Inspection on 09/12/08 for Pirton Grange Nursing Home

This inspection was carried out on 9th December 2008.

CSCI 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 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pirton Grange Nursing Home 24/09/09

Pirton Grange Nursing Home 04/06/09

Pirton Grange Nursing Home 17/04/08

Pirton Grange Nursing Home 12/09/07

Pirton Grange Nursing Home 20/09/06

Pirton Grange Nursing Home 19/01/06

Pirton Grange Nursing Home 15/07/05

Pirton Grange Nursing Home 30/09/04

Pirton Grange Nursing Home 14/04/04

Similar services:

Larches, The

Sunnycroft

Willowdene Farm

Grindley House Care Home

Highbury House Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Pirton Grange Nursing Home The Grange Pirton Grange Nursing Home Pirton Wadborough Worcestershire WR8 9EF     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: Christine Potter     Date: 1 8 1 2 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 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 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.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 41 Information about the care home Name of care home: Address: Pirton Grange Nursing Home Pirton Grange Nursing Home The Grange Pirton Wadborough Worcestershire WR8 9EF 01905821544 01905821257 admin@pirtongrange.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) : Pirton Grange Limited care home 58 Number of places (if applicable): Under 65 Over 65 0 0 0 0 past or present alcohol dependence past or present drug dependence dementia mental disorder, excluding learning disability or dementia Additional conditions: 58 58 58 58 The maximum number of service users to be accommodated is 58. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 58 Mental Disorder, excluding leaning disability or demetia (MD) 58 Past or present drug dependent (D) 58 Past or present alcohol dependent (A) 58 Date of last inspection Brief description of the care home Pirton Grange has extended the home and provided a purpose built unit referred to as Orchard Way. The existing home is a heritage listed building and is in the process of being modernised and upgraded. Pirton Grange is situated near the village of Pirton in Care Homes for Adults (18-65 years) Page 4 of 41 Brief description of the care home beautiful countryside south of Worcestershire. The home is two storeys with a lift to assist people with mobility problems to mobilise throughout the home. In Orchard Way all people are accommodated in single en - suite bedrooms which are specially equipped for their use. In addition to the bedrooms the home provides lounges, dining room, and specialist bathing facilities. The spacious landscaped gardens are accessible for people to use and provide a pleasant outlook from the home. The home provides 24-hour nursing care for people under the age of 65 years. There assessed health needs include Huntingdons Disease, Acquired Brain Injuries and other physical and mental health problems. People can be accommodated on long term and short term placements. Information regarding the home can be obtained from the Statement of Purpose and the Service Users Guide, which are available in the home. The European Care Group who owns other homes throughout the country owns the home. The home is without a registered manager at the moment, cover is being provided by a senior manager from the organisation. Information about the fees are not included in the Service User Guide, for up to date information about the fees please contact the home direct as the fees are based on individual needs and assessments. Additional charges are made for cigarettes and holidays abroad. Care Homes for Adults (18-65 years) 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 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 last Key inspection of Pirton Grange nursing home was 18th May 2008 and the home was given a quality rating of adequate. A Key inspection is where we look at a wide range of areas. This unannounced Key inspection started on the 9th, 12th, 15th and 18th of December 2008 by two inspectors and the pharmacy inspector. A random inspection was carried out 14th August 2008 to focus on the homes recruitment procedure. The inspection was brought forward following a series of allegations and complaints which were reported to us. As a result of some of these allegations the provider suspended the registered manager pending the outcome of their investigation. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers Care Homes for Adults (18-65 years) Page 6 of 41 the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home. Usually before a key inspection we request a Annual Quality Assurance Assessment (AQAA), however given the inspection was brought forward we used the information from the Key inspection in September 2007. The AQAA is a document where by the providers has the opportunity to share their developments and plans for the next 12 months. Information was gathered from speaking to and observing people who lived at the home. Eight people were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. The people who live at the home, the deputy manager and the staff were spoken to. Some people living there were unable to verbally communicate their views about the home due to their communication needs. Time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. Serious shortfalls were evident on the days of the inspections and an immediate requirement notice was issued on the poor management and administration of medication, fire safety and the home failing to report significant incidents and or accidents to us as is required under regulation 37 of the care homes regulations 2001. Information was seized using code b to evidence the non-compliance with the national minimum standards. Following the concerns and the additional information shared with us by the provider the home was referred to the safeguarding team. This is a multi agency team of professionals who decide how to ensure that the people using the service are being protected. What the care home does well: What has improved since the last inspection? What they could do better: As a result of this inspection immediate requirement notices were issued: Management and administration of medication which could affect the health and well being of people living in the home. Fire safety the service had failed to test the fire alarm system since July 2008 when the maintenance person left. This places people living at the home and staff working there at potential risk. The service failed to notify us of significant events required under regulation 37. Given the high degree of vulnerable people in the home by failing to advise appropriate authorities may affect the health and well being of the people living there. Failure for the home to comply with these immediate requirements could result in the CSCI taking legal action against the home. Other issues to be reviewed: By