Inspection on 18/05/09 for Abbey Care Home

This inspection was carried out on 18th May 2009.

CQC found this care home to be providing an Poor 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbey Care Home 11/11/09

Abbey Care Home 06/05/08

Abbey Care Home 08/11/07

Extracts from inspection reports are licensed from CQC, this page was updated on 06/08/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Great Clacton Hall 28 North Road Great Clacton Clacton On Sea Essex CO15 4DA     The quality rating for this care home is:   zero star poor 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 Finney     Date: 1 8 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 41 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 41 Information about the care home Name of care home: Address: Great Clacton Hall 28 North Road Great Clacton Clacton On Sea Essex CO15 4DA 01255420660 01255420660 info@careone.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Care One Ltd care home 11 Number of places (if applicable): Under 65 Over 65 0 0 11 0 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: 11 11 0 11 The registered person may provide the following categories of service: Care Home - PC to service users of the following gender: Both Whose primary care needs on admisstion to the home are within the following categories: Old age, not falling within any other category - code OP Dementia - code DE Mental disorder, excluding learning disability code MD Physical Disability - code PD Date of last inspection Brief description of the care home Great Clacton Hall is an established care home that provides residential care for older people. It is registered to care for eleven elderly people over the age of sixty-five, who may or may not have dementia. Great Clacton Hall is a detached period property situated in the centre of Great Care Homes for Older People Page 4 of 41 Brief description of the care home Clacton, close to the seaside town of Clacton-on-Sea. There are local shops, a supermarket, a G.P. surgery, pubs, churches and public transport nearby. Accommodation is in five single rooms and three double rooms; two of the shared bedrooms (with bath or shower) are on the ground floor and all other bedrooms are on the first floor. The bathroom is on the first floor. Access to the first floor is by means of a staircase. As there is currently no passenger lift, people using the upstairs rooms must be fully mobile. The home charges between £375.00 and £450.00 a week for the service they provide. Other services such as hairdressing and chiropody are available at an additional charge. This information was given to us in May 2009. Information about the home is available in the Service User Guide which can be obtained by contacting the home Care Homes for Older People Page 5 of 41 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: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as care plans, rotas, menus and personnel files. The provider completed an Annual Quality Assurance Assessment with information about the home and sent it to us at the Commission when requested. Throughout the report this document will be referred to as the AQAA. A visit to the home took place on 18th May 2009 and included a tour of the premises, discussions with people living in the home and members of staff. Completed surveys were received from a person living in the home, members of staff and a healthcare professional. Observations of how members of staff interact and communicate with people living in the home have also been taken into account. Care Homes for Older People Page 6 of 41 On the day of the inspection we were given every assistance from the manager and staff on duty. What the care home does well: What has improved since the last inspection? What they could do better: Provide the homes Statement of Purpose and Service User Guide in formats relevant to the people living in the home or wishing to use the home. This includes formats for people with sensory impairments, such as large print or spoken word. Care plans need to reflect peoples assessed needs. They should also contain appropriate information that is accurate and relevant to the individual. Care plans need to contain sufficient detail to guide staff and ensure that care is provided consistently and in ways that the person needs and wishes. Ensure that there are sufficient staff on duty at all times of the day and night to enable people to be supported safely and to have care provided according to their assessed needs and care plans. Risk assessments need to have sufficient details of what measures are to be taken to reduce identified risks so that people are safeguarded from harm. There needs to be sufficient staff on duty to ensure people are supported safely as according to identified risks. People who wish to be taken out to access community facilities should be supported to do so and there should be sufficient staff on duty to enable this to happen safely, which includes maintaining appropriate staffing levels for the rest of the people in the home. A wider range of fresh food should be available so people are supported to follow Department of Health healthy eating guidelines of five-a-day. The service must ensure that people are safeguarded from risk of abuse, in particular staffing levels must be appropriate to safeguard people from inappropriate behaviour. Repairs to the decor following maintenance, such as removing radiators or re-hanging doors, should be carried out in a manner that improves the appearance of the environment rather than to its detriment. Care Homes for Older People Page 8 of 41 Signage to assist peoples orientation would improve the environment for people with cognitive impairment and those who are becoming more forgetful. Deep cleaning of the home, including de-scaling of taps in the bathroom and taking measures to deal with the stained bath, would improve the environment for people living in the home. Dorguards designed to hold doors open and then close them in the event of a fire need to be operating appropriately. Other doors that do not have Dorguards fitted should be addressed by carrying out a risk assessment to assess whether Dorguards or other measures are necessary. The furnishings in the dining room need to be improved if all the people living in the home are able to be accommodated round the dining table should they wish. Also improvements to the standard of the seating is essential if elderly people are to be able to use them safely. Significant improvements need to be made to the outside of the premises if people are to be safeguarded from hazards. These improvements include safer access for people with mobility problems or sensory impairments, making safe trip hazards, improved lighting and appropriate precautions when there is building work in progress. Significant improvements need to be made to the outside of the premises if people are to benefit from a well-maintained environment. These improvements include maintenance of the garden and removing weeds and repairs to the homes broken name sign. Improvements to access within the building are necessary if people with deteriorating mobility are to continue to be able to access their bedrooms on the first floor. Staff should be provided with a minimum of three paid training days a year as recommended in the National Minimum Standards. This would ensure that people who live there are supported by people whose knowledge is up to date. The manager should have sufficient rostered hours when she is not providing care or doing housekeeping duties so that she can carry out her management role to ensure people benefit from a well managed service. The homes Quality Assurance system should be further developed to include an annual development plan for the home. This would ensure the home is run in the best interests of people using the service. The provider should be working professionally with the manager to ensure she is supported to achieve relevant qualifications in care and management. 