Inspection on 14/01/09 for Willow Bank Nursing Home

This inspection was carried out on 14th January 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willow Bank Nursing Home 21/01/08

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Willow Bank Nursing Home 5 Barwick Road Leeds Yorkshire LS15 8SE     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: Paul Newman     Date: 1 4 0 1 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 28 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 28 Information about the care home Name of care home: Address: Willow Bank Nursing Home 5 Barwick Road Leeds Yorkshire LS15 8SE 01132647924 01132648414 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Maria Mallaband Ltd Name of registered manager (if applicable) Mrs Linda Ann Oram Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 37 The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. Date of last inspection Brief description of the care home Willow Bank is a privately owned nursing home, originally built in the late 1950s and has been used as a care home since 1956. Set around the east side of Leeds and close to the motorway junction, the home has a well-maintained garden and two sun lounges.. The home is situated within walking distance to the local shops, library, hairdressers, surgery, pharmacy and public house. Care Homes for Older People Page 4 of 28 care home 37 Over 65 37 0 Brief description of the care home The home offers long term, respite and transitional care, and has twenty-eight single and four double bedrooms all with en-suite facilities. The fee charged by the home ranges between 725 pounds and 745 pounds per week. This fee includes the nursing contribution. This information was provided on 14 January 2009, during the inspection. Fees cover the costs of accommodation, care and laundry, with the exception of chiropody, hairdressing and personal newspapers. Information about the home including a Statement of Purpose and Service User Guide are available at the home. Up to date information about fees can be obtained directly from the home. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home 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 is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means that the people who use the service experience good quality outcomes. The accumulated evidence in this report has included, the previous key inspection, a random inspection carried out in May 2008, information we have received from the provider since the last inspection, what the service has told us about things that have happened in the service, these are called notifications and are a legal requirement, relevant information from other organisations and information from people living at the home, relatives, staff and other health care professionals. Care Homes for Older People Page 6 of 28 One inspector made an unannounced visit to the home that lasted six hours on 14 January 2009. Before the inspection visit, we asked the manager to complete an Annual Quality Assurance Assessment (AQAA). This is a self assessment that if completed thoroughly should tell us how the home is meeting National Minimum Standards, where we can find the evidence for this, what improvements have been made since we last inspected and what improvements are planned in the next year. The AQAA that was returned was adequate but could have provided more detail and this was discussed with the manager but it did give enough information for us to plan for the inspection visit. During the visit a number of pre selected documents were looked at and most areas of the home used by people living there were inspected, including some bedrooms. Apart from spending time with the manager, a good proportion of time was spent speaking with staff, visitors and people living in the home. Time was spent in communal areas watching what was going on and checking how the staff cared for and supported people. Surveys were sent out prior to the inspection to a proportion of people living at the home, their relatives, staff and health care professionals. Feedback was provided to the manager and the departing and new area manager who attended later during the day. This included an analysis of the survey results. What the care home does well: What has improved since the last inspection? What they could do better: This was a positive inspection. Having explored other possibilities, the medication storage room must now be re sited. This will make sure that temperatures are safe for drugs to be stored in and comfortable for nurses to work in. The area manager felt that this could be achieved by the end of June 2009. Care Homes for Older People Page 8 of 28 Two recommendations are made. We noticed that records kept in peoples rooms, like turning for pressure care, needed to be recorded more consistently and should be checked in the care plan audits that are carried out. This will fully evidence that people are getting the care they need. Although there has been some very good work done by the new activity organiser, the Company should seriously consider extending the number of hours available for activities to further develop the opportunities for people living at the home. 