Inspection on 25/02/09 for The Red House Nursing Home

This inspection was carried out on 25th February 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Red House Nursing Home 07/08/08

The Red House Nursing Home 16/08/07

Extracts from inspection reports are licensed from CQC, this page was updated on 20/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Red House Nursing Home Main Street Maids Moreton Buckinghamshire MK18 1LQ     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: Barbara Mulligan     Date: 2 5 0 2 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 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 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.csci.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: The Red House Nursing Home Main Street Maids Moreton Buckinghamshire MK18 1LQ 01280816916 01280924344 redhousenursing@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Paramjit Sohanpaul The registered provider is responsible for running the service care home 32 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 0 dementia Additional conditions: 32 The maximum number of service users who can be accommodated is: 32 The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia (DE) Date of last inspection Brief description of the care home The Red House is a large detached house in a quiet lane in the small village of Maids Moreton, close to the market town of Buckingham. The home is on three floors with shared and single accommodation. There is a lounge, dining room and conservatory on the ground floor. The home has pleasant gardens, with seating for residents and families. There are public transport links with the local town. There are qualified nurses on duty at all time, supported by a team of care staff. Residents register with the local general practice. Care Homes for Older People Page 4 of 29 0 7 0 8 2 0 0 8 Care Homes for Older People 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: two star good 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 unannounced key inspection was conducted over the course of one day and covered all the key National Minimum Standards for older people. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion. Information received by the Commission since the last inspection was also taken into account. The Commission received seven CSCI surveys from people who use the service. The inspection officer was Barbara Mulligan. The registered manager is Julie Roche. The inspection consisted of discussion with the registered manager and other staff, opportunities to meet with some people who use the service, examination of some of Care Homes for Older People Page 6 of 29 the homes required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff and service users 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? Medication practices have improved to ensure residents are protected from potential medication errors. The presentation of meals has been reviewed and the nutritional needs and the presentation of meals has improved. The security of the home and gardens has been reviewed and coded door locks and garden security has improved to ensure that residents have as much freedom as possible whilst minimising the risk that they may come to harm or become lost. Infection control procedures have been strengthened. There is liquid soap and paper hand towels in residents rooms, for use by staff, to reduce the risk of cross infection and residents no longer share hoist slings. All staff files have an upto date photograph of the staff member. Care Homes for Older People Page 8 of 29 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.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 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 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 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. Service users needs are assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. Evidence: Four completed needs assessments were examined, including those most newly admitted to the home. The assessment tool covers personal details, current and past medical history, medication taken on admission, allergies, personal history, mobilising, breathing, diet/nutrition, skin care, vision, hearing, oral care, orientation/mental state, behavioral difficulties and communication. All the assessments examined were fully completed and signed by the person completing the assessment. The pre-admission assessment has been reviewed, which enables the home to assess how they are able to meet the diverse needs of potential clients. Care Homes for Older People Page 11 of 29 Evidence: This information is readily available to staff who are expected to refer to the documentation to meet service users care needs. It is noted that the service users have been asked their preferred name which is indicated throughout any further documentation seen, this is noted as good practice. The assessment demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. In the homes compliment folder one comment made about the home said, the home was the nicest we looked at. It was clean, nice smelling, comfortable with nice food and lovely staff. The home does not admit service users for intermediate care. Care Homes for Older People Page 12 of 29 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. The health and personal care needs of people using the service are well met, with personal care delivered in a way that promotes respect and dignity. Evidence: The inspector case tracked the care of four people using the service, including those new to the home. Care plans were examined for these four individuals. At the previous random inspection care files were muddled and not user friendly. Although information needed was present in the documentation in most cases, it was not easily identified. During this visit it was noted that there has been improvement in this area and all care plans were in good order, presented in an easy to use format and were user friendly. The home has made improvements to the care planning documentation These are very detailed and informative and reflect the changing needs of the individual. Care needs are identified with a detailed action plan setting out guidelines detailing how staff will Care Homes for Older People Page 13 of 29 Evidence: meet those needs. All care plans observed are of a good standard. Care plans identify the social care needs of residents, and there is a diary that records what activities individuals have participated in. There was evidence that care plans are reviewed monthly and it is noted that this is a thorough process and not just no change written. Daily notes are detailed and informative and record the personal care received and activities that the individual has undertaken throughout the day. Most of the people using the service are registered with the same GP practice. The registered manager said they can register with their own GP if this is practical and agreeable to both parties and this was the case for two individuals living in the home. All service users have access to local NHS Services and this is evident in the care plans. Tissue viability assessments are in place for service users and these were seen to be reviewed on a monthly basis and pressure relieving equipment is in place for individuals who need it. A domiciliary optical service visits the home on an annual basis and as needs arise. Nutritional risk assessments are completed for each person and weight monitoring is undertaken on a monthly basis and recorded. This was evident in