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. Care Homes for Older People Page 9 of 41 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 41 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 41 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who want to consider using the service can expect their needs to be assessed, however they can not be confident that they will receive clear information about the service in a format that meets their needs. Evidence: The manager explained that the provider updated the homes Statement of Purpose in October 2008. This document has now been translated into Urudu. We asked the manager if there had been requests for information in this language but she was not aware of any. However, the information was not available in other formats such as large print or spoken word. As there are already people living in the home with sensory impairments the information in the Statement of Purpose and Service User Guide should be available in appropriate formats to meet their needs. The homes statement of purpose and service user guide was available in the entrance hall. Care Homes for Older People Page 12 of 41 Evidence: The provider stated in the AQAA, We assess individuals before admission to the home by using our own comprehensive assessment forms and We are planning to train our carers to do the assessment and risk assessment for the new service users. Records examined show that the pre-admission assessment contains a social history and a medical history. There is a personal information record documenting what the person generally enjoys, what they dislike, routine and habits, sensory and communication, mobility, interests, relatives, friends and social contacts. The manager showed us the format of new documentation that is being being introduced. This includes a generic assessment of needs covering a range of areas, consisting of maintaining a safe environment, breathing and circulation, communication, pain management, eating and drinking, mobility, mental health, expressing sexuality, controlling body temperature, personal hygiene and dressing, elimination, sleep and rest, fears for the future and dying, loss, change and adaptation. There is also a format for a range of assessments and risk assessments including moving and handling, falls assessment, physical dependency, continence, nutritional assessment using the Malnutrition Universal Screening Tool (MUST) and a Waterlow Pressure Sore assessment. There is also a format for a new general risk assessment covering more background areas such as significant events in the persons life, their formative years, occupational history, hobbies and interests, likes, dislikes and fears. The manager explained that the provider has supplied now folders for her to update so that everyone living in the home has consistent records. These folders were examined and are extensive and will take a considerable amount of time to complete. Due to the observed poor staffing levels in the home it is unclear how the manager will be able to complete this task as she has no dedicated supernumerary hours for management tasks throughout the day. It was also evident that the new documentation contained an extensive range of assessments many of which were in a tick box format. However, it did not contain an updated care plan format so that information gathered through the assessment process could be used to create and develop robust care plans with sufficient information to guide staff in meeting peoples assessed needs. National Minimum Standard 6 relating to intermediate care was not examined as the home does not offer this type of service. Care Homes for Older People Page 13 of 41 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor 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 can expect their healthcare needs to be identified and met although they can not be confident that the care planning and risk assessment processes accurately reflect these needs. Evidence: The provider stated in the AQAA, Every user of the service has an individual care plan and risk assessment based on their assessment and we have developed the individuals care plans for their care by identifying their needs. A sample of four care plans was examined. The care plans identify the need and what is the objective for the person and the plan of care. Details in the care plans was brief and the quality of the information was variable. Some of the care plans despite being brief, contained appropriate and relevant information. One appropriate care plan stated the needs as X requires help to maintain a good standard of hygiene. The objective for the person was to help X to Care Homes for Older People Page 14 of 41 Evidence: maintain [their]personal standards. This is a realistic objective for someone whose identified need is around assistance with personal hygiene. The actions were to Assist X to wash and dress. Encourage them to participate and maintain some involvement. Although this is adequate it could be improved by adding more details about exactly what aspects of care need to be provided by members of staff and what the person can do for themselves. Other care plans examined contained information that was not appropriate or relevant. On of these identified the needs as X is unable to dress [themselves] and with personal care and the objective for the person was to be able to care for [themselves] fully. This indicates a lack of awareness of the frailties of people with elderly needs. It is not a realistic objective for someone with needs that include personal care, who have lost those abilities through the aging process to regain them. Another inappropriate care plan identified the need as X can behave inappropriately with ladies by touching them unexpected and the objectives for the person stated X to respect others. X to behave as normal. Again this objective demonstrates a lack of awareness of what constitutes a realistic goal or objective for a person who has an identified inappropriate behaviour. The care plan actions stated carers to be present all the time when X is around with ladies and monitor [them] closely, especially mealtimes. When personal care is given to X always by two carers. We discussed this at length with the manager. She was able to explain that care staff know this persons needs well and will take measures such as arranging the seating at the dining table so that this person is not placed inappropriately close to a vulnerable female resident. We observed this happening at lunch when the person was encouraged by staff to take a particular seat at the table. It was noted that for this person two members of staff are required for any personal care. Staffing