the home not assessing people thoroughly prior to admission may place people living in the home at risk, and the home failing to meet the health and psychological needs of the individual. Person centred plans should be reflective of the individuals health, psychological and personal care needs and show how people are being supported to achieve their goals. This will ensure that people are getting the support they need to do the things they want to do. By not ensuring that all staff working at the home have the knowledge, skills and competences can compromise the care which people receive, this requirement remains outstanding from the last inspection. By not following the recruitment procedure may place vulnerable people at potential risk. The home was issued with an immediate requirement notice following the Random Care Homes for Adults (18-65 years) Page 8 of 41 inspection in August 2008. We received an action plan from Pirton Grange advising that they were adhering to the recruitment procedure and employing additional administration staff to review and update all the staff files. The management of complaints needs to be reviewed to ensure that people using the service feel that they are being listened to. To assist in monitoring peoples health, and protecting the vulnerable the home should ensure that all staff are trained in reporting accidents and incidents and refer to the appropriate authorities when necessary. All potential risks to people using the service should be minimised including the gas cylinders in the grounds and on the fire escape, some of the furniture in the bedrooms in the older building was hazardous for the people living there. Some more work should be done to make sure that the original home is safe, homely and comfortable to live in. The activities are not suited for all the people living at the home, so the people with more complex needs are not having access to activities for their needs. A system for ensuring that messages and any change in the individuals care is communicated effectively to all staff so that individuals care is not compromised. All staff should receive training in the peoples health needs so they know how this affects the people living there so they can support them effectively. By not listening to people who use the service through audits you are ignoring the individuals choices and preferences in the running of the home. 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 9 of 41 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 10 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, 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. People do not have sufficient information about the home to enable them to make an informed decision about whether they would like to live there. Peoples needs are not fully assessed to ensure that the home can meet their assessed needs prior to moving into the home. Evidence: Six peoples care records were reviewed which showed that prior to admission the person had a care needs assessment completed by a registered nurse. The assessment determines that the home has sufficiently skilled and competent staff and equipment to meet individuals assessed physical and psychological healthcare needs. The assessment also provides information to confirm that the individual will be safe, and will fit in with the other people living in the home. From discussion with the nurses and relatives, we were advised that, for some people living in the home, staff were not appropriately skilled in meeting peoples needs. The nurses provided us with details of the people that they felt were not suitable for the Care Homes for Adults (18-65 years) Page 11 of 41 Evidence: home. An example shared with us concerned one person who had been assessed by a nurse for possible admission, they considered them unsuitable for the home. The manager had then overridden the initial assessment and chose to admit the person into the home. This resulted in the individual trying to run away from the home. Various incidents had been reported about the person being aggressive towards other people living in the home and assaulting staff. Appropriate risk assessments had not been put into place to assist the staff in meeting the individuals physiological and physical healthcare needs. For example, a person with a past history of attempting suicide, had no risk assessment or protocol developed to provide guidance and directives for the staff. A second persons pre admission assessment stated that the individual was very anxious. No care plan had been developed to assist the staff in how to reduce this persons anxieties. A young person admitted to the home had no plan of care in place detailing how staff would meet the persons psychological needs and provide support that was appropriate for their age. Nurses reported that the manager doesnt listen to their opinions, and this has resulted in additional pressure for all staff. The manager had failed to consider if the staff had (a) the skills and (b) sufficient knowledge and understanding to meet the complex physical and psychological health needs of individuals. It would appear that the manager had also failed to consider how the person being admitted would fit in to the care environment, and with the people who were already living at the home. We were told by a relative that their choice of home had been limited due to the complex needs of their relative, and informed us that they had issues with the home not meeting the service offered prior to admission.. From reviewing complaints, people were disappointed with the level of care and facilities available at the home given its description as a specialised home. The Statement of Purpose and Service Users Guide were not available in the home at this inspection. We were told that copies were held on the computer. From information received through complaints, people were not provided with sufficient information about the home in suitable formats to assist them with their choice. Care Homes for Adults (18-65 years) Page 12 of 41 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. Care plans do not provide sufficient information for the staff to enable people to meet individual needs. Evidence: It was recommended at the last Key Inspection that the home should improve the quality of the care records, and provide a person-centred record for individuals. However, on reviewing the care records for six people at this inspection, there had been further deterioration in the quality of the care documentation. A care plan should provide a clear record of the individuals assessed needs, which includes their preferences on how their care needs should be met, what the person is able to do independently and what assistance is required from staff in order for the person to maintain their needs. Failing to maintain an accurate assessment and care plan may result in the individuals care needs not being met. The care records were in an A4 ring binder