the four files examined. Chiropody services visit the home on a six weekly basis. The home has a regime to prevent pressure sores in the provision of inflatable mattresses, monitoring of nutritional and fluid monitoring and other related health needs. There are turn charts, pressure relieving mattresses, appropriate skin preparations and fluid charts in place for people who have a pressure sore. There is a health care appointment sheet in each file and these are completed for visits by the visiting GP and other health care professionals. In general the medication protocols are well managed, organised and safely stored. Controlled medications are stored appropriately and a new controlled medicines cabinet has been installed following a requirement issued at the previous random inspection. The controlled drugs register was fully completed with two signatures for all entries. Medication Administration Records (MAR) were examined. Two people using the service had omissions for the 9:30pm medication the previous evening and a requirement is made for improvement in this area. Any medication administration record charts which were written in the home and those sampled during the visit were correctly written. At the previous random inspection it was identified that there was an absence of recording of the administration of skin preparations and dietary supplements and a requirement was issued for improvement. It is pleasing to see that this has been complied with and signatures were present for all skin preparations and dietary supplements. Clear guidance has now been provided for one service user who is prescribed as needed rectal medication for seizures. At the previous random inspection it was noted that there were no written guidelines Care Homes for Older People Page 14 of 29 Evidence: for many PRN medicines and this was often left up to individual nurses discretion to administer. A requirement was issued for clear guidance to be recorded within care plans for the management of PRN medicines. During this visit it was noted that information for the management of PRN medicines has been handwritten on each MAR chart and it is strongly recommended that this information is recorded within the care plans and contains more detail. On the whole people get their medicines as prescribed by their doctors. All medicines are given to people who use the service by trained nurses and no one looks after their own medicines. Medicines were stored securely for the protection of people who use the service. Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The routines of the home are flexible and residents have a choice as to how they spend their day. The meals are of a good standard and meet peoples nutritional and social needs. Special foods can be made available to meet residents heath, religious or cultural needs. Evidence: The routines in the home are flexible and care plans show preferences as to when they get up and when they go to bed. They are able to have meals in their room if they wish and this was the case for several individuals on the day of the visit. The home employs two people who undertake the role of activities coordinator. One works for two days and the other for three days. The registered manager said this has only become permanent in the previous ten days but was already proving to be beneficial to the home. The inspector was informed that the two activities coordinators will be meeting shortly to arrange a time table of organised activities for the home. On the day of the inspection a small group of people using the service were going out to lunch at the local pub. Examples of other activities include cooking and cake making, bingo, an excercise class and a film club in the afternoons. The home is hoping to Care Homes for Older People Page 16 of 29 Evidence: introduce a gardening club in the near future. The registered manager said that when people are being nursed in bed they will be visited by an activities coordinator who will massage hands, or paint nails or read which ensures people do not become socially isolated while being nursed in bed. The management ensured that the home keeps in contact with the local community and said that there is a monthly church service and a Roman Catholic priest visits the home to give Communion. There is a visiting hairdressing service and various visiting entertainers who visit the home. This was the case on the day of the inspection and the visiting musician joined service users for lunch. Menus were examined. These work on a four week rotating cycle and the inspector was informed that these are changed two or three times a year. The registered manager said that staff will discuss the menu with residents at breakfast time to ascertain their choice of meals for the rest of the day. Menus show a good choice of meals, and sweets. The inspector observed a lunch time meal in the main dining room. All meals were nicely presented and portions were adequate to meet the nutritional needs of service users. Overall the meal time was unhurried with service users being given sufficient time to eat. Staff were observed to be sensitive in their approach to residents and were seen to persuade individuals to eat in an appropriate manner. Nutritional screening in files was good. Service users are weighed on a monthly basis and a nutritional assessment was in place for all residents. Supplement drinks are available for people who need it. Care Homes for Older People Page 17 of 29 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints and safeguarding policies and procedures work well and residents and families feel their views are listened to. Evidence: The home has a complaints procedure, which is accessible to service users and their representatives. The Annual Quality Assurance Assessment informs us that the home has not received any complaints in the last twelve months and examination of the homes complaint log confirmed this. There is a copy of the complaints procedure in the complaints log and the address for the Commission needs to be updated. There is an updated complaints procedure in the entrance hall. There complaints procedure is contained within the Service Users Guide and Statement of Purpose. The Commission for Social Care Inspection has not received any complaints about this service since the previous inspection. Most residents and their families who returned the questionnaires said that they knew how to complain and who to complain to. Procedures are in place for the protection of vulnerable adults and staff have access to a whistle blowing policy. The home has a copy of the local authority safeguarding vulnerable adults policy. Training records demonstrate that staff have undertaken training in adult protection. The staff who returned the questionnaires also said that they knew what to do if a Care Homes for Older People Page 18 of 29 Evidence: resident, their family or anyone else had concerns about the home. The Commission for Social Care Inspection has not been notified of any safeguarding allegations made to the local authority, which is the lead agency in these matters. Care Homes for Older People 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, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment within the home is good and is being upgraded, providing people who use the service with an attractive and homely place to live. The laundry area is in a state of disrepair and needs to be improved to ensure the control of infection is maximised. Evidence: The Red House is a nursing home providing personal care and