levels in the home are poor, with only two members of staff on duty per shift during the day and one at night. In effect this would mean that if staff were providing personal care for this person during he day, there would be no-one else to care for the remaining nine people who were resident in the home at the time of the inspection. At night it would not be possible to provide personal care for this person as stated in the care plan. A fourth care plan examined contained some background information stating that the person does not like to mix with other residents and prefers their own company. We discussed this with staff and spoke briefly with the person who appeared contented. The personal information record for this person stated they spend all their time in their room watching television. A record dated 20th April 2009 states X is of sound mind, a very pleasant [person]. Holds a very good and interesting conversation. Staff explained that the provider called in the doctor and community matron to assess the person for depression and, although antidepressants were prescribed, the persons Care Homes for Older People Page 15 of 41 Evidence: decision has not changed and it remains their choice to spend their time in their own room. None of this is recorded in the care plan. The care plan for this person states X is unable to walk due to overweight. Although when we spoke to the person, they appeared tall but our observations were that this was not an overly large person. As they are unable to weight bear and as the home has no facilities to weigh someone whilst seated, it would not be possible to make a judgement that this person is overweight. There was no current weight recorded in the persons care plan. The stated objective for this person is to be able to mobilise independently. Through discussions with staff they were able to inform us that this person has not mobilised independently or walked for approximately eleven years. The plan of care for this person states Carer to assist with zimmer to X to stand up near [their] chair. Carer to provide passive exercise to X. Move Xs position every two hourly. Use hoist when moved from place to place. As reported elsewhere, the poor staffing levels in the home would mean that if two members of staff were providing support to assist this person safely with mobilising or hoisting, other people living in the home would be at risk through lack of support or supervision. Overall the care plans examined did not provide evidence that every person had individual care plans based on their assessed needs as the provider stated in the AQAA. Staff spoken with were able to demonstrate a good awareness of peoples healthcare needs. There was evidence in the records examined that people are supported to see relevant healthcare professionals where appropriate, including doctors, community nursing services and optician. People spoken with said they were well looked after and staff were observed to be attending their needs. However, recording needs to be in greater detail to reflect the commitment and good standard of work being carried out by staff on duty. We observed that with only two staff on duty per shift, whose responsibilities include all care, cleaning and cooking, there is little or no opportunity for paperwork such as reviewing or recording in care plans. A healthcare professional who completed a survey told us that what the home does well is, give good care and support and a member of staff who completed a survey stated, the home has always been friendly and very caring. At the time of the last inspection new risk assessments were being put in place. However, the risk assessments in the sample of records examined were mainly in a tick box format that identified the risk but had few details about what measures are in place to reduce the risk. Staff spoken with, however, were able to demonstrate a good awareness of identified risks for individuals living in the home. Care Homes for Older People Page 16 of 41 Evidence: One person had a local authority Risk Management Plan put in place following a recent safeguarding issue around money being lost or stolen. This was the only risk assessment examined that contained an appropriately robust level of detail. Overall the risk assessments in place did not provide evidence that every user of the service has a risk assessment based on their assessment as stated by the provider in the AQAA. There had been improvements at the time of the last inspection in procedures around medication. The home continues to operate a monitored dose system and medicines are stored in a locked cupboard. At the time of the last inspection we discussed controlled drugs with the proprietor who understood the requirements around secure storage for controlled drugs. We also discussed the importance of having an appropriate controlled drugs cupboard in the event that someone may be prescribed this type of medication. No one is currently prescribed controlled drugs. However, no progress has been made to ensure there is an appropriate facility available should anyone be prescribed medication that requires this level of security. We discussed this with the manager who intends to talk to their medication suppliers to see what help or advice they can give. People spoken with were complimentary about the way they are treated. As before, observations on the day of the inspection were that staff are courteous and treat people with respect. Interactions were seen to be relaxed, friendly and appropriate. Care Homes for Older People Page 17 of 41 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are not being offered opportunities to engage in meaningful and enjoyable activities that will ensure their expectations and preferences with regard to lifestyle are met. Evidence: The provider stated in the AQAA, We have developed individual activities plans for the individuals. We discussed activities with the staff, who were able to tell us what people like. One person who has developed cognitive impairment through the aging process enjoys interacting with bricks and toys and was observed to quietly enjoying this limited activity. Another person enjoys knitting. The manager said they had a gentleman coming the following week who plays the accordion. This is the first time this entertainment has been arranged so they will see whether people living in the home enjoy it. Staff told us that people love interaction and this is important to them. A person living in the home who completed a survey told us, I like the friendliness of the home. Care Homes for Older People Page 18 of 41 Evidence: Also, a member of staff who completed a survey stated, We are very friendly and treat our service users as extended family. With the poor staffing levels of only two carers per shift the amount of time available to arrange social or leisure pursuits or to support people with activities is extremely limited. On the day of the inspection we observed that staff did their best to take every opportunity to interact with people as they carried out their duties such as serving lunch. One member of staff took some time to play ball with people but after a few minutes had to stop to carry out some care duties. The manager said they also have skittles and large floor dominoes that they can use. Records examined did not contain individual activities plans