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Inspection on 29/10/08 for Pine Heath Nursing Home

Also see our care home review for Pine Heath Nursing Home for more information

This inspection was carried out on 29th October 2008.

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

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

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

What the care home does well

Observations at this time did show that staff consider the dignity of people living in the home. People`s preferences were asked and people chatted and laughed with the staff and among themselves. One resident said `staff are good here` and also that the `food is always good`. People may have preferred some small adjustment to the way their meal was served, for instance two people said `there was too much gravy` but they did say that the meals were generally good and there was always plenty. Any health matters are dealt with by calling the appropriate services for support and continued care. One person had support following an operation and said `I am the best I have ever been in my life`.

What has improved since the last inspection?

Most staff are now having supervision on a regular basis and all staff files seen at this time contained appropriate recruitment procedures to protect people. Staff have undertaken ongoing training in the home to enhance their skills and this training includes an awareness of areas regarding abuse. Staff did show a sound knowledge of this and other areas of care during conversations at this time.

What the care home could do better:

The environment is in need of upgrading and some areas pose a risk to people in the home. A risk assessment of the building is needed to identify areas that may be a risk and then a plan of action developed to address and minimise such risks. Care plans need to contain more detail of the actual person and not just clinical observations. This gives a more person centred plan of care and also informs any developments or changes in the person themselves. This information is essential to the development of new care plans and provides a basis for all the support that is provided. Staff must consider the appropriate security around the medication area and the confidentiality of residents with regard to personal information. Practises have been in place for some time and it appears that staff are not reviewing these to keep up to date and develop alternative methods to meet current standards. An audit of medication must be undertaken regularly and also of the way staff are dispensing medication, to evidence appropriate procedures and standards are maintained.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Pine Heath Nursing Home Cromer Road High Kelling Holt Norfolk NR25 6QD     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Brenda Pears     Date: 2 9 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. 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 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 03000 616161 (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 28 Information about the care home Name of care home: Address: Pine Heath Nursing Home Cromer Road High Kelling Holt Norfolk NR25 6QD 01263711429 01263711488 diane.varrall@virgin.net Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Diamond Care (UK) Limited Name of registered manager (if applicable) Diane Lynne Varrall Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Pine Heath is a care home providing personal care and accommodation for older people, some of whom may have dementia. The home is located on the main road between Holt and Cromer. The home consists of a two-storey building. Most of the rooms are single and of a good size. There is a passenger lift to allow easy access to all communal areas and private space. Communal space is limited, with the lounge accommodation half of what it should be for the number of registered places. However a large room just off the registered accommodation has been made into an activities room and is bright and airy. Activities take place in there every day. The grounds are attractive and extensive though would benefit from some concrete walkways so service users could enjoy them more. The fees depend on the level of care provided and on Care Homes for Older People Page 4 of 28 care home 42 Over 65 42 42 0 0 Brief description of the care home the size of accommodation accepted. A copy of the last inspection report and service user guide can be obtained on request. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate 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: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection undertaken on the 29th October 2008 and started at 10.30am. The focus of this inspection was on the previous requirements, on the core national minimum standards and on the quality of life for people who receive support in the home. The methods used to complete this inspection consisted of looking at the care a resident receives and the records that support this. Information was provided to us by the home on an assessment form known as an Annual Quality Assurance Assessment (AQAA). During the visit to the home we spoke to the manager, with members of staff and also with four residents and also with groups of people. Care Homes for Older People Page 6 of 28 These methods plus observations undertaken at this time and previous findings all inform the outcomes of this report. 