with lots of old papers. There was no order Care Homes for Adults (18-65 years) Page 13 of 41 Evidence: to the files with bits of old records stored in different places that made the review of the care plans difficult to follow. For example, a wheelchair maintenance check form was stored amongst the care plans. A care plan for a person with a pressure sore provided little guidance for the nurses on how to treat the wound. The care plan detailed how the person required two-hourly turns, and needed to sit in a chair for two hours each day. However, there was no record in place to prove that this was being completed. Staff told us that they were unsure if this was being done every two hours. The person was also on a fluid balance chart that was not being filled in accurately by the staff. On the 8th of December no entry was recorded and for another two days only two entries in the 24-hour day had been made. A carer told us that no one checked if the fluid balance charts had been completed. Staff had recorded on the medication administration chart for a person with diabetes controlled by insulin, that they were refusing their prescribed insulin. The care plan failed to provide clear guidance for the staff to follow when this happened. We asked a nurse how this persons blood glucose levels were being monitored, and we were told that they were not monitoring the blood glucose levels. The service had also failed to notify the persons GP that they were refusing the insulin. This places the persons health at risk and an immediate requirement notice was issued to safeguard and protect the individuals health, safety and wellbeing. We were subsequently advised by the home that the issue had been resolved within the timescale given. One persons care plan showed that they had lost six kilograms in weight between August and November 2008. The nutritional risk assessment had not been updated, and their body mass (a calculation tool that establishes whether a person is underweight, overweight etc.) had not been calculated. The person had previously suffered with an eating disorder, which the home had not risk assessed or developed into a plan of care to guide the staff. By failing to investigate the persons weight loss may place them at potential risk of being underweight and the associated health risks from this. Several incidents had been reported where a person living at the home was physically and verbally attacking staff and other people living at the home. Staff told us that this person was challenging. The care plan for this person failed to provide clear directions for the staff to follow when they became agitated. The service failed to report these incidents to appropriate authorities including the local authority safeguarding team, which could place vulnerable people at risk of being injured. An entry on a persons daily record clearly stated that only female staff should deliver Care Homes for Adults (18-65 years) Page 14 of 41 Evidence: this persons care. This had not been included in the care plan. Nurses and carers told us that they were not aware of this instruction or the reason why. Nurses and carers told us that communication between the staff was poor, and not all information regarding changes in peoples needs was being passed on to them. Staff told us that they felt intimidated by certain staff, and felt that they were not listened to. Staff told us that they did not feel that they were appropriately trained to meet the health needs of all the people in the home, especially the ones with challenging behaviour. Some of the comments received from staff and relatives: Concerned about the safety of some of the people living here especially those with more complex needs. Confidentiality procedures are poor. Some staff are very willing. Better now they have moved into the new building. We are not meeting our aims and objectives we are too rushed. On the last AQAA the service stated that it was their intention to develop more structured risk assessments before people moved in. The findings from this inspection prove that the home has not actioned this. Peoples risk assessments were brief or not in place, and failed to guide staff in minimising individuals potential risks. For example a person assessed at risk of choking had no risk assessment developed, and mental health assessments had not been completed for people living at the home. We were told by staff that some staff failed to follow guidance for minimising potential risks, and felt that this compromised the safety of some people living at the home. For example, staff were leaving objects within easy reach of one person who is at risk of putting objects in their mouth and choking. We saw people walking around the home and in the grounds. Many people were inappropriately dressed for the cold weather. One person was wearing only a tee-shirt with shorts. We saw little interaction between the staff and people living at the home. Some staff were overheard swearing in an area where people living at the home would use. Care Homes for Adults (18-65 years) Page 15 of 41 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. Activities are not meeting the needs of all the people living at the home so that they dont experience a meaningful lifestyle. Evidence: The home employs dedicated staff responsible for social, recreational, occupational, educational and leisure activities. However, during the days of our visits we saw little evidence of meaningful activities suitable for all the individuals living there. We saw people sitting in the lounges with the televisions on and some people were in their bedrooms with no stimulation. Several people were seen outside the front entrance of the home smoking. We were told by the staff that activities include music, bingo, body and soul, shopping trips, and some people go home for the day or weekend stays. The home provides a varied program of activities for some people, but for people with Care Homes for Adults (18-65 years) Page 16 of 41 Evidence: more complex or challenging needs there was a lack of social intervention appropriate for their age, aspirations or capabilities. A younger person was observed pacing up and down the corridors playing loud music that was disturbing the other people in that area. A person at the last inspection in May told us that they were waiting to have their computer sorted. We were told that this still had not been sorted out for them. One person told us that they would like to go out more. Staff told us that individuals preferences were not being met due to the staffing levels, and this meant poor outcomes for some of the people living in the home. One example given was that some people are getting up late, (sometimes after lunch) and this is not the individuals choice. A relative told us that the activities were good if you were mobile, but were not suitable for the people with advanced Huntingtons disease. Another relative told us that they made additional