as stated by the provider in the AQAA. The provider stated in the AQAA, Our service users are involved in the housekeeping of the home where possible. Through discussions with staff, our observations on the day of the inspection and examination of the daily records we could not find evidence that people living in the home were involved in the housekeeping. It was also our observations that people were too elderly and frail to be able to get involved in housekeeping tasks. Staff spoken with explained that the provider has plans to develop an area outside so that people can grow vegetables. The provider stated in the AQAA, We are planning to start a small plot in the grounds of the home for the service users to take part in gardening in order for them to develop their skills in horticulture and they will feel ownership of the home. They can also grow their own vegetables and have a nourished food at the home in the future. Through discussions with the manager and staff and through our observations there was no-one living in the home with either the physical or cognitive ability to be involved in this type of activity and we were unable to find anyone who had expressed an interest in gardening or horticulture. It is evident from the increasing elderly needs and frailty of the people living in the home that this type of activity would not be appropriate for them. As previously reported visitors are made welcome and the manager said that relatives sometimes take people out. However, the poor staffing levels severely restrict the opportunities people have to access the community. One person said they would like to go out for a walk sometimes. The provider stated in the AQAA, We have developed relationships with the local church for our service users to visit and practice their faith. Some of our service users use to visit the local shops and pubs for them to continue with their life skills and We also have risk assessments developed for the outings of the service users. There was no evidence to confirm either of these statements in the records examined nor was Care Homes for Older People Page 19 of 41 Evidence: there any evidence that that people went for outings. It was reported at the last inspection that people felt they had a degree of control within the home. For some people this remains the case. One person who prefers to stay in their room and not to interact with other residents is perfectly at liberty to do so. However, those people who enjoy activities such as going out for a walk or going shopping are unable to choose to do these things because of the poor staffing levels. The provider stated in the AQAA, Our meal times are relaxed and flexible to suit the service users activities and schedules. However, there was no indication that people living in the home had activity schedules and overall meal times were the same for everyone. At the time of the last inspection we reported that overall people were happy with the food. On this occasion someone said they miss the home made pies. We examined food stocks on a tour of the premises. There were good stocks of tinned food including soup, beans, spaghetti, corned beef, sardines and tuna. There were also good stocks of frozen food including vegetables, pre-packed frozen fish and frozen white bread. However, there was no evidence of fresh fruit and the only item of fresh vegetables was one cabbage which was evidently a few days old and was to be used for a roast chicken dinner the following day. The chicken which was being defrosted was very small and would not have been sufficient to feed four people with small appetites. The manager told us a member of staff was going to use some of the petty cash float to get another chicken at a local supermarket. We discussed what was the usual process for obtaining groceries and foodstuffs for use in the home. The manager explained that the provider does the shopping and brings it to the home whenever he visits. Although it was noted that there was sufficient quantity of store cupboard foods, it was of some concern that the procedure for planning and buying food on a daily basis, particularly fresh foods, did not involve people using the service or members of staff. The home is situated adjacent to a large supermarket but the arrangements mean that staff are unable to take advantage of the facilities it offers including buying fresh provisions such as fruit and vegetables on a daily basis. In addition, poor staffing levels also mean that people cannot be taken to the supermarket without leaving dangerously low staff support in the home. It was also noted that white bread was provided in bulk and frozen. People living in the home would benefit from having a choice of a healthier option of wholemeal bread and also of having bread bought fresh rather than frozen bread being used on a regular basis. Overall, the home does not provide sufficient fresh fruit and vegetables to ensure people are able to follow a healthy diet as recommended by the Department of Healths five-a-day guidelines. Lunch on the day of the inspection was sausages, gravy, runner beans, cauliflower and Care Homes for Older People Page 20 of 41 Evidence: mashed potatoes. Dessert was tinned fruit cocktail and custard. People appeared to enjoy their lunch. It was also noted that the dining table only seated eight people. As the home is registered for eleven and there were ten people in residence at the time of the inspection, this is inadequate if everyone resident in the home at that time wanted to eat at the dining table. We discussed with staff what the arrangements are for special occasions. The manager said they had a turkey, cake and crackers at Christmas and they always have a cake when it is someones birthday. Staff make sure these events are made special for people living there. The provider stated in the AQAA, The local advocacy informations are given to the individuals who are unable to exercise their rights. These are displayed on the residents notice board. The manager confirmed that advocacy information is available. Care Homes for Older People Page 21 of 41 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have access to a complaints procedure, however they cannot be confident that there is sufficient staff to ensure they safeguarded from harm. Evidence: The homes complaints procedure, as reported at the last inspection, remains appropriate. The provider stated in the AQAA, Our home has a complain policy and procedure at the home. Every service users are given this complain policy and procedure in their rooms. The manager confirmed this, however, the procedure should be available in a format that meets the needs of people living in the home, such as large print or spoken word for those people with sensory impairments. Observations of interactions between staff and people living in the home were open and friendly. People were seen to be confident talking with staff and discussing any issues. As reported in the staffing section of these report notes, staff had in-house training around safeguarding the previous year. Staff spoken with were able to demonstrate that they understood their responsibilities around recognising signs of abuse or poor practice and reporting any concerns. One safeguarding issue during the last twelve months was dealt with through the local authority safeguarding processes. The