Inspection on 02/09/08 for Stow Lodge

This inspection was carried out on 2nd September 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stow Lodge 23/10/06

Stow Lodge 13/02/06

Stow Lodge 18/05/05

Stow Lodge 02/11/04

Stow Lodge 17/06/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Stow Lodge Oval Way Gerrards Cross Buckinghamshire SL9 8QB     The quality rating for this care home is:   two star good 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: Chris Schwarz     Date: 1 1 0 9 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: Stow Lodge Oval Way Gerrards Cross Buckinghamshire SL9 8QB 01753886522 01753886522 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) The Fremantle Trust Type of registration: Number of places registered: care home 11 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home Stow Lodge is situated in a quiet residential area of Gerrards Cross, within walking distance of all local amenities. There is a bus route nearby and rail links. The home can accommodate eleven adults. The house is detached and situated in large grounds with parking at the front for several cars and a large rear garden. Each person has their own room, close to toilet and bathroom facilities. 11 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good 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: This unannounced key inspection was conducted over the course of a day with a further meeting with the homes manager a week later when she returned from annual leave. All of the key National Minimum Standards for younger adults were covered. The last key inspection took place in December 2006. Prior to the inspection, a detailed self-assessment questionnaire was sent to the manager for completion and comment cards were sent to a selection of people living at the home, staff and visiting professionals. Any replies that were received have helped to form judgements about the service. Information received by the Commission since the last inspection was also taken into account. Care Homes for Adults (18-65 years) Page 5 of 28 The inspection consisted of discussion with staff, opportunities to meet with people using the service, examination of some of the homes required records, observation of practice and a tour of the premises. Peoples equality and diversity needs were taken into account throughout. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff and people who use the service are thanked for their co-operation and hospitality during this unannounced visit. What the care home does well: What has improved since the last inspection? What they could do better: Peoples independent living skills need to be better promoted at the home in order that people using the service have as much involvement as possible. More could be done to extend the range of activities available to people using the service, to increase stimulation. Safeguarding procedures need to be instigated promptly where necessary to make sure that any incidents or allegations are thoroughly investigated without delay. Each service user needs to be given a version of the complaints procedure that they can make use of as part of the development of the person centred care plans. Verification is needed of a member of staffs continuing right to work in the country. Care Homes for Adults (18-65 years) Page 7 of 28 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 8 of 28 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 9 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are thoroughly assessed prior to admission and are given opportunity to visit the home beforehand to ensure it meets their needs. Evidence: A service users guide and statement of purpose were in place at the home to provide prospective users with information about what they can expect of the home. These had been updated since the last inspection and took into account changes in management of the home. There had not been any new admissions to Stow Lodge in the past year; records looked at on previous occasions have shown that new service users had been assessed properly before moving in and had been given opportunities to visit the service. A significant focus for the home and the provider is its reprovisioning plans for service users, in partnership with Buckinghamshire County Council. Two people have already left Stow Lodge since the last inspection to move into supported living accommodation. Detailed work had taken place in preparation for this to make sure their care needs had been recorded. Care Homes for Adults (18-65 years) Page 10 of 28 Evidence: Fess for the home were 608.37 pounds per week. Each person had an updated contract in their files outlining what the charges are for the service. These had been produced in a user-friendly format. Care Homes for Adults (18-65 years) Page 11 of 28 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples care requirements are noted within up to date care plans and reflect their diverse needs although staff need to promote service user involvement to make sure that people have as much input as possible into their care. Evidence: Care plans were in place for each person living at the home. A sample was looked at and found to be up-to-date with needs identified clearly. Care plan files contained a photograph of the person, a copy of their contract of residence, essential information such as their doctor, next of kin, preferred name, ethnic origin, religion and gender. Essential health care needs were noted plus details of requirements related to areas such as mobility, communication, washing and bathing, continence, personal grooming, food and drink, getting up and going to bed, social skills, general physical health, family and friends, leisure and recreation and independent living. Service users had been encouraged to sign their care plans. Files contained copies of review notes involving relevant parties and care managers from the local authority and a sheet at Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: the front of the files indicated when files had additionally been reviewed in-house. Each person had a named keyworker. At the previous inspection a requirement was made for care plans to be developed with the individual service users and produced in formats that they could understand. There was evidence in each of the files that the information contained within them was produced after the last inspection although the amount of involvement with people using the service, other than their signatures, is not clear. Care plans had not yet been fully developed in formats that people could understand although a start had been made on producing versions with photographs and plain text. It is expected that this work will continue over the coming months. Risk assessments were contained within each of the files looked at and these covered areas to encourage independence such as bathing, making hot drinks, carrying out household chores and safe management of epilepsy. All assessments had been dated and signed and were up-to-date. People using the service were involved in making some decisions about daily life such as helping to plan menus. Staff were observed doing things