payments for individual activity sessions that they felt were beneficial for their next-of-kin. We observed the meals being served during one day of our visit. The choice for lunch was either fish and chips or faggots. The meal appeared appetising, and staff were assisting people respectfully with their food. Comments were positive about the quality of the food. Some concerns have been reported that the home fails to consistently follow individual preferences, and fail to understand the need for a softened diet. We asked how the home monitors the dietary needs of people - especially those with Huntingtons disease. We were told that some people are on a food chart, but when these were checked they were not always completed. People who are able were seen helping themselves to drinks in the kitchenette area. It was difficult to access if the people with more complex needs were having adequate fluids, because fluid balance charts were either missing or not completed for the people we checked. We saw visitors coming and going throughout the days of our visits. One person was being accompanied by the staff on a home visit. Staff told us that they encourage visitors, and they are welcomed into the home at anytime. The home provides little in the way of meeting individuals religious beliefs that means that unless the person is able to go to their place of worship, they are restricted in following their faith. Care Homes for Adults (18-65 years) Page 17 of 41 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. By not administering prescribed medication as directed, peoples health and well being may be compromised. Evidence: Serious concerns were identified with the administration of prescribed medication to people using the service. On the first day of the inspection an immediate requirement notice was issued to safeguard peoples health, safety and wellbeing. Following this visit the pharmacy inspector visited to review the medication system and concluded that the immediate requirement had not been complied with. Nine peoples medicines were looked at together with their medicine charts and care plans. Two nurses were spoken with and all feedback was given to the acting and deputy manager. The medicine management was very poor and in some instances dangerous. Storage of medication was poor. Three medication trolleys were in use, one containing the bulk of medicines for one unit and the remaining two trolleys had medication split Care Homes for Adults (18-65 years) Page 18 of 41 Evidence: depending on the time of the medication round. Concern was raised that this may lead to errors, as one box of medicine prescribed to be administered at two different times can only be stored in one trolley - thereby increasing the risk of the medicine being administered incorrectly. One medicine was missing and, following a review of the daily records and care plans, evidence was seen that nurses had administered one medicine prescribed for one resident to another. This is bad practice and breaches the nurses code of professional conduct and standards for the safe administration of medicines. All medication remains the property of the person they are prescribed to. The medicines were not kept in a clear order in the trolley and the nursing staff had to hunt for each medicine to administer. This may lead to medicines not being administered simply because they cannot find them. Inadequate checking procedures were seen in the home. Whilst the prescriptions were photocopied, there was no evidence that; (a) the original prescription had been checked for accuracy and (b) the photocopy used to check the dispensed medication received into the home. In addition, not all copies of prescriptions were available to check the medicines against. The dose for one medicine was recorded on the medicine chart to be administered daily, but it had been recorded as administered twice a day. The label on the medicine bottle recorded a twice daily dosage. It could not be demonstrated exactly which dose was correct. Other homely remedies had been purchased. Their administration had not been recorded on the medicine chart and again there was no supporting protocol detailing their use. Nursing staff spoken with had a limited knowledge of correct systems to use to handle medicines safely, and also failed to understand what all of the medicines were prescribed for. Without such clinical knowledge, the nursing staff are unable to fully support the clinical needs of the people in the home. One nurse on duty did not know why three medicines had been prescribed - even though all caused sedation and were all administered after 6pm. She said the reason they had been prescribed was The resident says her name all the time and wanders. This is a very poor and worrying explanation why the particular medicines had been prescribed and subsequently administered. The care plans were inconclusive but one entry stated gets louder, requires one to one and has got worse over the past two weeks and the GP has recommended diazepam (a calming medication), with a full review in two weeks time. No review had been documented as taking place. This medication had not been administered as prescribed and nursing staff had recorded administering four tablets when they had not. The care plans also recorded that staff were to look for triggers for her challenging behaviour but did not record what these were or how to react to them. Care plans were not specific and would not help all staff look after and fully support Care Homes for Adults (18-65 years) Page 19 of 41 Evidence: people using the service. Another medicine prescribed for constipation had not been administered because the resident suffered from loose stools but a different laxative was still given. Again the nursing staff are not applying basic knowledge of the medicines they handle. Medicines had been recorded as administered when they had not been. Some were unaccounted for. This was a particular concern as some are used to aid sleep. Gaps were seen and it could not be demonstrated in some instances why a particular medicine had not been administered. Others had been administered but not recorded as such. The process of preparing medicines for administration and accurately recording what the nurses have done had not been followed in accordance with the nurses professional ethics and standards. Some medicines had been recorded on the medicine chart but none were available on the premise to administer. Others had been prescribed but not recorded on the medicine chart. Medicines prescribed to be administered in life threatening conditions, for example, an epileptic fit, had supporting protocols but there were incomplete records so it could not be demonstrated when they had been administered in all instances. Other medicines prescribed, for example to calm a resident if very anxious or aggressive, had no supporting protocols. Without such clear guidelines to follow or any outcome recorded when