local Care Homes for Older People Page 22 of 41 Evidence: authority have put a comprehensive risk assessment in place relating to this. However, the poor staffing levels have a significant impact on increasing the risks to people living in the home. A care plan examined identified someone who displays inappropriate behaviour towards females. Another care plan identified a different service user who requires two members of staff with mobility and transfers, for example from bed to chair. When there are only two members of staff on duty, which at the time of this inspection was all day and evening shifts, and they are dealing with personal care that requires two people, the other residents of the home are without support or supervision. In effect this means they are vulnerable to any inappropriate behaviour from another resident. This is an unacceptable risk directly related to inadequate staffing levels. Care Homes for Older People Page 23 of 41 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are satisfied the environment suits their lifestyle and is homely but they can not be confident that it is maintained to a standard that ensures their safety. Evidence: We carried out a tour of the premises which included communal areas, laundry facilities, the six single bedrooms upstairs and the two double bedrooms downstairs, kitchen, bathrooms and toilets. Peoples individual rooms contained some evidence of personal possessions, although a few peoples rooms were somewhat stark and lacking in personalisation. There were no locks on bedroom doors with keys available should people choose to lock their rooms. There were no names or pictures on individual doors to distinguish one room from another which would assist people who may be becoming confused or forgetful as a result of the aging process. Similarly there was no signage on bathrooms or toilets to assist peoples orientation. This is inadequate in a service that is registered for dementia and mental disorder. One improvement that was noted is that radiator covers have been installed since the last inspection. With the exception of this one improvement a general deterioration in how the premises were maintained was noted. Care Homes for Older People Page 24 of 41 Evidence: The provider stated in the AQAA, Our homes premises are suitable for the stated purpose and safe for our service users. The building is safe and well maintained. Two radiators had been removed from the walls in upstairs corridors and there were two large patches on the walls which appeared to indicate that no effort had been made to repair the decor where the radiators had been removed. On closer inspection, however, we saw that the paintwork had been patch painted with different coloured emulsion to the rest of the surrounding walls. In addition the screw holes used to hold the radiator to the wall had not been made good. This gave the environment in this area a neglected appearance. It was noted at the last inspection in May 2008 that a door leading to the corridor by the office and kitchen had been rehung to open the other way. The manager had explained this was for safety reasons. As part of this work a radiator had been removed from the wall to enable the door to open fully. It was noted at this inspection that the paintwork to the wall and the side of the door has not been made good in the intervening twelve months. The upstairs bathroom similarly was not well maintained. There was no plug in the hand basin and there was no liquid soap, although paper towels were available. The bath plug was not attached to the chain. There was a significant amount of limescale around one of the bath taps and scaling and stains on the bath underneath this tap, which appeared to indicate there were or had been issues with a dripping tap and the resulting damage had not been repaired. There are doorguards on some individual doors that are designed to keep the door open but to close it in the event of a fire. The Dorguards on the lounge and one persons bedroom were observed to be in working order. However, One Dorguard on a downstairs bedroom was observed to be ineffectual in keeping the door open because there was no metal stop on the floor and the Dorguard was not able to engage effectively on the carpet. The manager was replacing the batteries in the kitchen Dorguard on the day we arrived for the inspection. There are two doors in the corridor between the kitchen and the lounge that leads to the dining room, neither of which have had Dorguards installed. Staff need to carry plates of food through from the kitchen to the dining room and to enable them to do this find it necessary to wedge these doors open to have their hands free to carry the food. It is inappropriate to wedge doors open and thought needs to be given as to how staff can safely carry food through from the kitchen to the dining room and whether Dorguards need to be installed on these doors. Care Homes for Older People Page 25 of 41 Evidence: Overall the general standard of cleaning throughout the home and in peoples bedrooms was reasonably good and staff are to be commended for managing to maintain this standard on top of their other duties which include caring and cooking. However it is evident that non-routine cleaning could be better. Examples of this could be seen throughout the home were items such as ornamental vases or artificial flowers had quite thick dust on them. We observed that staff were kept busy throughout the day with other duties and the poor staffing levels did not allow the time for any deep cleaning of the premises. In the dining room the chairs around the dining table were old and mismatched. There were two odd chairs with slatted seats that were not comfortable to sit on. The slats on these particular chairs were a hazard both in terms of possibly pinching peoples flesh and in infection control as the gaps in the seat have the potential for harbouring dirt and germs. The remaining six wooden chairs had old and worn seats and bare wood was exposed where the finish was damaged. As well as being unsightly, the poor finish is an infection control risk when there are people living in the home with continence issues and the rough exposed areas could catch the fragile skin of the elderly people living in the home causing skin tears. Two of the chairs were of the type described as carvers, one of which has had the arms broken off and no effort has been made to repair the damage. Overall the furnishings in the dining room are not conducive to a pleasant dining experience. Overall this evidence does not support the providers statement in the AQAA that the building is safe and well maintained. The outside of the premises has deteriorated significantly since the last inspection. On arriving at the home we noted that the sign was broken and dilapidated. The gravel surrounding the main door to the side of the building showed signs of neglect and a significant amount of weeds had pushed up through the gravel. Flower pots that had previously been seen to contain flowers had not been maintained and looked dilapidated. Across this weed strewn gravelled area was a line of bricks in the form of a step marking a change in levels of the ground. This is not clearly defined and has some broken bricks, making it a trip hazard for anyone with poor vision. A serious concern was raised on the day of the