Inspection on 15/12/08 for Ruislip Nursing Home

This inspection was carried out on 15th December 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ruislip Nursing Home 03/01/07

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ruislip Nursing Home 173 West End Road Ruislip Middlesex HA4 6LB     The quality rating for this care home is:   three star excellent 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: Clare Henderson-Roe     Date: 1 5 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 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 27 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 Older People Page 3 of 27 Information about the care home Name of care home: Address: Ruislip Nursing Home 173 West End Road Ruislip Middlesex HA4 6LB 01895674267 01895623412 hancader@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Raziya Banu Cader,Hassam Cader,Javed Zulficar Ali Cader,Hannah Cader Name of registered manager (if applicable) Mrs Raziya Banu Cader 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 physical disability Additional conditions: As agreed on 10th July 2006, 7 named service users with a diagnosis of dementia can be accommodated, as agreed by the Commission for Social Care Inspection, for as long as there is no deterioration, which affects the well being of other service users. The rooms used for each service user will revert to listed categories for the home once the service user no longer resides at the home. The home must advise CSCI when a service user no longer resides at the home. Minimum staffing notice Date of last inspection 24 0 24 Over 65 0 24 0 care home 24 Care Homes for Older People Page 4 of 27 Brief description of the care home Ruislip Nursing Home is a converted detached house situated in a residential area of Ruislip. There is an enclosed garden to the rear of the premises. The accommodation consists of fourteen single bedrooms and five double bedrooms. There is a large communal room and a conservatory for service users to utilise. Local transport facilities are available in the form of buses and Ruislip Gardens and South Ruislip underground stations. Clergy from the Roman Catholic and Church of England Churches make weekly visits to the home, and arrangements to meet other religious and cultural needs can be made. The fees are from seven hundred and fifty pounds to nine hundred pounds per week. Care Homes for Older People Page 5 of 27 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: three star excellent 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: This was a key unannounced inspection carried out as part of the regulatory process. A total of 6 hours were spent on the inspection process. We carried out a tour of the home and service user plans, medication records & management, staff rosters, staff records, administration and financial records and maintenance and servicing records were viewed. 5 residents, 4 visitors and 6 staff were spoken with as part of the inspection process. The Annual Quality Assessment Assessment document and surveys received from residents, staff and healthcare professionals have also been used to inform this report. Care Homes for Older People Page 6 of 27 What the care home does well: What has improved since the last inspection? What they could do better: Some shortfalls were noted in the management of medications. These should be easy to address and thereafter medication management should be maintained in good order. Care Homes for Older People Page 7 of 27 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 Older People Page 8 of 27 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 9 of 27 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 home has clear information about the home freely available, thus people can find out what the home has to offer prior to moving in. Prospective residents are fully assessed prior to admission to ensure that the home is able to meet their needs. Evidence: There is information made available to prospective residents and their families and people are encouraged to come and look around the home prior to being admitted. Surveys completed by residents stated that they had received information about the home. A copy of the Statement of Purpose and the Service User Guide are available by the signing in book, and copies of the Service User Guide are in each bedroom. The content is well presented and easy to read and understand, giving a clear picture of the home and the care they are able to offer. The home has a comprehensive pre-admission assessment document and the Care Homes for Older People Page 10 of 27 Evidence: Registered Manager carries out a full assessment to ascertain if the home are able to meet the needs of the individual. The home also obtains copies of the Social Services assessment and any other related assessments that are available. Care Homes for Older People Page 11 of 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Documentation in respect of each residents nursing and healthcare needs is kept up to date, thus ensuring their needs are identified and met. Although medications are being managed, shortfalls identified could place residents at risk. Staff care for residents in a gentle and professional manner, respecting privacy, dignity, cultural and religious needs. The wishes of residents and relatives in respect of end of life care are ascertained and recorded, to ensure they are known and can be met. Evidence: We viewed 2 service user plans. These were comprehensive, personalised and up to date, providing a good picture of each resident and their needs. There was evidence of input from residents and their representatives in the formulation and review of the documentation. Risk assessments for falls and