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. Care Homes for Older People Page 8 of 28 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 –03000 616161. Care Homes for Older People Page 9 of 28 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 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager does assess the needs of any new client to make sure individuals can be fully supported before an agreement is undertaken. Evidence: These standards were not directly inspected at this time. However, at the last inspection it was found that pre admission assessments are undertaken and information provided to assist those thinking of moving into the home. Care Homes for Older People Page 11 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. While care plans are in place, the information contained in these documents is not complete and this is putting residents health and well being at risk. Practises relating to personal information must fully support dignity and confidentiality at all times. Evidence: Four care plans were reviewed at this time. Files contained information about pressure relieving equipment and clearly showed that healthcare needs are followed up by the appropriate medical services. One resident explained that following an operation and with support and care in the home, mobility had increased to a higher level than ever before. This person explained how happy they were and just how fit they now felt. All required medical support had been accessed throughout this process. However, information was minimal in many areas and documents were left loose in folders and not fixed to ensure they remained in the appropriate folder. There was also a note in one file for a blood test to be booked as soon as possible. There was no further information or evidence that this had actually been undertaken. Care Homes for Older People Page 12 of 28 Evidence: Information for the welfare and safety of residents was lacking. For instance, one care plan had an outcome of dependency as High level but contained no further details regarding the provision of care or actions for staff to follow. Three of the four care plans reviewed had blank care plan agreement forms. One file identified that the person used a hearing aid but there was no additional information to direct staff about communication and if the person always chose to use the hearing aid. Another care plan identified that staff must assist a person, for certain daily care needs. Two staff would be required to use a hoist but the file contained no risk assessment for such action. Sheets for care plans had been photo copied so many times that the directions and information copied could not actually be read. Staff had drawn in lines to allow them to enter daily records. Daily recording on care plans consisted mainly of observations about bodily functions and washing and eating. For instance one care plan stated passed urine, washed, creamed skin, bed changed and made comfortable. There was very little about the person, their mood or what conversation, if any, had been undertaken with staff. There is a list of those people due to have a bath and the date this will be undertaken on display in the corridor. The manager explained that relatives read this board and check if their relative has had a bath. However, the dignity of the individual and the fact that this is part of the provision of personal care was discussed with the manager. Discussions with staff did evidence that they have a sound knowledge of the needs of individuals in the home, but records do not reflect the level of care being provided. The medication trolley was found fixed to the wall and locked at this inspection. Records of the administration of medication were clearly completed, up to date and medication was in date and stored in an orderly way. However, when auditing the medication it was noted that an audit trail is not in place for pain relief. As an example, the box of tablets are not dated when opened and there is no ongoing amount for the tablets themselves. Staff do record who has taken pain relief and when but just how many tablets should remain in the box in not noted. The manager said that the deputy manager deals with medication but there was no evidence of any spot audits on medication or observations of staff practises being undertaken by either the manager or the deputy manager. Discussions were also undertaken regarding the routines in the home, as the medical room has the door propped open when it is not being used by staff. With access to confidential information and the need for security, this practise must be reviewed to Care Homes for Older People Page 13 of 28 Evidence: make sure medication is stored safely in line with current legislation. Keys are kept in a locked key cabinet and the main key to this cabinet has limited access for safety. Again, the security of this cabinet is not being protected by the current procedures and accepted standards in the home. Care Homes for Older People Page 14 of 28 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to take part in a range of leisure activities, to maintain contact with family and friends and are offered a variety of meals that they have chosen. Evidence: The home undertakes regular events that relatives and friends are invited to for instance there has previously been summer fetes, a garden party was held this year as well as a car boot sale. Family and friends are invited to celebrations and support the home a great deal. Entertainment includes outings with local organisations, trips to the beach and bingo sessions with prizes. There is a monthly music entertainer who visits the home and residents join in with the singing. The lunch that was served at this inspection looked and smelt appetising. There is a choice of two sittings and those needing assistance were treated appropriately and were unhurried at this time. Staff explained that residents have as much time as they need and can have any food they ask for at any time. This was also confirmed by staff in the kitchen who said they try to get whatever they are asked to get. Residents also said they felt they had a choice of foods and that meals were mainly good. There are Care Homes for Older People Page 15 of 28 Evidence: some staff who have worked in the home for some time and who know what