administered, full clinical support cannot be given. Medicines had been stored incorrectly. One nutritional supplement was not kept in the refrigerator once opened and not dated once opened. The refrigerator temperature was -9 degrees Celsius with a range of -8 degrees to -9 degrees Celsius. No action had been taken regarding this very low temperature to confirm the thermometer was accurate. It was not possible to confirm the exact temperature of the refrigerator. This would affect the stability of the medicines stored within, which may be detrimental to the resident when administered. Sharing of peoples medicines and nutritional supplements was common, and records did not exist for some administration. Some people suffered from weight loss but it was not possible to track exactly their diet or whether they had been administered the supplements as prescribed. One person had been prescribed a strong pain-relieving patch - not for pain but to relieve agitation and distress. We, the commission, were assured that the dose had been reduced but this caused an increase agitation, so subsequently increased. No thought was given that the person may have been suffering from withdrawal symptoms from the medicines. The care plans gave no indication as to the original reason why it had been prescribed, or any dose changes and an inappropriate reason why it had been continued to be prescribed. Nursing staff did not appear to know the Care Homes for Adults (18-65 years) Page 20 of 41 Evidence: clinical reasons why this medicine should be prescribed, neither did they challenge when it had been prescribed outside its product licence. Many people are prescribed medicines to be administered via a PEG tube due to swallowing difficulties. Care plans were inadequate and did not give enough details about how the medicines should be given or whether they were suitable to be administered via this route. There was no medical information on site for nursing staff to check individual medicines. Most tablets prescribed were crushed and administered. Alternative formulations to aid administration had not been explored. One person had swallowing difficulties and could not bite of chew and was at risk of choking but was administered very large tablets and capsules. These were crushed and put in her food. This is poor practice. An alternative formulation had not been sought. Staff signed that they had administered vitamins to one person, but there were four different unknown tablets/capsules in an unlabelled dosette box. The care plans did not record that these additional medicines had been checked for any drug interactions with the prescribed medication and nurses had not accurately recorded what they had administered. The home had vast quantities of prescribed medication on the premise. Some dated back many months. The ordering of new medicines was poor, as no account had been taken of these excess stocks on the premise. In addition there was no recognition as to why there was so much medicines left at the end of a 28-day cycle when only 28 days supply had been prescribed at any one time. A box of influenza vaccines was found in the refrigerator. These had not been administered to people in line with current guidelines. The nurse said that they had no anaphylactic medication, which must be available before any vaccines are administered in case somebody goes into shock. This had not been sought, so the vaccines remained unused. The home had three cabinets used to store controlled drugs. These did not comply with the Misuse of Drugs (safe custody) Regulations 1973. In addition, an envelope of money was found in one cabinet. All controlled drug cabinets must be reserved for the storage of controlled drugs to limit reasons for access. In one persons bedroom a pot of cream was found in use with no date of opening which could result in cross infection from the cream being contaminated. A nurse told us that it was several nurses responsible for the medication errors, and Care Homes for Adults (18-65 years) Page 21 of 41 Evidence: the system was not being audited effectively. They stated that the main issue was with the night staff. We were told by a nurse that, generally, the competencies of the nurses was poor. It was reported that the manager had been aware of the issues, but had failed to address the shortfalls. Following this inspection an immediate requirement was left for staff to ensure that all medicines are given as prescribed and records reflect practice on the 15th December 2008. This had not been met by the 16th December 2008 as the medicine charts had not been checked against the copies of the prescriptions. We were assured that this would be done by the close of the 16th December 2008. Failing to comply with the immediate requirement notice may result in the CSCI taking enforcement action against the service. When we checked, the home had subsequently complied with this requirement. Care Homes for Adults (18-65 years) Page 22 of 41 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. People are not always confident that their views are being listened to and acted upon. Lack of staff training and awareness does not ensure that people are fully safeguarded from harm. Evidence: Following the last Key Inspection in May 2008 there have been a number of adult protection issues and complaints raised. Several were from a former employee who raised allegations about certain members of staff. The outcome of many of these allegations is not yet known as the police are the lead investigators, and their investigation is not yet complete. The home is under the scrutiny of multi-agency safeguarding authorities and the commissioners that fund placements for the people receiving care in the home. The complaints received are similar to previous ones received, and include concerns about the poor environmental standard of the original building, poor communication between the staff (messages not being passed on), staff not being aware of various changes to a persons condition and the behaviour of people which causes disruption for others using the service. In addition to the known complaints and safeguarding referrals, the area manager found numerous incidents recorded as an accident that should have been referred to Care Homes for Adults (18-65 years) Page 23 of 41 Evidence: the multi-agency safeguarding team used to investigate concerns raised. The home had also failed to notify the CSCI of these incidents that they are required to do under Regulation 37 of The Care Homes Regulations 2001. This is a way in which we monitor the home, and peoples health and well being living in care homes. On the 9th December 2008, the area manager advised us that as a result of their findings, they would voluntarily suspend admissions to the home whilst investigating the issues. We were told that the complaints register had disappeared therefore we were unable to determine if the home were adhering to their complaints procedure. An