Inspection on 19/05/09 for No 9

This inspection was carried out on 19th May 2009.

CQC found this care home to be providing an Adequate 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

No 9 22/01/10

No 9 22/05/08

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Tyne and Wear Autistic Society 9 Thornhill Park Sunderland SR2 7JZ     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: Hilary Stewart     Date: 1 9 0 5 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: Tyne and Wear Autistic Society 9 Thornhill Park Sunderland SR2 7JZ 01915154656 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Jaqueline Herbison Mr David Wake Type of registration: Number of places registered: Tyne and Wear Autistic Society 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 only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Learning Disability Code LD - maximum number of places 6 Date of last inspection Brief description of the care home Evidence: The home is a large Victorian semi detached house next door to another TWAS registered home. There is a good-sized front garden at the front and a small, enclosed space at the rear. Inside the home is spacious with all rooms far exceeding NMS. Decor Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 6 Brief description of the care home has been kept neutral to minimise distraction and arousal, and allows each room to be personalised according to assessment and personal choice. The accommodation includes: Entrance porch Hall with staircase to all floors Lounge Dining room Kitchen - with a significant amount of work and storage space. WC Garage and laundry - this space may be adapted to create an indoor leisure area Six bedrooms, all are adjacent to the two bathrooms. One bed has been specifically supplied in accordance with assessed need. Sleep in room Office - fully equipped. All facilities, fixtures and fittings are of good quality. The home charges from 1649.77p to 2115.38p per week. 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: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. How the inspection was carried out Before the visit we looked at the information we have received since the last visit on 22nd May 2008. How the service dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The providers view of how well they care for people and the views of people who use the service and the staff. An unannounced visit was made on 19th May 2009. During the visit we observed the people who use the service as they were unable to Care Homes for Adults (18-65 years) Page 6 of 29 communicate their views. We talked to the staff and the manager and looked at information about the people who use the service and how well their needs are met. We looked at other records which must be kept and checked that staff had the knowledge, skills and training to meet the needs of the people they care for.We also looked around the building to make sure it was clean safe and comfortable. We checked what improvements had been made since the last visit.Then we told the manager what we found. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? What they could do better: Care Homes for Adults (18-65 years) Page 8 of 29 A record is kept of the food served to each resident at the home, if this was more detailed it would show that they all have a satisfactory diet which is varied and nutritious. This will help them to maintain their health. If repairs were carried out in the bathrooms. Also the broken radiator covers and the holes in the walls were repaired this would make it less likely that of the people who live at the home or a member of staff may injure themselves. If all of the care plans stated how many staff and of what gender were needed to support people staff would be sure they were providing the people at the home with the support and care they need. If the residents financial records were accurate and correct this would make sure that their money was accounted for and show that the home was safeguarding them and protecting their interests. 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 9 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 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, 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 have their needs assessed before they move into the home. The manager will only offer as placement if they know that the assessed needs of the person can be met at the home.They then use this information for the care plan. People can visit the home before they make a decision. Evidence: The manager said that the people who live at the home have had their needs assessed before and after they move in. A person can only move into the home if they are certain that their needs can be met there. The manager said that the assessment is carried out by them or their manager. They carry out a three day assessment which includes collecting information from any previous placements. People can visit before they move in permanently, so they can be gradually introduced to the other people who live there. 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 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 care plans for each person who lives there so staff have the information they need to meet the needs of the people at the home. Some needed more detail. People are supported to become more independent but at the same time staff look at the risks to keep them as safe as possible. Evidence: The manager said that the people who live at the home are consulted as much as possible about their care plans. Each person has a key worker who supports them to develop and agree their care plan. As the people at the home have Autistic Spectrum conditions they did not give their opinions during the visit. Records showed that each person has a care plan. Each persons care plan contained information for staff about areas such as the persons physical health, personal care needs, social skills and activities timetable. The plans had enough detail for staff to know how to support the people at the home. However it did not state in personal care plans what gender of staff or how many were Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: needed to carry out personal care tasks. For instance one person needs support to have a bath but it did not state in their plan the number or gender of staff needed to carry out the task. The staff could describe how they work consistently with the people and they knew how to support them. Records showed that the care plans are monitored regularly and updated. The manager said that they plan to introduce an electronic person centered planning system in the near future. Staff said that the people who live at the home are given choices as much as possible.They take part in planning the activities.Their timetables showed that they had different individual activities. The manager and staff said that they consult the people who live at the home as much as possible. There are some general risk assessments about the home itself and also individual ones to support the people to have a more independent lifestyle. Records showed that risk assessments had been carried out on daily living and activities for each person. The manager said that they update them regularly. People are supported to become more independent but at the same time staff look at the risks to keep them as safe as possible. 