Inspection on 19/11/08 for Middleton Lodge

This inspection was carried out on 19th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Middleton Lodge 22/01/08

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

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Middleton Lodge Mount Pleasant Station Road Middleton St George Darlington, County D DL2 1JA     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: Tanya Newton     Date: 2 1 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 29 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 29 Information about the care home Name of care home: Address: Middleton Lodge Mount Pleasant Station Road Middleton St George Darlington, County D DL2 1JA 01325333993 Telephone number: Fax number: Email address: Provider web address: middleton.lodge@googlemail.com Name of registered provider(s): Type of registration: Number of places registered: Potensial Limited care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 10 The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Learning disability Code LD, maximum number of places: 10 Date of last inspection Brief description of the care home Middleton Lodge is a single storey building that has been refurbished to provide a modern living environment for ten people with a learning disability. The home is set in its own grounds and provides single room en-suite accommodation. Inside the building there are two dining rooms, two lounge areas, an activities room, kitchen and laundry. Outside there are garden areas and parking areas for visitors and staff. The home is in the village of Middleton St George and can be reached by both public and private transport. Local shops are nearby. Fees for this home were £735.00 per week. Individual agreements are in place for one to one support. We know that the fees do not cover all items and that personal items such as clothing, hairdressing etc has to paid for in addition to the fees. Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 10 Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor 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 inspection was unannounced and carried out over two days. The inspection was carried out over eight hours. Prior to the visit the home were asked to complete an annual quality assurance assessment (AQAA). This provides CSCI with information about the home. During the inspection time was spent talking to people living at the home, staff and the owners/managers. Records were also looked at. Care Homes for Adults (18-65 years) Page 6 of 29 What the care home does well: What has improved since the last inspection? What they could do better: 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 7 of 29 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 8 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although some information is available about the home, it is not in formats that can be easily accessed or understood by people living at the home. The homes own assessments were incomplete and contracts were unavailable. Evidence: Three case files were looked at during the inspection. Although assessments were in place from the placing authority, the home had not completed their own assessments to demonstrate how they would meet peoples needs. Contracts were not available in individual care files. These are required to provide people with information about their terms and conditions of residence. This was a recommendation in the previous report which has not been met. The statement of purpose and service users guide were not available in user friendly formats. These documents provide people with information about the service. This was a recommendation made in the previous inspection which has not been met. Care Homes for Adults (18-65 years) Page 9 of 29 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Records in the home were poor and did not provide sufficient information to demonstrate how peoples needs would be met. Evidence: Three case files were looked at during the inspection. There was no care plan in place for any of the files which were looked at and the information in the files was out of date. Although planned interventions are required for the individuals, they were not recorded. Any information available was outdated and had not been reviewed. There was no evidence to support how the individuals could make decisions or choices. There was limited information available regarding risk taking and the risk management strategies in place were either incomplete or had not been reviewed. Case files must be kept up to date and must include a care plan which demonstrates how the home will meet an individuals needs. Care Homes for Adults (18-65 years) Page 10 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing numbers in the service are having a negative impact on the activities that people can participate in. This must be addressed so that peoples social, recreational and leisure needs are met. Evidence: Although it is recognised that the home are trying to provide some suitable activities to people living at the home, the current staffing levels have a negative impact on this. Three of the people accommodated require one to one support, there is no evidence to say whether or not this is being achieved. Staff confirmed that the lack of staff on duty did impact on people going out and also impacted on in house activities. There was little evidence of people participating in meaningful activities, although one person was seen assisting with baking in the kitchen. In the main people were sat in the lounge watching TV. Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: There is a room for activities, but little evidence to show how this was being utilised. People were seen to be walking freely around the home, staff support is required if people want to go out and staff said that it was difficult to achieve as there had to be enough staff to support people at home as well as those who were going out. People are able to visit the home and visiting times are not restrictive. People are also supported in visiting their relatives, providing transport is available. Although staff said that peoples rights were respected, the lack of written information does not support this. Care plans should demonstrate how people are supported to make decisions and choices. Staff are responsible for preparing the meals at the home, people living there can be involved in baking providing there is sufficient staff support. The home does have a menu in place, but recording systems do not show how people are offered choices about what they wanted to eat. One of the people goes horse riding and staff did say that some trips took place providing there were sufficient staff on duty. Care Homes for Adults (18-65 years) Page 12 of 29 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Poor record keeping and low staff numbers impact on the way peoples health and personal care needs are being met. Evidence: Peoples health and personal care needs are being neglected by the lack of written information held within the home. Each