immediate requirement notice was issued for the home to start recording complaints and adhere to their complaints policy. We were told by relatives and staff that they did not feel that their complaints were listened to, an example being the poor communication. Staff felt that they were not updated with changes in a persons health, and relatives felt that their information was not passed on to staff delivering the care. The service has failed to follow the local multi agency guidelines, and staff working at the home have failed to use the whistle blowing policy which places vulnerable people at risk. This was also reported at the last key inspection in May 2008. To ensure that all people living in the home are protected all staff should be aware of the procedure and their accountability to whistle blow i.e. alert other agencies when they have concerns. Care Homes for Adults (18-65 years) Page 24 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, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. By failing to maintain all areas of the home where people live effectively, health and safety problems may occur that could affect the well-being of people using the service. Evidence: We were advised at the last Key Inspection in May 2008 that on completion of the new building all the people would be transferred to the new building and the original home was to be upgraded and refurbished throughout. This would provide a more suitable environment suited to the people using the service. However, this did not happen. We were told that eleven people had remained in the original home. They were going to the new building during the day and returning to sleep in their rooms at night. This is of concern given the poor standard the environment is in. The bedrooms were in poor decorative order. There was a lack of privacy for people in the shared rooms and there were inadequate furnishings. We requested that a badly stained mattress was changed during our visit as people should expect to have a clean bed to sleep on. The home was dirty and odorous with poor lighting throughout. The workmen were working upstairs and we were told that they do not access areas where people are being accommodated. However staff told us that they were accessing these areas. No risk assessment had been developed whilst this work was being carried out. The area manager advised that the health and safety representative from the company was Care Homes for Adults (18-65 years) Page 25 of 41 Evidence: visiting the home tomorrow to deal with these safety aspects. The new unit was completed in May 2008, and is purpose built. Each floor consists of two units, which have a communal area, a dining area and a kitchenette area where refreshments can be made. However when we looked round, we found these areas to be dirty, with uncovered bowls of sugar, broken drawers, and lots of drink spillages. It had been suggested that, when the unit was registered, clear signage and colour themes should be used to help people find their way around the home. This had not been done. The corridors are wide and spacious and allow people in wheelchairs to move around the home freely. Some of the bedrooms have fitted ceiling hoists which help the more disabled people to be transferred in and out of bed. A good range of equipment was seen in use. One relative told us that they had purchased their own chair and mattress to be used in the home. The home has specialist baths and showers so that people can have the choice of either a bath or shower. The bedrooms seen were clinical, and showed little reflection of the person using the room. Parts of the home were dirty especially the baths, and the home was cluttered with equipment. The grounds are well laid out providing a nice area for the people to use when the weather permits. Lots of rubbish was observed in the grounds including a gas cylinder all of which was easily accessible for mobile people. Staff told us that they were pleased with the new environment and felt that it was meeting the needs of people living there. Care Homes for Adults (18-65 years) Page 26 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, 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. The recruitment procedure does not ensure that people are safeguarded from harm. Some staff training is required to ensure that they have the knowledge and skills to meet peoples needs effectively. Evidence: Following the last Key Inspection in May 2008 where we advised the service to follow their recruitment procedure to assist in protecting people living there. In August 2008 we received an allegation was made that the home had recruited staff and not followed their procedure. A random inspection was completed to check staff recruitment. As a result an immediate requirement notice was issued. We received confirmation and an action plan stating that the home had complied with this requirement and staff had been suspended whilst awaiting their criminal records bureau (CRB) clearance. However during this visit it was evident that the home had failed to recruit staff safely. We looked at four staff files and these showed that for one person, a reference had not been requested from the applicants most recent employer. The four people had commenced without a criminal records check or POVA first check. The two nurses files showed that the home failed to verify the qualification with the Nursing and Midwifery Council (NMC). We asked for additional information to ensure that the home had verified the nurses registration with the NMC, and this had not been completed for any Care Homes for Adults (18-65 years) Page 27 of 41 Evidence: of the nurses working at the home. When the area manager was advised of this he contacted their head office to verify all the nurses registration who were working at the home. One persons file showed that they had a criminal record however the home had failed to develop a risk assessment. Evidence was taken from the home using a code b notice (under The Police and Criminal Evidence Act 1984) which may later be used if enforcement action is taken. We were concerned about the staff competency and skill mix in meeting the health and welfare needs of the people living there. Given the medical conditions of the people living there, a nurse with a psychiatric qualification should be on duty throughout the 24- hour period. On two visits to the home, no psychiatric nurse was on duty. We were also concerned that given the home specialises in the care of people with Huntingtons disease no staff have attended formal training about this condition. This was a requirement at the last key inspection in May 2008. On reviewing the incomplete training records, and from discussions with staff, there was a shortfall in training provided for both carers and nurses. Some staff had received no training in the last twelve months. We have received concerns from other health care professionals and relatives specifically