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 28 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 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them 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. People can decide to live at the home based on up to date and accurate written information that is available and visits to the home so they have a clear picture of the services and facilities provided. People are properly assessed before admission so all concerned can be sure the home can meet their needs. Evidence: The home has a service user guide and statement of purpose on display in the reception area. These accurately reflect the services and facilities provided at the home and had been updated to reflect the recent change in area manager who is responsible for the home. Visitors spoken with said that they had looked at other homes before choosing Willow Bank for their relative. They had been warmly welcomed at the home, been given good information and felt there was a nice homely Care Homes for Older People Page 11 of 28 Evidence: atmosphere and this was the primary reason for making the choice to live there. Surveys that were returned showed that people felt they had been given enough information before making the decision. Three care plans were checked to make sure that a pre admission assessment had been carried out. There was different documentation used in the files and the level of detail varied, nevertheless the essential care needs had been identified and used as the basis of the plan of care. Easy care documentation was also held on file. There was a noticeable improvement in the level of personal detail (lifestyle preferences and choices) for people more recently admitted to the home. The Company has reviewed all of the care plan documentation and is introducing a new standardised approach. This was available for inspection and training has been provided in its use. Care Homes for Older People Page 12 of 28 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. People get the care they need and the care plans provide sufficient information and guidance to staff on how to meet peoples needs. People get the support and treatment of specialist health care professionals when they need it. People are treated with respect and live in a dignified way. Evidence: The three care plans that were checked showed that information from the pre admission assessment had been accurately used to complete a care plan. The home is introducing new standardised corporate documentation provided by the Company. This was available for inspection and training has been provided. The plans seen addressed individual health, personal and social care needs and are supported by a range of risk assessments. The written guidance for staff to follow was clear. Nutritional screening is done and there was evidence of monthly weight checks or more often if necessary. Care Homes for Older People Page 13 of 28 Evidence: The manager has been encouraging the development of care plans to include as much detail as possible to make sure that staff are person centered and know the personal lifestyle preferences and choices that make each persons quality of life and living experience at the home as good as possible. To further assist in this development, one member of the care staff has been given responsibility for the oversight of care plans and training of care assistants. One of the care plans checked was for a person who had risk of pressure sores. The equipment provided for this was checked and was working efficiently, but the recording of position changes that were required had not always been completed. This recording should be consistent and the care plan audits that are carried out should check these records. There was evidence in the care plans of contact with health care professionals and one survey returned from a doctor commented that the home communicates well and is sensitive to the needs of residents and their relatives. The home is involved in the Leodis Care Home project that dedicates healthcare services to the home. A nurse practitioner visits the home weekly and the GP with primary responsibility for the home made written comment in a survey that he felt the home generally did everything well. The home has a policy on the safe handling, storage, disposal and administration of medication. These were discussed with nurses on duty and observations and checks made including controlled drugs. These were sound. Previous inspection reports have made reference to the high temperature in the ground floor drugs storage room. The last year has seen daily monitoring of temperatures and several attempts to resolve the problem. A decision has now been made to re site the room. The surveys, conversations during the day and observations made, showed peoples dignity and privacy is promoted. People looked well cared for regardless of whether they were up and about or being cared for in bed. Staff were seen knocking on doors and making sure that doors were closed at times when personal care was being given and people spoken with said that staff look after them well and sensitively when assisting them with bathing, washing and dressing. Indeed the professional and warm way that staff related to people, including visitors, was one of the most positive features of the day. The views expressed in surveys were positive and these are some of the written comments made by people living at the home and relatives: A pleasant caring and professional staff who have always helped my mother. My Care Homes for Older People Page 14 of 28 Evidence: general impression is that the standard is very good. I have visited my wife almost daily over the last 20 months and am happy with the general atmosphere at Willow Bank. The nurses and carers are friendly and helpful. Similarly, the comments made during conversations with visitors suggest a high degree of satisfaction and they felt the home was good at letting them know when there were problems. Care Homes for Older People Page 15 of 28 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. People are able to keep in touch with family and friends and lead their chosen lifestyle as far as they are able. People have the opportunity to join in a range of social activities. People have nutritious meals and snacks that offer them choice so that they can eat healthily with support, assistance and encouragement if they need it. Evidence: The results of the CSCI surveys suggest that people are satisfied with these aspects of