inspection about some excavation work that has been carried out to the front of the property to a depth of what appeared to be almost one metre, leaving exposed pipes and a long open trench. There were no warning signs and no effort had been made to fence this area off. The excavation extended to the side of the property that houses the main entrance door, where people would be walking to access the home. There was no outside light at the front of the building where this long exposed trench was dug out, increasing the risk of Care Homes for Older People Page 26 of 41 Evidence: someone being hurt if they were unable to see the danger in the dark. An immediate requirement was left giving the proprietor 48 hours to make the area safe and when we returned to the home at the end of this period a fence had been erected around the excavation. The provider stated in the AQAA, Our service users have the unrestricted access to the home and the grounds. We had significant concerns around hazards to the outside of the property that would restrict access or make it dangerous. The main entrance to the right side of the building has steps leading to the main entrance door, which would make it inappropriate for wheelchair users, those with restricted mobility or people who are unsteady on their feet as a result of elderly needs. The other exit from the home for wheel chair users is through the French doors leading from the dining room, which involves negotiating the step at the base of the doors and then down a sloped path to the left. this path is obstructed by the steps leading from another side door, which necessitates the person pushing the wheelchair to go around the steps across the grass which is difficult to push a wheelchair across and which is a hazard when the grass is wet. At the end of the path there is an area of small stones or shingle to be negotiated leading to either a steeply sloped grass bank or some shallow steps. Neither of these exits is appropriate for the majority of people currently living in the home. It was noted during the course of the inspection that there appears to have been a significant change in the abilities of the people living there, with more people showing evidence of mobility difficulties. We discussed this with the manager. When questioned the manager responded that four people would need wheelchairs for going out as they could only walk short distances. In view of the fact that the home is registered to care for people with physical disability, these access hazards are unacceptable. This evidence contradicts the assertion that people living in the home have unrestricted access to the home and grounds as stated by the provider in the AQAA. The provider stated in the AQAA, Our home has no lift currently. This is stated in our statement of purpose. Due to this we only care for the wheelchair users in the ground floor level of the home which meets the fire regulations. At the time of the last inspection it was noted that the only access to the first floor is by means of a curved staircase. The proprietor told us at the time that he had plans to install a passenger lift. On the day of the inspection we were told the excavation to the front of the property relates to the work that needs to be carried out for an extension to accommodate this lift. We questioned staff about the excavation work. We were told that the trench was dug out in the autumn of last year but no further work has been Care Homes for Older People Page 27 of 41 Evidence: carried out. In view of the fact that twelve months has passed since the proprietor told us he had plans for a passenger lift and approximately six months has passed since the digging was carried out, the lack of progress is of some concern. As noted earlier people are increasingly finding it more difficult to negotiate obstacles, which includes the narrow, curved staircase. This is an unacceptable risk to the health and safety of the increasingly frail people living in the home and the staff who have to help them negotiate the stairs. Of the people whose bedrooms are upstairs, records examined contained comments from two of them relating to their difficulties with the stairs. One person stated in one of the homes own quality assurance surveys, I wish we had a lift. I am finding it difficult to go up and down stairs and another person said I wish the lift would go in, my legs are bad. Care Homes for Older People Page 28 of 41 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can not be confident they are cared for by a competent staff team in sufficient numbers to meet their needs. Evidence: There are two members of staff on duty per shift both in the mornings and evenings. One of the rostered members of staff during the day is the manager. Some people living in the home require the support of two people either for safe moving and handling or for the safe provision of personal care (see evidence in section relating to Health and Personal Care). The manager and carers also do all the cooking and cleaning. On the day of the inspection one member of staff due to work the afternoon shift came in early to enable the manager to be freed up to assist us during the inspection. This was arranged by the carer on duty following a call from the provider to authorise the additional hours. Both carers were observed to be kept busy seeing to peoples needs, cooking lunch, cleaning and supporting one person who needed full assistance with eating. This left virtually no time for supporting people with or organising any kind of social activity. One carer spent a short time playing with a ball with some people in the lounge but had limited time available before she had to stop to carry out another task. Staff are to be commended for working hard and keeping up cheerful interactions with Care Homes for Older People Page 29 of 41 Evidence: people whilst carrying out their duties. We observed that they were kept very busy. A member of staff who completed a survey stated, I feel staffing levels are below par at the home. The manageress has to cook, clean, see to service users, keep all paperwork up to date and see to staff. I feel if we had a cook and another member of staff on duty she would not be so run off her feet which would also benefit the service users and the home would run far more smoothly. There is only one member of staff on duty at night and there are people living in the home whose care plans clearly state that they require two members of staff either for mobilising or because of inappropriate behaviour. Through discussions the manager said that she would come in if needed in an emergency. However, the night-time staffing levels are clearly inadequate and pose a significant risk to those whose assessed needs are not able to be met by one person. On the day of the inspection we had a telephone conversation with the proprietor in the late afternoon. At that time we had not finished the full inspection. However, we did inform the proprietor of our concerns around poor staffing levels that were insufficient to meet the needs of the people living in the home. There are 4 more people than there were at that time and peoples needs are changing. The proprietor told us that the additional residents had only been there for about a week. Records examined showed that one person who was admitted on a respite basis had indeed