about the management of people living at Pirton Grange with Huntingtons disease. Training records showed that staff had not received basic training (for example in moving and handling, these were last dated May 2007). Staff told us that they had not attended abuse training; fire training and the nurses had not attended clinical updates. Staff comments included: Poor protocols in place, we are not meeting our aims and objectives and all the staff are hardworking. Staff told us that moral is low at the moment, and they feel that they are not being told what is going on. Two nurses were working their resignations and told us this was because of the poor management and general lack of organisation. One nurse stated that they did not wish to risk their nursing registration by working at the home any longer. In response to some of these issues the company have made a senior nurse responsible for training and assessing all the staffs training needs. They are also completing induction training for the staff who have worked at the home for a long period to try and improve overall quality of care being delivered. On discussing staffing levels with the staff we were told that the predicted numbers should be sixteen staff on days, but that number can be as low as eight when people fail to turn up for work. Comments included: we are always rushed, some people are not getting up until midday and (Im) concerned about the safety of some of the Care Homes for Adults (18-65 years) Page 28 of 41 Evidence: people living in the home. We heard a call bell sounding and, after five minutes, it had not been answered. We requested that the staff answer the call. On walking around the home some of the areas were not being supervised by staff. We were told that no staff meetings had been provided for the staff and staff were not happy talking about issues because they fear things are passed on in an unprofessional manner. Care Homes for Adults (18-65 years) Page 29 of 41 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 management of the home does not ensure that it is run in peoples best interests. Evidence: Prior to the inspection the organisations area manager told us that the registered manager had been suspended following concerns raised at their monthly audit visit. We were asked to meet with representatives from the organisation. At the meeting (day one of the key inspection) we were told about the homes interim management arrangements in the absence of the registered manager. We were also updated on recent incidents that had occurred in the home, and the action the organisation was taking to safeguard the people living at the home. The providers agreed not to admit anyone else into the home so as to allow the incidents to be investigated, and to provide some stability for the people living there and the staff working there. The manager was registered in July 2008 by CSCI. It was of concern that a number of records we asked to look at could not be found. These records included complaints, staff references, criminal records bureau (CRB) Care Homes for Adults (18-65 years) Page 30 of 41 Evidence: checks, POVA 1st checks (these are checks performed by the Criminal Records Bureau against the national list that contains the names of people who have been deemed unsuitable to work with vulnerable people and, if clear, allows providers to employ staff under supervision before a clear CRB check is completed), NMC (Nursing and Midwifery Council) verifications and training records. We were concerned to see a high number of incidents which should have been referred to the safeguarding team, and which had not been investigated. The incidents were recorded as accidents, and had not been followed up. To ensure the safety of people living at the home, all staff must ensure that all incidents are reported, and ensure that action is taken to safeguard the people involved. A system should be introduced to show the difference between an accident and an incident. We were concerned that (a) the fire alarm had not been tested since the summer and (b) staff could not find the records, but told us it had not been tested since the maintenance person left. An immediate requirement notice was issued for the fire alarm to be tested. Evidence was seized using a code b notice due to us receiving a complaint from a member of staff alleging that the fire alarm was not being tested. Concerns about the health and safety of people living in the home were raised in relation to the environment. We observed large cylinders of gas on the fire escape with cigarette ends next to them. This indicates that people have been smoking in close proximity to the gas cylinders - which could result in a fire and or an explosion occurring, as the compressed gas is flammable. Gas cylinders were also in the grounds and were not secured in any way. We were told that the gas cylinders belonged to the workmen upgrading the original building. We were advised that they were sleeping in a caravan in the grounds of the home. Care Homes for Adults (18-65 years) Page 31 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 20 13 (2) Medication administration 16/06/2008 records must document what has been administered in order to ensure that the people who use the service are safeguarded. This remains outstanding 2 22 22 So that service users can be confident complaints are taken seriously, the home must follow the agreed procedures for investigating and responding to complaints. This standard was not met, an immediate requirement notice was issued 16/06/2008 3 32 18(1)a Staff must attend 30/09/2008 appropriate training so that they are able to demonstrate they have the knowledge, skills and confidence needed to ensure residents? health and emotional needs are met. this standard was not met at this inspection Care Homes for Adults (18-65 years) Page 32 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 1 2 14 The pre-admission process must be made more robust to ensure that only people whose care needs can be met are admitted to the home. The wellbeing of people using and potentially using the service will be safeguarded. 30/04/2009 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 6 12 The needs of people with chronic healthcare conditions such as diabetes must be carefully and comprehensively safeguarded and addressed. To safeguard the health, safety and wellbeing of people using the service. 11/03/2009 2 6 12 Reg 12 (1) (a) Care plans should be comprehensive and reflective of the individuals care needs. To promote and ensure proper health and welfare of the people living in the home. 30/04/2009 Care Homes for Adults (18-65 years) Page 33 of 41 3 9 13 When a risk is identified to a 28/04/2009 persons health, safety or wellbeing, a risk assessment must be completed that provides clear guidance and instruction to staff about minimising or eliminating the actual or potential risk identified. To safeguard the health and welfare of people living in the home. 4 20 13 Nursing staff must record the administration of all medication onto the medication administration record charts each time medication is given to a person using the service. When prescribed medication is not administered, a defining code and reason must be entered onto the administration chart. To safeguard people using the service. 