each person prefers and how they like their food. Portion sizes differ as each person has their own preference about how meals are set out and just how much they would like. Staff explained that residents enjoy their meal times and have a good chat among themselves and with staff. The kitchen was clean and tidy at this inspection and staff said that choices are made daily about meals and there is always a hot option at the evening mealtime. Special diets for diabetics are also catered for. One person who was eating in their room stated that Food is always good and I enjoy it, another person said I could not eat all my dinner as the gravy was too thick. When asked if they had asked for thinner gravy this person said I do not want to be a trouble. Another resident said that meals always had lots of gravy on the plate. There is an activities room that is spacious and has comfortable chairs as well as a table and chairs for undertaking activities. Halloween was being planned and quizes were also being arranged for residents. The room is large, bright and provides a comfortable area for activities and general socialising. This room is also used when the home has people from the local theatre visiting. The home currently has 12 days booked for entertainment in December this year. There is a clear record of what activities are undertaken by which residents and these inform the development of any further programme of activities. The manager said that regular meetings with residents had been changed to more one to one discussions as previous meetings had not been very successful. However, group meetings will be tried again in the near future. Care Homes for Older People Page 16 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents know who to complain to and feel they will be taken seriously, however, full information must be provided to support any person wishing to make a formal complaint. Evidence: While previous inspection and records do show that complaints are dealt with appropriately, the home has not amended the contact details for the Commission. This was a previous requirement and these details and contact details for the local authority must be made available in the home. Residents said that they do know who to speak to and feel they will be listened to. However, two residents did point out that the stained carpets have been mentioned to staff and to date, no action has been taken to improve this. Staff were aware of abuse and how to interact with residents. Staff in all areas of the home expressed concerns for the well being of residents and said that they have no problem with speaking out if they felt anyone was behaving inappropriately. Care Homes for Older People Page 17 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does provide a clean environment, however, communal areas and carpets do not meet with current standards and pose a risk to people. Evidence: The home welcomes all visitors and some people were relaxing in the lounge area while others were in their rooms. It was clear from speaking to residents that they move about the home freely and some have developed friendships. During the afternoon, some people were having their hair done by the hairdresser. There are two lounge areas and the activity room for socialising. There are also plans to add a conservatory onto the ground floor lounge area to provide a private space for visitors when needed and a further choice for residents to relax. The ground floor lounge area has a very marked and stained carpet and the carpet on the first floor and on the stairs is also badly stained. The carpet on the first floor corridor area is also badly worn and frayed in places, causing a risk to the well being of residents. As previously stated, this matter has been raised by certain residents who feel this is spoiling their home. The dining room tables and chairs are also very worn and look shabby. This was Care Homes for Older People Page 18 of 28 Evidence: discussed at this time with the manager who explained that the environment is being reviewed and new dining chairs are currently on order. One room on the first floor also had a badly stained carpet with an old bed that was frayed, as was the armchair in this room. Though beds had been made and sheets were clean, the lower part of the divan bed did not have a cover and as these were found to be very worn and frayed, the room did not look comfortable and homely. Due to the demand for cold water during the hot months of the year, the home now has cold water dispensers on all floors. Residents said this is particularly nice for them and they are enjoying being able to get their own water. Care Homes for Older People Page 19 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent 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 good 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 have their needs met by a consistent staff team who are trained and supervised, providing stability and continuity of care. Evidence: The staff in the home at the time of this inspection consisted of one activities coordinator who works full time, six care staff, one person who undertakes general duties where needed, one deputy, three housekeepers, one cook, one kitchen assistant and the manager. The maintenance person was on annual leave at this time. Staff have regular training and they explained that this has consisted of hearing and sight loss, risk assessment training and all core training is regularly refreshed. Training undertaken includes moving and handling, fire safety, protection of vulnerable adults (POVA), basic food hygiene and refresher information regarding handling and dispensing medication. The manager explained that staff are spot checked when administering medication but there was no evidence to support this. One member of staff who administers medication stated that she had not been observed at any time since their first