only been in the home for a few days. However, another three had been there for a longer period; one for two weeks, another for 3 weeks and one since November 2008. It is evident, therefore, that the inappropriate and unsafe staffing levels have been ongoing for a number of weeks. A member of staff who completed a survey told us, I feel we have inadequate staffing levels at night as we have only one member of staff on at night. We have four with high dependency and one client who has inappropriate behaviour towards women and should have two carers at all times. The provider stated in the AQAA, All staff receive five training a year. At the time of the last inspection the proprietor had put in a programme to update staff training and there had been some improvements including in-house safeguarding training. Through discussions with staff and the sample of records examined it was evident that the staff team have had Moving and Handling training, Dementia Awareness and administration of medication training. There was also evidence that the manager and another member of staff had completed training around the Mental Capacity Act and Managing Violence and Aggression. There was also some evidence of Care Homes for Older People Page 30 of 41 Evidence: Food Hygiene, Infection Control and Fire Training. The manager explained that there was some training booked for the coming week on Hygiene and Catheters and medication. She also said that they plan for all staff to have training around the Mental Capacity Act. The National Minimum Standards for Care Homes for Older People recommends a minimum of three days paid training a year. The evidence in the records examined falls short of this and does not support the providers statement in the AQAA that staff have five training days a year. As reported at the last inspection, all but one member of staff has an NVQ qualification. Staff were observed to be doing their jobs efficiently and effectively and were following appropriate procedures. Staff spoken with knew people well and understood their needs. Care Homes for Older People Page 31 of 41 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home cannot be confident that the manager has sufficient time to ensure the home is managed in their best interests. Evidence: The manager explained that she has continued to develop her skills and knowledge through training courses. She has completed training around the Mental Capacity Act and Dementia training (level 2). She is currently in the process of doing a palliative care course (level 2) through distance learning with the support of an assessor. The manager spoke with enthusiasm about these courses. Through discussion the manager demonstrated a willingness to gain an NVQ at level 4 and the Registered Managers Award but these are expensive courses and there is an expectation that she will fund the course herself. The provider stated in the AQAA, The manager of the home has 19 years experience in care. She has no NVQ in care at level 4 and management qualifications as yet. She only has a qualification as NVQ 2 in health and social care. She has undertaken to gain a qualification in health and social care at level 3 Care Homes for Older People Page 32 of 41 Evidence: currently. She is sign posted to undertake NVQ level 4 in health and social care and the management training by the managing director. The provider has not specified how he will support the manager to achieve these qualifications and we are unclear what sign posted means. Given that the manager is willing to undertake the award, it is of some concern that the manager is still not enrolled on the course and there has been no progress towards this in the past year. Although there has not been progression for the the manager in gaining relevant qualifications, it is evident that she is using her own time to update her skills and knowledge. As reported in the staffing section, staffing levels were observed to be poor and the manager is included as a carer. This restricts the amount of time the manager has available to carry out her management duties, which has a significant impact on the day-to-day management of the home. In view of the evidence that staffing levels are unacceptably poor, in effect so much of the managers time is taken up with duties including caring, cooking and domestic tasks, there is little time available for the day to day management of the home. A member of staff who completed a survey told us, Most of the staff have been here for years and the manageress and staff have a good working relationship with each other and service users. The manageress works alongside us an has been a tower of support to staff and service users. We reported at the time of the last inspection that the proprietor visited the home regularly and took a hands on role in the managing of the home by implementing new procedures, updating policies and dealing with staff disciplinary issues. The AQAA document that was submitted to us was completed by the provider. The AQAA is a document that relates to the outcome groups as laid out in the National Minimum Standards. There are more than one set of standards and the set that relate to Great Clacton Hall are the National Minimum Standards for Care Homes for Older People. The AQAA document that was submitted by the provider related to the National Minimum Standards for Care Homes for Adults aged 18 to 65. Some of the information provided in this document demonstrated a lack of awareness of the needs and abilities of the client group that Great Clacton Hall is registered to provide a service for. We further reported that the manager should achieve appropriate qualifications in care and management to develop skills to continue to improve the day to day management of the home. It is evident from the evidence now available that poor staffing levels which leaves the manager with no time for management duties is a greater barrier to Care Homes for Older People Page 33 of 41 Evidence: good day-to-day management of the home than the managers current lack of qualifications. We previously reported that the home now has a process in place around Quality Assurance. Records examined contained satisfaction surveys. To the question Do you have any complaints about the home or the staff? one person had responded, No, not with the staff, but I wish we had a lift. I am finding it difficult to go up and down stairs.. This person further said, The staff treat us well. We discussed quality assurance with the manager who informed us that, as well as the satisfaction surveys they meet with residents monthly to talk about what they like, such as food. The manager explained that they try to do this after a meal when people are together in the dining room. In view of the fact that a resident has expressed concerns about the stairs in the homes own satisfaction surveys and there has been no progress in a year in making these planned improvements, this does not give us confidence that the home is being run in the best interests of people living there. The processes around supporting people with their finances remains as it was reported at the last inspection. Receipts are kept for purchases and records maintained. One person continues to be supported by a member of staff acting as a Department of Work and Pensions appointee, transactions are recorded and there is an