home life. At the last inspection visit in May 2008, we noted that there was not a lot going on for people but were told that the home was busy trying to recruit an activity organiser. There has been a most positive change since then. An enthusiastic person was appointed who has given the home some heart and changed the atmosphere. People living at the home now feel there are good activities for them to join in including trips out to pubs and shops. There is a range of activities provided in house that are announced on the news boards and in the newsletter that the organiser has started to publish. These include visiting entertainers and Motivation and Co. The Care Homes for Older People Page 16 of 28 Evidence: newsletter is good, containing lots of information, news articles, recipes, facts, picture gallery and puzzle pages. The organiser said that she felt well supported by management and had been able to gather lots of resources together that are being well used. The organiser spends time with individuals who are being cared for in bed. The organiser records the activities that people have been involved in and has ideas on improving the information recorded about people, their past lives, hobbies and interests and personal preferences. It is clear that there is still scope to build on this improvement as the hours available to the organiser are limited and the Company should consider extending these so that more time can be spent with individuals and groups. It was clear that relatives are encouraged to visit, there was a regular flow of visitors throughout the day. They said that they are made to feel welcome in the home, some said they think the staff are marvelous, there is plenty going on and that they are kept informed of important issues like changes in health or accidents. The home has links with local schools that visit and entertain especially at festival times. Local clergy visit twice monthly and provide opportunities for communion. The current cycle of menus seen, provides variety and choice and meets the special dietary needs of people who might be diabetic or need soft or pureed meals. Nutritional screening is carried out with monthly weight checks or more frequent if necessary. People enjoyed the main meal of the day and it was good to see staff supporting and encouraging where necessary. Comments from visitors and people living in the home suggest that the food is consistently good. People spoken with said that they enjoyed choice in their daily routines and are able to choose when they get up and go to bed and where and how they spend their time. They looked well cared for, were happy and the relationships with each other and with staff were relaxed. Care Homes for Older People Page 17 of 28 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. If people have concerns about their care, they or people close to them know how to complain and feel comfortable in doing so. Their concerns are looked into and actions taken to put things right. The care home safeguards people from abuse and neglect and takes actions to follow up allegations. Evidence: The home has a formal complaints procedure that is displayed in the reception area and is included in the service user guide. People and relatives spoken with said that they felt comfortable in raising issues. Regular residents meetings are held where they can air their views and make suggestions. People and relatives are encouraged to raise matters straight away so that things can be sorted out quickly, but where the formal complaints procedure is used, there are good records kept to show what the problem was, what actions were taken and how things were resolved. Staff spoken with and the training records seen showed that training is provided in recognising abuse and actions that must be taken if abuse is suspected. There are policies and procedures to support this. Other checks made during the inspection visit on recruitment, medication and money Care Homes for Older People Page 18 of 28 Evidence: held for safekeeping all met requirements. Care Homes for Older People Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe and well maintained home that is clean, pleasant and hygienic. Evidence: A tour of the premises was made and things were found to be clean, well maintained and to the credit of the housekeeping staff, free from unpleasant odours, especially taking account of the high levels of incontinence. Bedrooms were comfortable and personalised and there is a programme of redecoration and refurbishment. The manager has submitted her request for improvements over the next year and this is being considered by the Company. A priority must be the re siting of the drugs storage room so that drugs are stored and nurses work in comfortable temperatures. The home has a maintenance person who is able to keep up with general day to day problems and improvements and safety checks. Specialist equipment is provided as part of the necessary nursing care for individuals and requirements to move and handle people safely. Training is provided in its use. The emergency call system was checked and a speedy response made and the people spoken with said that this was normal. With the exception of the drugs storage room, no obvious health and safety hazards were noted and the records of safety checks on equipment were available and those checked were up to date. Care Homes for Older People Page 20 of 28 Evidence: The surveys and conversations with people suggest that they consider the home to have a homely atmosphere and always clean and tidy. Staff were seen to wear protective clothing, said there was always a plentiful supply and there was good attention to infection control. Care Homes for Older People Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent 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. People have safe and good support