Inspection on 06/07/09 for The Rambles

This inspection was carried out on 6th July 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Rambles 20/08/07

The Rambles 13/03/07

The Rambles 06/06/06

The Rambles 25/11/05

The Rambles 02/08/05

The Rambles 08/02/05

The Rambles 16/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: The Rambles 90 Farleigh Road Backwell North Somerset BS48 3PD     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Melanie Edwards     Date: 0 6 0 7 2 0 0 9 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 29 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.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: The Rambles 90 Farleigh Road Backwell North Somerset BS48 3PD 01275790072 Telephone number: Fax number: Email address: Provider web address: www.brandontrust.org Name of registered provider(s): Type of registration: Number of places registered: The Brandon Trust care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is 6 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) Date of last inspection Brief description of the care home The Rambles is a detached house in a residential area, offering supported living for up to 6 younger adults with learning disabilities. It is in large gardens on a main road, within a short drive of several local towns and approximately half a mile from local shops. Three bedrooms are on the first floor. One bedroom is in an annexe to the rear of the home, with its own lounge. 6 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 29 Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate 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: Please note residents have complex needs and this makes it harder for them to express their views verbally. We spent time talking to six members of staff about how they help and support the residents and about their training and development needs. We saw staff help residents with their range of care needs. We looked at a number records that relate to the running of the home as well as care records. The records we saw included a copy of the statement of purpose, the service users guide, one residents care plan, four medication records, menus, the complaints procedure, staff training files, the staff duty record, supervision information, accident records and the fire book. Care Homes for Adults (18-65 years) Page 6 of 29 We saw the home throughout. We found the home was operating within the required conditions of registration which we impose. The conditions of registration set out the type of care and the needs of persons as well as the numbers of persons who may stay at the home. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is useful information for people to find out about the service provided at the home. However the statement of purpose must set out the reasons for the use of the secure key pad system to enter and exit the home. Residents needs are assessed, however residents would benefit further if a suitably qualified person reviews nursing needs assessments. Evidence: We read a copy of the service users guide and statement of purpose to find out what information is available to read about the home. The statement of purpose is informative. There is a CD rom version of the service users guide for people who may prefer this. We saw photos included in the service users guide. The aims and objectives of the home and the type of care to be provided are clearly explained in both documents. The name and contact details of the Brandon Trust along with experience of staff are included. The service users guide includes a range of useful information about the home. However, there is currently no information in the statement of purpose about the reasons for the use of a keypad security system to Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: exit and enter the building. There needs to be up to date information about the reason for the use of the security pad system. There also needs to be information about the arrangements in place to assist people who do not require this additional security. This information is needed to demonstrate that the use of the key pad security system is in the best interests of residents. To see how well residents are supported to meet their needs we looked at one residents assessment record. We saw that an assessment of the residents physical, mental health and social needs has been carried out. The assessment included a personal profile about the person. This includes the persons life history, social history, mental health history and information about family and friends. The assessment record had been evaluated and updated on a regular basis. However one main part of the persons assessment had been clearly identified as being a nursing needs assessment. The assessments had been signed and dated to say it had been reviewed. However it had not been formally evaluated and updated by a registered nurse. This is required to ensure that the residents nursing needs are clearly identified and they can still be met. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents care plans mostly show how needs are met. However peoples legal rights may not be being fully upheld. Residents are being supported to take risks in their daily lives. Evidence: To see how well the needs of residents are assessed we read one persons assessment record and care plan. We saw a detailed assessment had been carried out of the physical, mental health and social needs of the person. We also saw in the assessment information about the likes and dislikes of the person and their preferred choice of social and therapeutic activities. The assessment had been written in a person centred style, this helps staff to see the person as a unique individual with their own wishes and aspirations. We saw evidence recorded in the assessment that it had been regularly evaluated and updated, (Please see also our comments about nursing assessment information in the previous section of the report ). This helps to show us Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: that residents needs are monitored. To find out how well residents needs are met we read one care plan. We saw detailed information written setting out how to help the resident with their complex health needs. However due to one persons really complex needs that have directly impacted on the other residents, a decision has been made to provide the person with care in a small flatlette in the home. This area is kept secure and the person has at least one to one support from staff. However we could not find any up to date information in the care plan written to explain the reasons for this practice. The staff we met explained to us the safety reasons for the person living in a separate, secure part of the home. We told the acting manager that as this is considered a deprivation of a persons liberty, there needs to be a robust, detailed, accurate and up to date written assessment in place to explain this practise. The staff who we met conveyed in discussion and through observations that they had a good understanding of the needs of the residents. We saw staff talking to people in a warm and patient manner. This helps to show that residents are well supported by staff. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are really well supported to take part in a range of social activities. Residents are supported to be a part of the community. Residents are well supported to have personal relationships. Evidence: Residents are really well supported by staff so that they can go out on a daily basis and do a range of social and therapeutic activities. We saw one resident go out in the homes minivan for an afternoon trip to Leigh Woods and then for dinner. We also saw one resident go out for a drive to Clevedon with the support of day care staff. This is a good way for residents to be able to take risks in their daily lives. We saw detailed information in the care plans about potential risks the person may Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: face, and any risks from particular activities that they take part in both in and out of the home. This is good evidence that shows residents can live a varied and meaningful life in and out of the home. We saw a good range of information written in residents records that showed staff aim to support them to maintain their independence in their daily living. We saw that residents get up at different times during the morning. This is a good way to demonstrate that residents different preferences are respected. We were told that the home has an open policy about visitors. There are residents who have friends and family who come to the home to see them. One resident went out to meet family during the inspection. The lunchtime meal was cold meat sandwiches. Staff were asking residents what they would like for lunch. This is a good example of residents being able to exercise choice in their lives. We looked at the residents menu choices to see if residents eat a varied and well balanced diet. The meal choices we saw were well balanced and varied. One of the residents very kindly made us lunch during the inspection, we were made a ham sandwich which was really tasty. Care Homes for Adults (18-65 years) Page 15 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are being well supported with their needs. Residents medication is overall being administered and disposed of safely. However a risk assessment needs to be done to make sure the use of security waist money belts (by staff) to carry medication in is safe. Evidence: We saw a health check record maintained in residents care records of the persons physical health needs and medical appointments. This record shows us when residents opticians, chiropody, dentist and GP appointments have taken place. This helps to demonstrate how residents health care needs are being met. We saw information in the daily records that showed that staff monitor and observe the health of residents and call the doctor, if they are concerned about the health of the residents. We saw information that showed that residents receive support and treatment as required from the specialist Psychiatrist. Staff explained to us that they monitor residents physical health as well as provide emotional support. This helps to Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: demonstrate that residents health care needs are being met. As we have already mentioned earlier in the report, we saw evidence in the care records that showed that the preferred daily routines of residents and particular likes and dislikes have been recorded. This helps ensure residents needs are met in the way that they would like. The staff we met were familiar with the information in care plans and how best to support people with their care needs. We looked at the procedures and systems in place for administration storing and getting rid of residents medication to monitor if the systems are safe. We looked at the medication administration charts of four residents. We saw a photo of the person kept with each record. This should ensure medication is administered correctly to the person named on the chart. The medication administration charts were legible, up to date and contained the signature of the dispensing member of staff. This demonstrates medication is given to residents safely. The reasons for any omissions had also been written on the charts. However we were told by the staff that due to specific residents very complex health needs they carry medication in money belts around their waist. The staff told us this is done to ensure medication is given very promptly if needed. We spoke to our regional pharmacy inspector after the site visit to the home. The pharmacy inspector advised the home to carry out a full risk assessment, setting out the reasons for this current practice and also taking into account any other more suitable ways of storing the medicines concerned. The stock of medication held in the home was satisfactorily organised. Care Homes for Adults (18-65 years) Page 17 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported to make complaints about the service. There are systems in place to protect people from abuse. Evidence: We looked at the complaints record book and we saw that there had been no recent complaints made about the service since before the last inspection. One of the residents has an outside advocate who represents them and supports them in making sure their views are properly represented. This is a good example of making sure residents rights are upheld. The staff that we met demonstrated a good understanding of supporting residents if they think the person concerned wants to make a complaint. Staff explained that they advocate for residents and ensure their views are made known. We saw procedures and guidance information on safeguarding vulnerable adults from abuse. This helps to protect vulnerable adults who live at the home if staff can get hold of the right information to ensure their protection. The staff do training to help them better understand issues around the protection of vulnerable adults from abuse. Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: The staff on duty were able to explain the procedure they would follow if an allegation of abuse was made in the home and that they would report without delay all such allegations to the appropriate senior member of staff. Care Homes for Adults (18-65 years) Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home that is suitable for them. The home is clean and generally satisfactorily maintained. However parts of the communal areas are not adequately decorated. Evidence: The Rambles is in a residential area of the village of Farleigh in North Somerset. The home is a short distance from the main shopping area of the village. The home is near to a bus stop, local shops, coffee shops, a pub and a church. This means residents are able to be a part of a community if they want to be. The home is a two storey building and people use all parts of the building. There is no lift so the home may not be suitable for someone with reduced mobility. We found the home looked satisfactorily clean in all areas that we saw. The environment looked to be generally satisfactorily maintained. One resident kindly showed us their bedroom. The bedrooms looked clean and adequately maintained. All bedrooms are for single use. We saw that rooms had been decorated in different colours, this should help to makes rooms more personalised for Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: the residents who live in them. Residents had their personal possessions in their rooms. We saw residents sitting at the dining room and in the lounge together. We noticed that residents looked relaxed in their environment. However the standard of decoration in communal areas is noticeably poor, wallpaper has come off the walls along certain corridors and in parts of communal rooms. This detracts from the homeliness of the environment that the residents live in. We saw bathrooms near to communal areas and bedrooms. However we were told that due to the needs of some of the residents, the bathrooms and toilets do not have clean hand towels and soap in them. We advised that a suitable way of ensuring these items are easily available for people must be put in place. It could make people experience a loss of dignity to have to ask for toilet paper soap and towels. This could also increase risks in the home from cross infection. Care Homes for Adults (18-65 years) Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are met by enough, competent and qualified staff. Evidence: We looked at the staff duty record for July of this year to check on the number of nurses and care staff who are on duty to support residents to meet their needs. We saw that there are a minimum of five staff on duty for a day shift consisting of care staff and registered nurses. There are three staff at night including one registered nurse. We saw the residents being very well supported by the numbers of staff on duty. We also saw residents go out into the community and for a drive in the country. The staff we spoke to demonstrated that they had a very good understanding of how to support the residents if they became agitated and angry. Based on the evidence from the inspection the number of staff on duty at any time are meeting residents needs. We did not fully check recruitment procedures on the inspection. Brandon Trust keep staff records at its head office. We carry out regular checks of staff employment files at the head office to ensure the Trust follows safe recruitment practices to protect residents. We did find out during the site visit to the home that the two most recently recruited staff had completed Criminal Records Bureau checks to make sure they are Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: suitable to work in the home with the residents. We saw a sample of four staff members training records. We saw evidence that staff had done training and updating of their knowledge in matters relevant to the needs of the residents over the last twelve months. All the staff we met demonstrated to us a really good understanding of the very complex needs of the residents who live at the home. The staff said they also work well as a team and that they communicate among themselves very effectively. This benefits residents if they are cared for by a supportive team of staff. Care Homes for Adults (18-65 years) Page 23 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a new management structure in place for the effective running of the home. There are ways for residents views to be listened to and represented. The health and safety of residents and staff is protected. Evidence: The home is currently run by an acting manager who also runs another care home for Brandon Trust. The acting manager will be applying to us to be registered as the manager for the home. They are supported in their role by a lead nurse as they themselves are not from a nursing background. The staff who we met, said after a period of time with no manager things had, improved having someone in charge of the home. There are residents house meetings held with residents and staff. We saw recent meetings records and these showed us that staff were helping residents to make Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: choices for the menus in the home. This is a good example of residents being supported to make their views and wishes known. We did not look at any specific quality monitoring information about the service. We did discuss this subject with the acting manager who told us that they are monitoring and reviewing overall standards of care in the home at this time. We found that the environment looked safe and generally satisfactorily maintained in the areas we saw. See also our previous comments in the report about the environment. The staff do regular training in food hygiene. This is a really good way for staff to help residents to prepare and cook food in a safe way. The home has just been awarded a five out of five star award from North Somerset Council environmental health department. This is really good evidence to show that staff handle food really safely in the kitchen. The staff do training in health and safety matters including first aid, infection control and fire safety. This should help protect residents if staff are knowledgeable and well trained in health and safety subjects. The fire logbook record was checked and showed us that weekly and monthly tests of the fire alarms and the fire fighting equipment were being carried out and were up to date. Care Homes for Adults (18-65 years) Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 4 The statement of purpose 21/07/2009 must set out the reasons for the use of the keypad entry and exit system to the home. There must also be guidance for people who do not require this security. The legal rights of residents. 2 6 15 Care plans must include a deprivation of liberty assessment if residents freedom has been been restricted. This requirement relates to the locking of a residents door to their living accommodation. Legal rights of residents. 21/07/2009 3 24 23 A programme of redecoration 08/10/2009 in the home must be put in place. To ensure residents live in a homely and suitable environment. 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 Care Homes for Adults (18-65 years) Page 27 of 29 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 2 2 19 Nursing needs assessments should be reviewed and updated by a suitably qualified person. Undertake a risk assessment for the use of security waist money belts by staff to carry certain residents medications in Ensure people have soap and hand towels for bathrooms and toilets, to wash and clean their hands. 3 30 Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!