accommodation for thirty older people. The home is situated in the village of Maids Moreton and accommodation is over three floors. There has been an ongoing programme of redecoration in the home since it has been bought by new owners. The dining room has been decorated, and has new furniture which has made it brighter and more homely. Interior doors leading onto stairways have been fitted with new coded locks for safety and the home has purchased new laundry equipment, new kitchen equipment and a new bathroom. Bedroom furniture including some new beds and chest of drawers, wardrobes, new lounge chairs & furniture, new garden furniture has been provided and the lift has been refurbished. Care Homes for Older People Page 20 of 29 Evidence: At the previous inspection a requirement was issued for the security of the home and gardens to be reviewed to ensure that residents have as much freedom as possible whilst minimising the risk that they may come to harm or become lost. It is pleasing to see that this has been complied with. Coded door locks and the garden has been made more secure with locks on the gate. The laundry area was observed to be in a state of disrepair. The floor was concrete and the finish not impermeable. Neither the floor or the walls in the laundry area are easily cleanable. The room is cluttered and although new laundry equipment has been purchased, the environment to undertake the laundry needs to be improved to ensure the control of infection. This will be a requirement of the report. Care Homes for Older People 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 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. Staffing levels are good and staff are encouraged to gain qualifications in care. Recruitment procedures are thorough and protect residents from unsuitable carers. Evidence: The homes staff rota demonstrates that there are adequate numbers of staff on duty at all times to ensure the personal and healthcare needs of residents are met. Feedback from staff surveys is positive about the staff training and one comment made said, there has been an improvement in the staffing and we are being offered a lot of extra training and a further comment made from a relative said, you dont have to worry so much because you know the staff know your relative and mum is happy, she knows all the staff and they know her. The care team are also supported by full time housekeeping laundry and catering teams. The home continues to support staff on NVQ training and at the time of this inspection sixteen care staff had completed NVQ level 2 training or above and four were working towards this qualification. The registered manager explained that the home employs a multi-cultural workforce and equality and diversity issues are addressed both by people living in the home and staff. The recruitment files for the two most recently appointed staff and a further two Care Homes for Older People Page 22 of 29 Evidence: files for staff recruited several years ago were examined. All files looked at contain the necessary documentation as detailed in schedule 2. There was evidence that the persons identity had been checked, two references had been obtained and criminal records bureau disclosures sought. The Annual Quality Assurance Assessment tells us that all the people who have worked in your home in the past 12 Months, whether they be permanent, temporary, agency or volunteer have had satisfactory preemployment checks. The registered manager said that the home has its own Induction Programme which includes in-house policies and procedures and mandatory training. There is evidence in the files examined that staff have completed an induction. Four staff training files were examined and these show that mandatory training has been completed for care staff and nurses. Evidence of further training seen in staff files includes epilepsy training, challenging behaviour, managing violence, nutrition, equality and diversity and understanding and preventing MRSA. Care Homes for Older People Page 23 of 29 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 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 a consistent service to people using the service and there are systems in place to protect the health and safety of service users. Evidence: The manager has been in post since September 2006. Prior to this she was assistant manager for two years. The registered manager is a registered nurse and has completed the Registered Managers Award. Further training undertaken by the registered manager includes, first aid, fall and fractures, employment law, dementia awareness, health and safety and supervision and appraisals. Staff meetings take place regularly and staff spoken to confirmed this and copies of minutes of the meetings are held on file. There is a quality assurance programme in place which the registered manager sends out to relatives/representatives twice yearly. The home also holds regular relatives meetings and minutes are available to view. The registered manager undertakes a Care Homes for Older People Page 24 of 29 Evidence: range of regular audits including a care plan and medication administration audit. There are records of monthly visits on behalf of the registered provider and there is a folder containing compliments and thank you letters, mainly from the relatives of service users. Secure facilities are available for the safekeeping of valuables if required. The home does not manage residents money on their behalf. Small amounts of personal allowance may be kept in the home. Records are kept and receipts are given for any expenditure incurred on behalf of residents. Records were seen for fire safety. These cover the homes fire procedures, practice fire drills, fire prevention, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm system is undertaken on a weekly basis and evidence was seen of this. There is a fire based risk assessment dated 17/09/2008. Evidence of mandatory health and safety training demonstrates that staff are up to date with this training. Service reports are in place for the maintenance of hoists and the lift. There are service certificates for PAT testing 04/07/08 and electrical installation 21/07/06. There was no evidence of service certificates for Gas appliances and this is not recorded on the AQAA. The inspector requests that this information is sent to the Commission. There are systems in place for water chlorination and kitchen hygiene. COSHH sheets are up to date and accurate. The inspector looked at Infection Control guidelines that are available for all staff. Care Homes for Older People 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 Older People 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 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 10 13 The registered person is required to ensure that complete and accurate records are kept of all medicines given to people. To ensure that service users are protected by the homes medication policies and procedures. 30/03/2009 2 26 23 The registered person is required to ensure the laundry area is in a good state of repair and suitable for purpose. To ensure the spread of infection is minimised. 30/09/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 10 It is strongly rcommended that the guidance for the administration of as needed medicines is recorded in detail within the care care pans. Page 27 of 29 Care Homes for Older People Care Homes for Older People Page 28 of 29 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. 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