other identified risks were in place and had been updated. Bedrail risk assessments and written consents for their use were available. Documentation had been updated monthly and whenever there had been a change in a residents condition. Care Homes for Older People Page 12 of 27 Evidence: We viewed wound care records. Risk assessments for pressure sores, individual care plans for each wound and wound dressing records plus photographs were in place, which gave a good picture of the progress of each wound. There was evidence of input from the tissue viability nurse specialist and pressure relieving equipment was seen in use throughout the home. Assessments for nutrition, moving & handling and continence had been carried out. Care plans were also in place for all needs identified. There was evidence of input from the GP, tissue viability nurse, physiotherapist, speech & language therapist and Macmillan nurses. The home has input from 7GPs and there is a clear list available with contact details for each GP practice. We viewed medication records and management. For each resident there is a sheet that has a photograph, GP details, allergy information and any other relevant details recorded. A list of registered nurse signatures and initials was available. All administration of medications had been signed for. Receipts are currently recorded in 3 different places, and we recommended that receipts are always recorded on the medication administration record (MAR). In some instances we found a large stock of a medication available and discussed the need to audit all boxed medications in the home and adjust the monthly orders accordingly until any excess stocks have been used up. Paracetamol was being supplied in individual named boxes, whereas previously the home had obtained a bulk stock for this medication. However, staff were still following the procedure for bulk supplies and not administering from each residents individually labelled pack. For one medication with specific administration instructions these had not been recorded and it was not clear if staff were aware of them. In one instance where a medication had a variable dose, the actual dose being given on each occasion was not being recorded. This was being recorded in other variable dosage medication records viewed. Liquid medications, eye drops, creams and inhalers had been dated when opened. For residents on warfarin therapy the latest blood test result and dosage instructions are kept with the MAR. When a medication had been omitted, the reason for this had been clearly recorded. All medications for disposal are recorded and the correct method of disposal was in use. Controlled drug records were complete and up to date, and a stock check is carried out at each handover. A monthly medication audit is carried out, however the system in use should be reviewed to ensure a process for identifying all shortfalls is included on the audit tool. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. Comments received on the surveys show that staff are looking after the residents well and provide a high standard of individualised care. There was evidence of cultural and religious needs being identified and met. Where English is not a residents first language, staff are available to converse with the residents and also a communication book has been developed to help all staff Care Homes for Older People Page 13 of 27 Evidence: communicate effectively and understand the residents wishes. Residents looked well groomed and were dressed to reflect individuality. Bedrooms had been personalised and residents are able to bring in some of their own possessions, in line with health & safety. The home has a deprivation of liberty safeguard questionnaire and a mental capacity form, and these are being completed with each resident, to ensure that where able residents maintain control over their own wishes and are listened to and respected. The home also has documentation in respect of health deterioration and end of life care wishes, which are completed when a residents health deteriorates. The wishes of the resident and their family is discussed when a redisents condition deteriorates, and the possibility of discussing this as part of the admission process was discussed with the Registered Manager. The home has regular contact with and input from the Macmillan nurse team and community matron and from comments received it is clear that a high standard of care is provided at all times. All registered nurses have undertaken a 5 day training course in palliative care. Care Homes for Older People Page 14 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The activities provision at the home is good and varied, catering for the interests of each resident. The home has an open visiting policy, thus ensuring residents maintain contact with family and friends. Advocacy information is available, thus ensuring that each residents right to independent representation is respected. The food provision at the home is excellent and varied, meeting each residents individual preferences and dietary and cultural needs. Evidence: The home has a full time activities co-ordinator who takes a keen interest in each resident and their interests and abilities. A map of life and an individual activity programme is completed for each resident, so that their life history, interests, hobbies and present abilities and preferences are ascertained in order to provide them with activities they enjoy. All residents are encouraged to join in the daily activity sessions, and their choice to join in or not is respected. One to one sessions are held with residents who do not wish to or are not able to participate in group activities. The home celebrates a diverse range of festivals and significant days, and provides entertainment, food and decorations relevant to each one, with pictures of such events being taken and kept in an events diary. The activities programme covers a 7 day Care Homes for Older People Page 15 of 27 Evidence: week, and it was clear from comments received that activities are very much a part of each day and staff understand the importance of keeping the residents minds and bodies as active as is possible. The residents receive a large print local magazine and the mobile library also visit monthly. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are always made welcome and offered refreshments. Representatives are kept up to date with any issues to do with their loved ones. Advocacy contact information is on display in the home, to include Age Concern, Independent Mental Capacity Advocates and the Public Trust Office, and this information is also included in the Service Users Guide in each room. We viewed the kitchen and it was clean and tidy. Residents are offered a choice of meals and these are recorded and met. There is a 4 week menu and a list of what each resident likes for breakfast. There was a good supply of fresh, frozen, tinned and dried foods available. The home has introduced food pictures and name labels, so that residents can see what they are being offered. We sampled the lunchtime meal and this was well presented and tasty. Residents commented on the good food provision in the home and it is clear that the cook works very hard to ensure that she provides food that each resident enjoys. Dietary needs for medical, cultural and religious needs are recorded and are met. The home has attained a excellent 5 Star Scores on Doors rating from Environmental Health. Home baked cakes are available for tea and overall the food provision at the home is excellent. Care Homes for Older People Page 16 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are clear complaints and safeguarding adults procedures in place, understood by staff and residents and adhered to, thus empowering and protecting the residents. Evidence: The home has a clear complaints procedure and this is on display in the home and contained within each copy of the Service User Guide. An easy read version is also available, and this had been shown to and explained to each resident, who had signed to say they had understood it. The responses in the surveys confirmed that residents know how to make a complaint. There had been 2 complaints in the last 12 months, one of which had been investigated by the Primary Care Trust. The other had been sent to the home via CSCI, and this had been fully investigated, documented and responded to. The home has a safeguarding adults procedure and also follows the Hillingdon Safeguarding Adults documentation. Staff spoken with had received training in safeguarding adults and were very clear to report any concerns. Again, the homes procedure had been written in an easy read format, and residents had read it and signed to say they had understood it. The information in the surveys evidenced that residents feel they are being well cared for and know how to report any concerns. Care Homes for Older People Page 17 of 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being well maintained, providing residents with a comfortable, homely and safe environment to live in. Infection control procedures are in place and are adhered to, thus protecting residents. Evidence: An environmental audit had been carried out and a comprehensive redecoration and refurbishment programme, with timescales for completion, had been drawn up. We carried out a tour of the home and there was evidence that the redecoration and refurbishment plan was being adhered to. The fire risk assessment was last reviewed in October 2008 and updated to include additional equipment for evacuation purposes. The home was clean, fresh and homely throughout. There is a day room and also a conservatory for residents to sit in. The garden is well maintained and a new ramp has been installed to improve access from the conservatory into the garden. There is a gazebo and garden furniture so that residents and their visitors can sit out in good weather. The laundry and sluice are housed in the same room. The room was very clean and there is clear demarcation between the 2 areas. The home has one washing machine and one tumble dryer, both of industrial standard, and the washing programmes include hot washes for infection control. Infection control procedures in place and are Care Homes for Older People Page 18 of 27 Evidence: being followed. Protective clothing to include gloves and aprons are available. Infection control is being well managed at the home. Care Homes for Older People Page 19 of 27 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. The home is appropriately staffed to meet the needs of the residents at all times. Systems for vetting and recruitment are in place and are practiced, thus protecting residents. The staff are well trained and have the skills and knowledge to meet the needs of the residents effectively. Evidence: The home was being appropriately staffed to meet the needs of the residents. Copies of the staffing rosters were provided, and these evidence that the staffing is maintained at a level to meet the needs of the residents. Staff spoken to said that they enjoy working at the home and that there is good teamwork. Domestic and ancillary staff are employed in such numbers as to keep the home clean, fresh and safe. All the care staff are qualified to NVQ level 2 or 3 in care or hold an equivalent qualification. Several staff are undertaking NVQ level 4. The comprehensive training matrix shows that staff undertake regular training sessions in