audit trail. A sample of documents relating to Health and Safety were available and found to be in order. Portable Appliance Testing (PAT) was carried out in April 2009, the gas installation had a maintenance check in September 2008, emergency lighting, smoke alarms and fire equipment were checked In April 2009. Electrical installation had been checked in January 2008. Care Homes for Older People Page 34 of 41 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 21 23(2)(a) People must have access to 30/09/2008 all areas of the home, designed for their use. This includes ensuring people with restricted mobility have means to access the facilities on the first floor, including the bathroom. This is a repeat requirement from the inspection carried out on 8/11/07. Timescale of 31/01/08 to meet the requirement was not met. Care Homes for Older People Page 35 of 41 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 7 13 The registered person must ensure that there are sufficient staff on duty at all times. This is so that people can be supported appropriately with their assessed needs as recorded in their care plans and the assessed risks as identified in risk assessments. 30/06/2009 2 12 16 People who wish to be taken 30/06/2009 out to access community facilities must be supported to do so. There must be sufficient staff on duty to enable this to happen safely. 3 18 13 There must be sufficient staff on duty at all times to ensure people are safeguarded from abuse. This would ensure that people living in the home are safeguarded from the 30/06/2009 Care Homes for Older People Page 36 of 41 inappropriate behaviour of others. 4 19 23 Improvements to access 30/09/2009 within the building must be made to ensure people living in the home are able to access all areas they need to. This is necessary to ensure people with deteriorating mobility are to continue to be able to access their bedrooms on the first floor. 5 19 23 Arrangements must be put in place to ensure appropriate precautions are put in place in a timely manner when any building work is in progress. This includes improved lighting and safety barriers. This would ensure that people using the service are not exposed to risks. 6 19 23 Arrangements must be put in place for safe access to the property. These arrangements include removing or making safe trip hazards and ensuring there is appropriate and unobstructed access for wheelchair users. These improvements would ensure that people with mobility problems or sensory impairments would be able to access the home safely. 7 19 23 Dorguards designed to hold doors open and then close 30/06/2009 30/09/2009 30/06/2009 Care Homes for Older People Page 37 of 41 them in the event of a fire must be operating appropriately. Other doors that do not have a Dorguard fitted should be addressed in a risk assessment that identifies why a Dorguard is or is not necessary. This would ensure that in the event of a fire risks to people living in the home are reduced. 8 27 18 The proprietor must ensure 30/06/2009 that there are sufficient staff on duty at all times of the day and night. This is to ensure that people are supported safely and care is provided appropriate to peoples assessed needs. 9 31 12 The registered provider and the registered manager must maintain good professional relationships with each other. This would ensure that the manager is supported to achieve relevant qualifications in care and management so that the service is well managed in the interests of the people who live there. 10 33 24 The provider must ensure that a robust quality assurance system is established. This would ensure that the wishes and concerns of 30/06/2009 30/09/2009 Care Homes for Older People Page 38 of 41 people living in the home are acted upon and the home is run in the interests of the people using the service. 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 1 The service should make their Statement of Purpose and Service User Guide available in formats relevant to people living in the home or wishing to use the home. This includes formats for people with sensory impairments, such as large print or spoken wood. Care plans need to reflect peoples assessed needs. They should also contain appropriate information that is accurate and relevant to the individual. Care plans need to contain sufficient detail to guide staff and ensure that care is provided consistently and in ways that the person needs and wishes. Risk assessments need to have sufficient details of what measures are to be taken to reduce identified risks so that people are safeguarded from harm. The provider should consider how they are to ensure that there is an appropriate facility available for the storage of controlled drugs that complies with relevant legislation should anyone living in the home be prescribed medication that requires this level of secure storage. Routines of daily living and activities within the home should be available which suit peoples preferences and capacities. A wider range of fresh foods should be available including fresh fruit and vegetables so that people can be supported to follow a varied diet in line with the Department of Health five-a-day guidelines for healthy eating. The homes complaints procedure should be accessible to everyone living in the home in a suitable format that makes the information clear. The furnishings in the dining room need to be improved if all the people living in the home are to be able to be accommodated round the table should they wish. Page 39 of 41 2 7 3 7 4 7 5 9 6 12 7 15 8 16 9 19 Care Homes for Older People 10 19 Signage to assist peoples orientation would improve the environment for people with cognitive impairment and those who are becoming more forgetful. Improvements to the standard of the seating in the dining room are necessary if elderly people with fragile skin are to be safeguarded from skin tears. Repairs to the decor following maintenance such as removing radiators or re-hanging doors should be carried out in a manner that improves the appearance of the environment rather than detracts from it. Significant improvements need to be made to the outside of the premises if people are to benefit from a wellmaintained environment. These improvements include maintenance of the garden such as removing weeds and repairs to the large broken sign attached to the wall to the front face of the building. Deep cleaning of the home, including de-scaling the taps in the bathroom and taking measures to deal with the stained bath would improve the bathing experience for people living in the home. Staff should be provided with a minimum of three days paid training a year as recommended in the National Minimum Standards. This would ensure that people living in the home can be confident that they are supported by a skilled team of carers with up to date knowledge. The manager should have sufficient rostered supernumerary hours to enable her to carry out her management role and ensure people living in the home benefit from a well managed service. The manager should have sufficient supernumerary hours to enable her to complete relevant qualifications in care and management. 11 19 12 19 13 19 14 26 15 30 16 31 17 31 Care Homes for Older People Page 40 of 41 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 41 of 41 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!