person must have a care plan which documents how their needs will be met. As the home is using a significant number of agency hours it is paramount that written information describing how each individuals needs will be met is kept up to date. The staffing arrangements are having a negative impact on the way in which peoples health and personal care needs are being met. Some of the people living at the home require one to one support from staff. it is not possible to provide this support when staffing numbers are running consistently low. Due to the high level of care needs of some of the people placed at the home these staffing numbers put people at risk. Copies of support plans from other professionals such as speech and language were missing. This puts people at risk as staff do not have the written guidance required to care for them. The lack of care planning, appropriate risk management and intervention plans mean that peoples health and Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: personal care needs may be being neglected. The information recorded in the home is out of date or missing which potentially puts people at risk. Medication systems were viewed. The home currently uses the nomad system. A check was made on the medication recording, storage and administration systems. There were some gaps in the MAR sheets although it did appear to be missed signatures rather than non-administered medication. There are no pictures on medication boxes or MAR sheets which help staff to identify the person they are giving medication too. This was a recommendation made in the previous inspection. The manager said that all staff who administer medication have received training in the safe handling of medicines. Concern was raised regarding the number of people on PRN medication, as there was no guidance for staff to follow regarding when it should be administered. This practice is unsafe and puts people at risk. One person had run out of Tegratol medication, although this was highlighted on the 14th as being required it was not delivered to the home until the 18th. of the month. Care Homes for Adults (18-65 years) Page 14 of 29 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although there are policies in place to manage complaints and adult protection, these are not always being adhered too by staff working at the home. Evidence: The home has a complaints system in place, this is written in a standard format and is not very user friendly. Two complaints had been recorded in the complaints book. All staff have signed to say that they have read and understood the complaints procedure. The adult protection procedure was looked at, it contained all of the required information for staff to make a referral to the local authority. Some serious concerns were raised prior to the inspection. These were referred to the local authority under their safeguarding adults procedures. A number of serious incidences were recorded in the home where it was alleged that physical violence had taken place towards staff and people living at the home. Recording systems were poor and did not accurately reflect what had happened. There were no clear behaviour management strategies and incidents were not being reported to the local authority under their safeguarding procedures or CSCI as required under regulation 37. Care Homes for Adults (18-65 years) Page 15 of 29 Care Homes for Adults (18-65 years) Page 16 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally the home provides a good standard of modern accommodation. Evidence: A tour of the home was taken. The home is a single storey building which had been refurbished. Rooms are individually furnished and decorated to peoples choice. All bedrooms are en-suite with either showers or baths. The home has a large kitchen with a smaller kitchenette. There are two lounge areas and a dining room. There is also an activities room. The home has a fully equipped laundry and an infection control procedure. Generally there were no unpleasant odours in the home. Care Homes for Adults (18-65 years) Page 17 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing numbers in the home potentially put people at risk. Evidence: Concerns were raised prior to the inspection about the lack of staff members on duty and the impact this is having on both staff and people living at the home. The manager and staff said that there should be five staff on each shift. The area manager said that for the people accomodated there should be four staff on duty. Rotas were looked at, most shifts were operating on three care staff, however on some shifts there are only two staff on duty. As some of the people accommodated require one to one support, current staffing numbers do not support this. Care staff are also responsible for carrying out cooking and cleaning duties at the home. Due to problems with the recruitment of staff a number of agency staff hours are being utilised. One staff member said, It makes it stressful and demanding and puts pressure on you, the staffing numbers effect what people living here are able to do, staffing levels need to improve. Staff training is required in areas such as de-escalation and in breakaway techniques. Some staff said that they did not feel competent in dealing with difficult or challenging Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: behaviours. Although a number of training courses had been booked previously to update mandatory traning, some staff chose not to attend them. The home has booked additional training to provide staff with the skills and knowledge they need to carry out their jobs. Recruitment files were not accessible during the inspection, so were not looked at. There were no concerns with these in the previous inspection of the home. The area manager said that people were being recruited safely and that two references and a criminal record bureau (CRB) check were always carried out prior to people starting employment. A formal programme of staff supervision needs to be carried out to monitor peoples performance and to highlight any training needs. This was raised in the previous inspection report and has not been actioned. Care Homes for Adults (18-65 years) Page 19 of 29 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes mangement arrangements, quality assurance systems and record keeping may be having a negative impact on people living at the home. Evidence: The home has a manager who is currently in the process of applying for registration with The Commission. The manager has not been sending CSCI notifications of incidences which have taken place in the home (Reg 37s). Quality assurance systems were looked at, Regulation 26 visits are not taking place reguarly. These are monthly visits from the registered provider or a nominated individual, which report on the standards of care being provided in the care home. The last visit took place in July 2008. The manager said that she has no super nummery hours and is working all of her hours on the floor. This means that management tasks are not being carried out. Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: Health and safety records were looked at. Monthly and weekly checks for the emergency lighting and fire equipment were last carried out in August 2008. The gas safety certificate was unavailable. Risk assessments were last carried out in July 2007 and had not been reviewed or updated. Records to monitor health and safety must be kept up to date to safeguard people living and working at the home. The accident book had gone missing and the emergency call alarm for staff to summon help had broken and was left disconnected for three days. Although the alarm had been fixed by the time the inspection started, there were not enough fobs for each staff member to summon help if required. The home were told to rectify this immediately and personal alarms were given to all staff on duty. Documentation was poor with records either missing or incomplete. The policy on managing aggression was unavailable. Incident reports were not being completed. Care Homes for Adults (18-65 years) Page 21 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 22 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 2 14 Assessments must be carried out to ensure that peoples needs can be met by the home. Assessments are required to ensure that the home can meet peoples assessed needs. 15/01/2009 2 5 5 A contract must be given to each person living at the home which details the terms and conditions of residence and information relating to fees. Contracts must be available to all people living at the home. 15/01/2009 3 6 15 A care plan must be 15/01/2009 available which demonstrates how the home will meet peoples needs. Care plans are required to ensure that all aspects of peoples needs can be met by the home. Care Homes for Adults (18-65 years) Page 23 of 29 4 9 13 The registered person must ensure that unnecessary risks to people are identified and as far as possible eliminated. Risk assessments are required to ensure the health, safety and well being of people living at the home. 15/01/2009 5 18 12 The way in which peoples health and personal care needs are to be met need to be documented within their plan of care. Records of any input from other professionals must also be maintained. Peoples health and personal care needs must be recorded so that they can be monitored. 15/01/2009 6 23 13 The registered person must ensure that all concerns or allegations of abuse are reported to the local authority under their safeguarding procedures. This includes reporting any alleged physical violence. Accurate records must be kept to safeguard people living and working at the home. Issues were not being reported under safeguarding procedures or under Regulation 37. 15/01/2009 7 32 18 The registered person must 15/01/2009 ensure that at all times suitably qualified, competent Care Homes for Adults (18-65 years) Page 24 of 29 and experienced people are working at the care home in such numbers as are appropriate for the health and welfare of service users. Staff numbers must be appropriate to meet the assessed needs of the people living at the home. 8 35 18 Staff must receive training 15/01/2009 appropriate to the work they are to perform. This must include training relevant to the people placed and include de-escalation and breakaway techniques. Mandatory training for staff must also be kept up to date. Staff training is required so that staff have the skills and qualifications to care for people. 9 37 12 The registered person must ensure that the home is conducted in a way which promotes and makes proper provision for the health and welfare of service users. Management practices do not promote or make proper provision for the welfare of service users. 10 38 12 The registered person must make proper provision and where appropriate, treatment, education and supervision of service users. 15/01/2009 15/01/2009 Care Homes for Adults (18-65 years) Page 25 of 29 Management arrangements must take into account the needs of service users. 11 39 26 The registered person must 15/01/2009 ensure that visits are carried out to the home under Regulation 26 and that a written report is prepared regarding the conduct of the home. Reg 26 visits need to be carried out on a monthly basis and a copy of the report held on the premises. 12 39 24 The registered peson must 15/01/2009 establish and maintain a system for reviewing and improving the quality of care provided at the home. The registered person must ensure that management arrangements improve the quality of care being provided at the home. 13 41 17 Records specified in 15/01/2009 Schedules 3 and 4 of the care homes regulations must be maintained and kept up to date. Records within the home must be held and kept up to date. 14 42 13 The registered person must 15/01/2009 ensure that unecessary risks to the health and safety of service users are identified and as far as possible eliminated. Care Homes for Adults (18-65 years) Page 26 of 29 Health and safety systems must be kept up to date to safeguard people living and working at the home. 15 42 23 The registered person must 15/01/2009 ensure that adequate arrangements are made for the maintenance and testing of all fire equipment and the training of staff in fire prevention. Fire drills must also be carried out so that people working at the care home are aware of the procedure to be followed in the event of a fire. Regular fire maintenance checks, staff training in fire and fire drills must be provided to safeguard people living and working at the home. 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 statement of purpose and service users guide to the home should be available in alternative formats, to make them accessible to people living at the home. People living at the home should be given more opportunities to make decisions and choices, this information should be included within care plans. People living at the home should be helped to access the local community in which they live. Additional staffing is required to do this. Opportunities to maintain family links and friendships outside of the home should continue to be developed. The registered person should ensure that people are offered choices at mealtimes and that menus show the Page 27 of 29 2 7 3 13 4 5 15 17 Care Homes for Adults (18-65 years) alternatives that are available. Menus should also be available in different formats to support people in making choices. 6 20 Photographs of people taking medication should be placed in the medicines administration record sheets. This would help to reduce the possibility of medication administration errors occurring. People living at the home should receive a copy of the complaints procedure in a format that they can understand. The registered person should ensure that people working at the home are appropriately supervised. Supervision should take place at least six times each year. 7 8 22 36 Care Homes for Adults (18-65 years) Page 28 of 29 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. Care Homes for Adults (18-65 years) Page 29 of 29 - 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!