topics relevant to the diagnoses and needs of the residents. In addition the home provides a training setting for social work placements and nurses undertaking refresher courses in nursing, and has found that this has been very beneficial for the students and for the home, as expertise is shared. Staff spoken with confirmed they receive a goodly amount of training. The staff at the home are well trained and receive the ongoing training and Care Homes for Older People Page 20 of 27 Evidence: updates to provide them with the skills and knowledge to care for residents effectively. We viewed 3 sets of staff employment files and these contained all the information required under Schedule 2 of the Care Homes Regulations 2001. The home has the Skills for Care common induction standards induction programme, and all new care staff complete this training. In addition all new staff undertake the general induction programme for the home, which covers orientation to the home as well as care and health & safety topics. Care Homes for Older People Page 21 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Registered Manager has the qualifications and experience to manage the home and is open and approachable, managing the home effectively. There are excellent systems in place for quality assurance, and the home constantly strives to improve on the good practices already in place, thus providing an ongoing process of management and practice review. Monies held on behalf of residents are well managed and securely stored. Systems in place for the management of health & safety in the home are comprehensive, robust and are adhered to, thus safeguarding residents, staff and visitors. Evidence: The Registered Manager is a first level registered nurse with qualifications in general and mental health nursing, and has completed the NVQ level 4 in Management. She has post-graduate qualifications in teaching and assessing and holds an NVQ assessors certificate. The Registered Manager has also undertaken several training courses in topics relevant to her role and the diagnoses and needs of the residents. It was clear Care Homes for Older People Page 22 of 27 Evidence: from the comments received from residents, visitors and staff that the Registered Manager and her management team are approachable and supportive. The home has a very thorough system in place for quality assurance. There is a comprehensive system of auditing to cover all aspects of the home and these audits are carried out mainly monthly, with action being taken immediately to address any issues identified. There are 6 monthly reviews with residents and their representatives, and again, any issues identified are promptly addressed. Regular staff meetings and resident meetings take place and minutes are kept. Surveys are sent out to members of the multi-disciplinary team for feedback about the home. There are also resident and relatives surveys conducted. Survey results are published and made available to people who are interested. We received very positive feedback on surveys from residents, healthcare professionals and staff, and also from visitors present at the time of inspection. Policies and procedures are reviewed annually and whenever there is a significant change. The home is always looking for ways to improve on their practice in all areas, and the home is to be commended for this. The home holds small amounts of monies on behalf of residents. Clear records of income and expenditure are maintained and receipts for any expenditure are available. Monies are securely stored. We sampled the servicing and maintenance records and these were up to date. Risk assessments are in place for all equipment and safe working practices and these are updated annually on a rolling programme. Staff have received training and updates in health & safety topics, and training is arranged in the use of any new items of equipment, for example, the ski pad used for evacuation in the case of a fire. Every bedroom has a maintenance check file, and checks of nurse call, heating, curtains, lighting, furniture, clock, electrical appliances, paintwork and bedrails are carried out weekly. These are in addition to the ongoing thorough maintenance checks being carried out weekly. Fire drills are carried out on a regular basis for day and night staff and records are maintained. Health & safety is being very well managed and therefore the home provides a safe environment to live in, with staff who are fully trained in health & safety. Care Homes for Older People Page 23 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 27 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 9 13 Where a medication is 13/02/2009 prescribed with a variable dose, the actual dose given each time must be recorded. To show accurately the dosage being administered each time. 2 9 13 Where a medication has specific administration instructions these must be recorded and understood by staff administering medications. To ensure each medication is administered correctly. 13/02/2009 3 9 13 Medication must only be administered to the resident for whom it is prescribed. To ensure each resident uses their own supply of medications. 13/02/2009 Recommendations These recommendations are taken from the best practice described in the National Care Homes for Older People Page 25 of 27 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 9 That a full audit of medication stocks be carried out and stock levels be monitored closely to avoid excess stocks of any medications. That all receipts are recorded on the medication administration record. 2 9 Care Homes for Older People Page 26 of 27 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. 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