the service and protect their privacy and dignity. The layout of the home must meet people physical needs. 5 34 19 Staff must not be recruited until the proper checks and procedures are in place. People are at risk where the home allows people to work who have not been recruited safely. 6 35 19 The home must make sure that all their staff have the required training. People must be supported by staffing who have the right training. 7 37 24 The home is not managed consistently. The lack of consistency of management means that important ares have been overlooked and previous requirements not met. 8 42 7 Risk assessments must be completed. People are at risk where all their needs have not been properly assessed. 16/01/2009 16/01/2009 16/01/2009 16/01/2009 22/01/2009 Care Homes for Adults (18-65 years) Page 29 of 31 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 17 Clear food planning should be introduced to ensure that peoples nutritious needs and choices are fully met. Care Homes for Adults (18-65 years) Page 30 of 31 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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