06/03/2009 5 20 13 Prescribed medication must only be administered in accordance with approved protocols. To safeguard people using the service. 06/03/2009 6 20 13 A quality assurance system must be installed to assess staff competence in their handling of medicines. Appropriate action must be taken when these indicate that medicines are not administered as prescribe 26/02/2009 Care Homes for Adults (18-65 years) Page 34 of 41 and records do not reflect practice. This is to ensure that all medicines are administered as prescribed and this can be demonstrated. 7 20 13 All medicines that are administered must be in date, stored correctly in accordance with their product licences and be labelled by a pharmacist. All prescribed medicines must be available for administration and must be administered to the person they are prescribed to only. The practice of administering medicines dispensed to one service user to another must cease immediately. This is to ensure that the correct medicine is administered to the service user they have been prescribed and dispensed to and to ensure that the stability of the medication is not compromised. 8 20 13 The purchase and installation of a Controlled Drug cabinet that complies with the Misuse of Drugs safe custody Regulations 1973 is required. It must be reserved for the storage of Controlled Drugs only. 26/02/2009 06/03/2009 Care Homes for Adults (18-65 years) Page 35 of 41 This is to ensure that all controlled drugs are stored correctly 9 20 13 All nursing staff must be 26/02/2009 trained to adhere to the medication policies and procedures and also become familiar with the indications and side effects of the medicines they handle. This is to ensure that all nursing staff handle medicines correctly. The quantity of all medicines 30/04/2009 received and any balances carried over from previous cycles must be recorded. This is to enable audits to take place to demonstrate the medicines are administered as prescribed. 11 20 13 A system must be installed 26/02/2009 to check the prescription prior to dispensing and to check the dispensed medication and the medicine charts against the prescription for accuracy. All discrepancies must be addressed with the healthcare professional. All dose regimes must be clearly written on the medicine chart, and checked by a second member of staff for accuracy to ensure that the staff have clear directions to follow. 10 20 13 Care Homes for Adults (18-65 years) Page 36 of 41 This is to ensure that the service user receives the correct dose as prescribed at all times. 12 20 13 The medicine chart must 30/04/2009 record the current drug regime as prescribed by the clinician. It must be referred to before the preparation of the service users medicines and be signed directly after the transaction and accurately record what has occurred. This is to ensure that the right medicine is administered to the right service user at the right time and at the right dose as prescribed and records reflect practice 13 22 22 The complaints procedure 30/04/2009 must be available in a format suited to the individuals using the service. To assist people using the service to make a complaint. 14 23 21 Robust procedures must be 30/04/2009 developed to ensure staff can riase concerns and be confident that their concerns will be acted upon. To safeguard people using the service. 15 24 16 All areas of the home being used by people must be suitable for their needs and lifestyle. 26/04/2009 Care Homes for Adults (18-65 years) Page 37 of 41 To ensure that the peoples health and safety is met and privacy respected. 16 24 16 Keep all parts of the home clean and free from offensive odours. People live in a clean home. 17 33 18 The home must show that the staff have the necessary knowledge, skills and competencies to meet the assessed needs of people using the service. Peoples health care needs are safeguarded. 18 34 19 The home must ensure that 30/04/2009 all staff employed have been recruited with all the appropriate safety checks completed. To assist in protecting the people living in the home. 19 39 24 Reg 24 (1)(a)(b) The home 12/05/2009 should establish and maintain a system for reveiwing the quality of care and service provision, in a format suited to the needs of the people using the service. To ensure that the veiws of people using the service are being listened to. 20 42 12 Reg 12 (1) (a) the home must ensure that all areas used by people living in the home are not hazardous by 12/03/2009 30/04/2009 26/04/2009 Care Homes for Adults (18-65 years) Page 38 of 41 removing and securing any potential risk items. To prevent people in the home from risk of accident or injury. 21 42 12 The home must ensure that all accidents are reported and where necessary referred to appropriate authorities. All staff must be trained to ensure that they know the procedure to follow for accidents and incidents that occur in the home. To ensure that the health and well being of the people who live in the home is not compromised. 22 42 37 The home must notify the 30/04/2009 CSCI of any significant event in the home as soon as possible. To assist in safeguarding the people who live in the home. 30/04/2009 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 To ensure that people have sufficient information about the home the Statement of Purpose and Service Users Guide should be produced in a format which the people can understand. The home should demonstrate that all individuals choices about their care needs are respected and included in their care plan. The home should ensure that all information about people Page 39 of 41 2 7 3 10 Care Homes for Adults (18-65 years) is respected and staff know when information given them in confidence must be shared with their manager or others. 4 11 To ensure that the persons spiritual needs are met, a review and evaluation of religious services and spiritual opportunities available should be undertaken by the home. The home should ensure that all the individuals are provided with opportunities to participate in fulfilling activities. Individuals choice of routines should be their preferred choice, and all staff should respect their wishes. Individuals care plans should reflect their expressed wishes. For example, preferred times of getting up, preference for male or female carers, clothes and staff should respect their choice. 5 12 6 7 16 18 Care Homes for Adults (18-65 years) Page 40 of 41 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 © (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 Adults (18-65 years) 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!