for service users which they are likely to be able to do themselves, such as getting coats ready to go out for the day and other tasks which they could manage with assistance such as putting together their packed lunches for day services and preparing drinks. It is recommended that peoples independent living skills be better promoted at the home in order that people using the service have as much involvement as possible. No one was managing their own money. Each person had a wallet kept in the office with individual transaction records kept and receipts retained to verify expenditure. Three wallets were checked and found to tally with the recorded balances. Staff had signed alongside each transaction. Care Homes for Adults (18-65 years) Page 13 of 28 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. People using the service have opportunities to attend day services and access the community although more could be done to extend the range of activities available, to increase stimulation. Evidence: Records on peoples files showed that they access various activities as part of day service attendance such as youth club, pottery, outings, college and football as well as a life skills group. One of the people spoken with said he goes into Gerrards Cross to do his shopping and receipts of financial transactions showed that people have meals out occasionally. People can also attend a local Gateway Club and Causeway. All but one person who has retired attend day services during the week and are transported by each of the services buses and drivers. It was noted in one of the care Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: plan files that a care manager raised during a review that service users were not having opportunity to pursue regular activities or have home days from day service attendance due to staff shortages. In discussion with the homes manager, it was agreed that more could be done to provide varied activities for people using the service and some ideas had already been talked about such as taking a couple of people to the garden centre and train journeys for a couple of enthusiasts. Menus are produced with input from people using the service. Notes of a recent staff meeting showed that staff are being encouraged to facilitate service users trying different options and having more variety in their diets. On the second day of visiting the home, a member of staff was starting to prepare peoples packed lunches for the following day at 3.00 pm and without their involvement; it was observed that the bowl containing fruit was placed out of reach on top of the kitchen cupboards. A recommendation has been made under the previous section to better promote peoples independent living skills. People using the service were maintaining contact with family and friends. Minutes showed that consultation meetings had taken place between the home and relatives in November last year and May this year to keep them updated on events and to listen to any concerns. Care Homes for Adults (18-65 years) Page 15 of 28 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of people living at the home are well met, promoting health, well-being, taking into account their preferences and religious or cultural requirements and ensuring that they receive medication in a safe and consistent manner. Evidence: Peoples health care requirements were clearly noted in their care plans and provided up-to-date information to make sure that people receive the support needed. There were separate files containing information about health care appointments containing a photograph of the person, essential information, records of weights, appointments attended and outcome, plus assessments for nutritional screening, risk of developing pressure damage, moving and handling and managing status epilepticus where relevant. The files that were looked at showed that people using the service were being supported to attend for routine screening checks as well as specialist appointments, making use of community health care facilities rather than domiciliary visits. Accidents and incidents were being recorded and kept in a file. Health care passports had been set up to provide a useful and portable record of peoples needs. Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: Medication was being managed using a monitored dose system whereby tablets are pre-packed by the pharmacist into sealed blister packs which staff then administer from. Medication was being kept secure in a separate room with lockable cupboards and cabinets. A medicines fridge was also available if needed. Medicines were being stored appropriately and kept in a tidy manner with checks of room temperature undertaken regularly. Medication administration records were in good order with signatures alongside prescribed dose times. Staff had a medication policy to refer to in the homes operations manual for guidance. The home had obtained individual metal cabinets for each person to have in their bedroom and was waiting for the next supply of medication to be dispensed in separate blister packs so that staff could administer from the persons own room, rather than centrally. Care Homes for Adults (18-65 years) Page 17 of 28 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints and adult protection procedures are in place to listen to views of people who live at the home. Evidence: Complaints and safeguarding procedures were in place at the home. There was also guidance for staff on dealing with challenging behaviour. A complaints log was being maintained; compliments were also noted. Where follow up action was needed after a complaint, records showed what had been done to remedy matters. Staff indicated in surveys that they knew what to do if anyone raised any concerns about care. No complaints had been made direct to the Commission. A care manager commented that one set of relatives felt that their concerns had not been responded to appropriately. Records within the home showed that the manager is trying to improve this relationship. It is recommended that each service user is given a version of the complaints procedure that they can make use of as part of the development of the person centred care plans. In information provided in the self-assessment, one safeguarding referral was noted. Details of this were seen on one of the care plan files. Minutes of a meeting involving relevant parties showed that the incident involving possible unexplained injury to a service user whilst on holiday, had not been reported to the Social Services Department by staff at the home, in line with procedures. The injury could be Care Homes for Adults (18-65 years) Page 18 of 28 Evidence: explained - it occurred following a seizure and was witnessed, but staff had not noted bruising or mentioned this to the day service or the service users family. When the service user attended day services on return from holiday, day service staff saw the bruising and initiated investigation. A notification was later made to the Commission by the homes operations manager. The issue as far as the home is concerned is that information about the incident was not communicated effectively