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. The people who use the service experience healthy stimulating activities, supported by staff who value them, while maintaining links with their families and friends. This means they can have new experiences and interests and do not become isolated. They are provided with varied nutritious meals more detail is needed in the records. Evidence: The manager and staff said that they arrange a variety of outings for the people who live at the home. Records showed that some people had been involved in a variety of activities such as going out shopping or for walks. Some people had been to a disco and a pub. The manager said that they hope to support the residents to plan a holiday. Last year some people had gone to a safari park . Some people havent decided where they want to go yet , one person wants to go to Butlins. On the day of the visit two people had gone bowling with staff another had gone out Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: for their lunch. The manager said that the organisation that runs the home have employed an activities coordinator which the home will be able to access. The manager said that all of the residents attend college. Staff and the manager said that relatives and visitors are welcome and encouraged to visit at any reasonable time throughout the day and evening. Records showed that people who live at the home had received visits from friends and other people involved with their care. The manager said that the residents have been asked for their opinions about the food provided as much as possible and the menus are based on their likes and dislikes. Special diets can be catered for. One member of staff said they have a choice every day and we get plenty of money for food. Hot drinks and snacks are always available throughout the day and evening although some people need support from staff for their safety. The manager that this has been risk assessed, if people can not independently use the kitchen, the reasons for them needing support are written in their care plan. The kitchen was well stocked and there was fresh fruit and vegetables. Staff were observed sitting with people at meals times and talking with and supporting them.The manager said that the meals served at the home are the choice of the people who live there. Meals served at the time of visit looked appetising and nutritious. The people can have a meal different from that displayed on the menu if they choose. The manager said that food served is recorded for each person. Records needed more detail to show that each person was having a varied nutritious diet every day. The daily routines within the home are structured around the people who live at the home. Sufficient staff were on duty to enable residents to take part in activities individually. The activities are based upon what the people like to do. Staff and the manager said that the people are involved in domestic routines. 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. People have personal support when they need it so they can be as independent as possible. Health care needs are met, which ensures that people stay healthy. Evidence: The care plans identify the personal support that the people need with everyday tasks. They had enough detail for staff to know how to meet their personal and emotional needs. The manager said that the home has a key worker system which enables individuals to identify with a particular member of staff. Staff could describe how they meet the care needs of the people at the home. One member of staff said we try and promote independence as much as possible one health professional, when asked what they thought the home did well said support the service users to live life to their full potential. The manager said that staff respect peoples privacy and dignity. Staff offer guidance and support around peoples hygiene and well being for example advice on what to wear for certain occasions. Staff were observed treating people with respect and consideration during the visit when one person experienced a seizure. Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: The manager said that peoples ability to self medicate has been assessed by their care managers. At the present time no one at the home self medicates. The manager said that all staff who administer medication have completed a twelve week training course and have been assessed as competent in this area. A photograph of each person is on their medication care plan as a safety measure. The medication records were up to date and complete. Staff were familiar with the homes procedures and one member of staff demonstrated how they could safety administer medication. At the front of then medication file there was a list of staff specimen signatures. Not all staff had completed them. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are dealt with so any problems are taken care of quickly which helps good relationships to be maintained. Staff know about and all have had training in how to protect people from harm, so the people who live at the home are kept safe. Records of residents finances were incorrect. Evidence: Policies and procedures are in place that demonstrates how the home responds to complaints. The manager said that the home had not had any complaints since the last visit. Staff actively encourage the people who live at the home and their families to tell them their opinions of the service as much as possible. All of the people are given a copy of the homes complaints procedure when they move in. The service has policies and procedures on safeguarding adults to inform staff what to do if they think a person at the home could be suffering from abuse.The manager said that staff are more aware of the signs and symptoms and the need to report suspicions of danger harm or abuse immediately. The manager and staff could describe what actions they would take to safeguard the people who live at the home from potential abuse. Staff said that they had received training in the procedures they need to follow to raise an alert. The manager said that all staff are to receive refresher training in the next twelve months. The manager and staff said that they have received training in how to manage Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: peoples behavior. They do use physical intervention at the home. The manager said that all staff have been trained in accepted forms of physical intervention. One member of staff said we get refresher training once a month. Records showed that when a physical restraint occurred it was recorded in detail in a bound book. A check was made of the residents money held at the home. All were found to be incorrect and did not tally with the amounts recorded in the homes account book. The manager said that this would probably be staff error and that they would deal with this immediately. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe and clean home, although some repairs and improvement are necessary. Evidence: The home is comfortable, warm and clean. There are enough bathrooms and showers for the people who live at the home.The manager said that there are plans to improve the bathrooms. The sealant in one bathroom needed to been replaced around the bath and on the floor as there was a gap in the covering which could make it difficult to clean properly and lead to a risk of cross infection, the bath panel was damaged. All of the bathrooms had hand soap and paper towels. The radiator cover in the top and middle bathrooms were damaged and could cause injury. Staff said that the radiator covers that are made of hardboard and get damaged quite frequently. The landing light did not not work and one of the bedroom doors was damaged. Each person has their own bedroom and they looked comfortable and clean. They were all personalised and made very individual. One of the rooms had locks on wardrobe doors, the manager said that this was risk assessed and the reasons for this Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: were written in the persons care plan. The laundry is organised and clean. 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. Sufficient numbers of staff are in post to meet the diverse needs of the people who live at the home and they have opportunities for training so they know how to give them good care and meet their needs. Furthermore the home has a recruitment procedures in place, which help to prevent risk of harm to the people who live there. Evidence: Staff said that they receive training, which helps them with their work. The manager said that all staff receive the training and support they need. Staff said and records showed that they all have mandatory training such as first aid, food hygiene and safeguarding adults. The manager said that all staff have undertaken vocational training. One member of staff said the training is very related to the work another said I would like to start my NVQ3. Sufficient staff were on duty at the time of the visit. Staff said and records showed that sufficient staff had been on duty in the home the previous week.The manager said that they always manage to cover sickness and holidays. One member of staff said there are usually plenty of staff and another said the unit is fully staffed. The manager said that all staff have been CRB Criminal Records Bureau checked at an enhanced level to make sure they are suitable people to work at the home. All staff go Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: through a recruitment process and they cannot not start to work at the home until this is completed. They are interviewed and are only successful when they have two satisfactory references. Copies of staff records were not complete at the home. The manager said that the organsiation human resources department have all of the records. However they do see the checks. 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. The registered person is qualified and experienced and runs the home in the best interests of the people who live there and there are procedures in place that make sure they are protected as much as possible. Evidence: The manager said that the people who live at the home and their families are asked their views about the running of the home as much as possible and quality assurance audits are carried out every quarter. The information is used to improve the service. One of the improvements was to send out news letters to families. Staff said and records showed that the people have key workers who monitor their care at the home. The people who live at the home were unable to make their opinions known during the visit as they all have difficulty communicating verbally with people. However they looked comfortable and relaxed with the staff. Staff were observed supporting people to communicate their needs by offering them choices for instance giving them a choice at meal times and a choice of trips out. Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: Safety checks have been carried out on the equipment in the home such as testing electrical equipment and the servicing of the central heating boiler. Fire safety risk assessments had been completed. The fire logbook showed that fire drills and fire instruction take place. Staff said that they have fire drills and instruction. Records showed that regular training is provided for staff in fire safety and first aid. The manager said and records showed that they are qualified and experienced to run the home effectively. It was observed that there was a friendly atmosphere at the home and a pleasant rapport between the people who live their, the manager and staff. The staff said that they could approach the manager with any concerns. Staff said that they liked working at the home. One member of staff said there is always good communication within the unit another said we definitely get enough support. The manager said that staff receive individual supervision six times a years and they have regular staff meetings. Records showed that individual formal supervision takes place. 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 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 17 The manager must keep an 22/06/2009 accurate record of all money deposited by service users. The record must show the date on which any money was used. Residents money must always be accounted for in a clear and transparent way to make sure they are safeguarded. 2 24 13 The manager must make sure that damaged radiator covers are replaced or repaired and the sealant around baths is repaired or replaced. They could cause injury or cross infection. 30/06/2009 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 6 17 All care plans should state how many staff and of what gender are needed to support people with personal care. The manager should make sure that a detailed record is kept of food served to each person at the home to demonstrate that each person is having a well balanced nutritious diet. The manager should make sure that all staff have signed the specimen signature list in the homes medication records. 3 20 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. 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