medication training. There are regular staff meetings and supervision is formally undertaken with notes being sealed and dated on staff files. However, one member of staff stated they had Care Homes for Older People Page 20 of 28 Evidence: not had formal supervision during the last 18 months Discussions were undertaken regarding dementia training as staff have not had any in depth training in this subject. One member of staff said that they and other staff had brought up the need for training in certain areas but that this is usually discussed but then no further action is taken. All relevant daily events are discussed between staff at the change over of shifts and noted in the handover book for reference. Staff were observed while undertaking staff handover and discussions were respectful and thorough, with staff asking questions to make sure they had all the appropriate information to support residents. During discussions at this time, staff expressed a thorough knowledge of residents and their needs. We looked at two staff files at this inspection and both contained all required documentation in line with appropriate recruitment practices. Care Homes for Older People Page 21 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home that is, in the main, run in their best interests but all practises must fully support the health and safety of both residents and staff. Evidence: The manager is available to speak to people when they wish and this was confirmed through discussions with staff and residents carried out at this time. Questionnaires are sent out yearly to obtain opinions regarding the quality of care in the home. The manager stated that professional visitors have not been surveyed to date but that this will be considered in the future. While the proprietor does visit the home, there are no quality assessment reports completed. These are required under regulation 26 of the National Minimum Standards. Such assessments show that the provider regularly monitors the quality of services delivered inside the home and also the quality of the environment both inside Care Homes for Older People Page 22 of 28 Evidence: and outside of the building. Testing regarding fire alarms was up to date, servicing records were also up to date as was the testing of all electrical equipment in the home. Care Homes for Older People Page 23 of 28 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 7 15 The registered persons must 31/01/2008 ensure that a service user plan is in place for all service users. Care plans must be developed in compliance with Schedule 3 of the Care Homes Regulations 2001. This requirement has been carried forward, and must now be complied with to avoid further legal action being taken. 2 18 13(6) The registered persons must 31/01/2008 ensure all staff receive training about abuse awareness and are fully conversant with the homes policies and procedures in this regard. 3 37 26 The registered provider must 13/02/2008 ensure that visits to the home are made monthly and that a copy of the visit report is sent to the Commission. This requirement has been carried forward, and must now be complied with to avoid further legal action being taken. Care Homes for Older People Page 24 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The care, health and social needs of people must be written into individual care plans. An agreed care plan to be signed by the resident and/or a representative. To fully inform staff how to meet the needs of the individual and deliver care and support appropriately. 18/12/2008 2 8 13 The safety and welfare of 18/12/2008 people must be safeguarded by full risk assessments being developed and these must contain clear directions as to how any risk can be minimised. Particularly with regard to direct support and care being provided by staff. 3 9 13 The registered person shall 28/11/2008 make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal Page 25 of 28 Care Homes for Older People of medicines received into the care home. Medication to be safely handled, stored and audited to support the health and welfare of residents and meet current guidelines and legislation. 4 10 12 The registered person shall 28/11/2008 make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. Particularly with regard to private and personal details of care. 5 16 22 The registered person shall supply a written copy of the complaints procedure to every service user that includes the contact details of the Commission. That this information is available in the home to support any person wishing to make a complaint. 6 19 23 The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. To meet the collective and individual needs of residents in a comfortable and homely way in line with relevant guidance. 26/12/2008 28/11/2008 Care Homes for Older People Page 26 of 28 7 19 13 The registered person shall 28/11/2008 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. An environmental risk assessment to be completed to support the health and safety of all persons in the home. 8 38 26 Where the registered 26/12/2008 provider is an individual, but not in day to day charge of the care home, he shall visit the care home in accordance with this regulation. The person carrying out the visit shall inspect the premises, records and complaints and prepare a written report on the conduct of the home. This is to ensure standards in the home are meeting with regulations and a copy of this report is to be available for inspection by the Commission. 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 12 That all activities are detailed in individual care plans to support the care provided and inform any changes in the care plan. Care Homes for Older People Page 27 of 28 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 28 of 28 - 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. 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