from staff who are competent and well trained. Staff go through a thorough recruitment process that includes checks to make sure they are suitable to care for them. Peoples care needs are met by staff whose training is kept up to date and are well supported and supervised by the manager. Evidence: The surveys that were returned and the conversations during the day give a clear indication that people, relatives and professional visitors think there are enough staff on duty and that they are well trained and competent. The home is good at retaining staff and the conversations with staff showed that they had a good team spirit and like working with each other. One newly appointed member of staff described the home as being one big family. A written comment in a survey returned by a member of staff summed up other views expressed during the day: All staff attend training regularly and fulfill NVQs in Health and Social Care. The nursing staff are there to support us and we them. We try to work as a team and always show empathy and understanding with all service users to give them the best care. The personnel files for three staff were checked to make sure the home carries out good recruitment procedures. All staff had application forms, job descriptions, induction checklists, a contract of employment, two references (one being from the last employer) and the necessary checks with the Criminal Records Bureau had been made. This makes sure Care Homes for Older People Page 22 of 28 Evidence: that people are protected from staff who may not be suitable to work in the care industry. There is a training programme and the records seen and conversations with staff showed that they are up to date with safe working practice training that includes fire safety, food hygiene, moving and handling, infection control, the protection of vulnerable adults and for those staff involved in medication, the safe handling of medication. The home exceeds targets for the numbers of care staff who should gain a National Vocational Qualification (NVQ). From what was seen during the visit, people look well cared for, have good and warm relationships with staff and there is a good friendly atmosphere in the home. Visitors also have good relaxed relationships with staff. Care Homes for Older People Page 23 of 28 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. People get the right support because there is effective and supportive management. There is an open approach to staff, people and visitors that makes them feel valued and respected. People are safeguarded because the home has clear financial and accounting procedures, keeps records properly and makes sure that staff understand policies and procedures and follow the way things should be done. Safety checks on facilities and equipment make sure the home is a safe place to live and work. Evidence: The manager is an experienced nurse with a relevant management qualification. There was evidence in the surveys and from conversations during the visit that people think she is approachable and supportive. The manager is supported by an area manager Care Homes for Older People Page 24 of 28 Evidence: who visits regularly. The home carries out its own satisfaction survey and actions are taken to make some of the improvements suggested. The previous survey results were displayed on the news board. There are regular resident meetings where they can express their views about home life and similarly regular staff meetings and individual supervision sessions for them to discuss work, any problems and their individual training needs. The Company has its own quality assurance systems for checking that the home is meeting National Minimum Standards. Part of this process is for the area manager to write monthly reports on the conduct of the home and these are sent to the Commission and help us monitor what is going on. A new area manager has recently carried out her first audit and made a copy available during the inspection. The homes administrator presents as efficient and organised and holds some peoples personal money for safe keeping. She described and demonstrated the systems for making sure that money is safe and properly accounted for. One persons records were checked and receipts for all purchases were held to support the transactions. Based on this, people can be assured their money is well looked after and accounted for. Staff were seen to be wearing protective clothing to reduce the risk of cross infection and their training is up to date. Barrier nursing practice was seen for a person infected with MRSA picked up in hospital. The AQAA confirmed that regular safety checks are made of facilities and equipment to make sure the home is a safe place to live and work. Staff are trained in safe working practices and are up dated on a regular basis. Some checks were made of records of safety checks, like fire safety, and were found to be up to date. Accident records were also seen and these are audited by the manager to see if measures can be taken to reduce the risk of accidents. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 23 Having explored other possibilities, the medication storage room must now be re sited. This will make sure that temperatures are safe for drugs to be stored in and comfortable for nurses to work in. 26/06/2009 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 7 Records kept in peoples rooms, like turning for pressure care, should be recorded consistently and checked in the care plan audits that are carried out. This will fully evidence that people are getting the care they need. The Company should seriously consider extending the number of hours available for activities to further develop the opportunities for people living at the home. 2 12 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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