and passed on to relevant people. It is accepted that since this time measures have been put in place to remind staff of correct procedures and there have not been any further occasions to use safeguarding procedures. Training records showed that staff had attended safeguarding training in 2007 and this year. Care Homes for Adults (18-65 years) Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean, well decorated and adequately maintained, promoting a positive environment for the people who live there and providing them with comfortable surroundings. Evidence: Stow Lodge is located in a residential road close to the centre of Gerrards Cross. There are rail and bus links nearby and a range of shops, places to eat, banks, pubs, churches and other facilities. The building is a large detached property with accommodation on three floors. There is parking at the front for several cars and a large, well maintained garden area with trees, shrubs and lawn plus patio furniture for people using the service to make use of. The top floor is used as office and staff sleeping in space. Accommodation for people using the service is on the ground and middle floors. All of the bedrooms are single occupancy and vary in size and layout. Some people had personalised their rooms effectively and those who were asked said their rooms were comfortable. Each room had a wash hand basin and was close to toilet and bath/shower facilities. There are two lounge areas on the ground floor, one a quiet room, and a dining room next to the kitchen. Kitchen and laundry areas were clean and in good order. An odour problem in the downstairs bathroom had been dealt with since the last inspection and flooring had been replaced in a number of bathrooms Care Homes for Adults (18-65 years) Page 20 of 28 Evidence: and toilets where it was stained or worn. All parts of the home that were seen were clean and in a good state of décor. Care Homes for Adults (18-65 years) Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides staff cover to meet needs and undertakes thorough recruitment procedures, coupled with effective training to ensure staff have the right skills and competencies to support the people who live there. Evidence: Two staff were on duty at the start of the inspection with rotas reflecting that this is the typical level throughout the waking day. There was a board in the hallway with photographs and names of the people on duty, the current rota was displayed outside the kitchen for anyone to see who would be on duty and a copy of a sheet with the names and photographs of headquarters staff was displayed. At the time of the inspection four staff were absent from the rota for various reasons; any shortfalls in staff numbers were being made up with relief staff rather than agency workers. Training records reflected that eight staff plus the manager had achieved National Vocational Qualification at level 2 or above, some other staff were working towards this. Records of mandatory training showed that the manager had already booked refresher courses where staff require updates to courses attended in previous years and the dates for these were indicated. Courses such as safeguarding adults had been attended in 2007 and 2008, first aid and food hygiene were well covered. Seven Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: people had attended training on epilepsy with a further person booked to do this, two staff had attended a course on the Mental Capacity Act 2005 and there had been input on responding to challenging behaviour. There were minutes of five staff meetings for this calendar year. Staff commented in surveys that there were good training opportunities at the home and that they felt supported in their roles. A care manager commented on the fact that there were staff shortages and that communication could be improved but noted that a service users review had been well managed. Recruitment files of new staff were looked at and showed that all of the necessary clearances and checks had been undertaken before staff started to work at the home. The managers attention was drawn to a work permit which expired last year and a recommendation is made to obtain verification that the member of staff has a continuing right to work in the country. Care Homes for Adults (18-65 years) Page 23 of 28 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 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 a competent and experienced manager to promote continuity and quality of care for the people who live there and ensuring that risk is safely managed to reduce the likelihood of injury or harm. Evidence: There has been a change of permanent manager at the home, with managers of other services providing support on a temporary basis in between. The present manager joined the home in May this year and is very experienced in social care. She has achieved the Registered Managers Award and is working towards National Vocational Qualification level 4. Staff and people using the service gave positive feedback about her. There have been regular monitoring visits by the provider to evaluate quality of care and one of the trustees had visited in the spring. Additional monitoring is undertaken by the operations manager each month. A quality audit was undertaken in September 2007 by the provider and an overall rating of adequate was awarded. Many of the Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: areas highlighted for attention in the audit had been attended to by the time of this visit. There was good regard for health and safety at the home. There were certificates for gas safety, satisfactory electrical installation, testing of portable electrical appliances and hoist servicing. Thermostatic valves had been checked in January this year, microbiological sampling of water took place and was found to be satisfactory in July last year and fire extinguishers had been serviced in April this year. The last visit by the fire officer took place in September last year and a recommendation to review the fire based risk assessment had been addressed. The last visit by an environmental health officer took place in September 2006 with a minor issue raised but overall good standards witnessed. Generic and individual risk assessments were in place, including personal emergency evacuation plans. Care Homes for Adults (18-65 years) Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 23 13 Safeguarding procedures are 30/10/2008 to be instigated promptly where necessary. This is to make sure that any incidents or allegations are thoroughly investigated without delay. 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 7 Peoples independent living skills are to be better promoted at the home in order that people using the service have as much involvement as possible. Each service user is to be given a version of the complaints procedure that they can make use of as part of the development of the person centred care plans. Verification is needed of a member of staffs continued entitlement to work in the country. 2 22 3 34 Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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