Care Home: 93-95 Canning Road

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Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 93-95 Canning Road 93-95 Canning Road Wealdstone Middlesex HA3 7SP     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: Tony Lawrence     Date: 0 2 0 3 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 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.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: 93-95 Canning Road 93-95 Canning Road Wealdstone Middlesex HA3 7SP 02084248186 02084240879 canning_road@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Support for Living (Harrow) Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 6 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 6 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 categories: Learning disability - Code LD Date of last inspection Brief description of the care home 93-95 Canning Road is a registered care home providing personal care and accommodation for up to 6 people who have a learning disability. At the time of the inspection there were no vacancies in the home. The Registered Provider is Support For Living and the Responsible Person is Mr Nigel Turner. A new Manager has been appointed and will start work in the home at the end of March 2009. Paddington Churches Housing Association owns the building and is responsible for maintenance. Care Homes for Adults (18-65 years) Page 4 of 28 Brief description of the care home The home is located in a quiet residential road in Wealdstone, on the outskirts of central Harrow. There are parking restrictions in the road outside the home and in the immediate vicinity. Car parking is only allowed to permit holders between 10 and 11 am and between 2 and 3 pm. The home is close to shops, pubs, transport and other community amenities. All the homes bedrooms are single, and none have en-suite facilities. The home has a garden to the rear of the property that is accessible through the lounge and kitchen. The weekly placement fee for the service is determined by an assessment of the needs of the potential resident. Information about the service provided and the level of fees may be obtained, on request, from the provider. Care Homes for Adults (18-65 years) 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 Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection of the home took place on Monday 2nd March 2009 from 09:30 - 15:30. We spent time in the home reviewing outcomes for residents against the key National Minimum Standards for care homes. We did this by talking with people living in the home, staff and the interim manager. We checked care records kept in the home and saw all communal areas and two residents bedrooms, with their permission. We also used the providers Annual Quality Assurance Assessment (AQAA) to inform judgements we have made in this report. Care Homes for Adults (18-65 years) Page 6 of 28 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 28 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may want to live in the home know that their care needs will be assessed as part of the homes admission procedures. Evidence: I decided to live here. I like it here, but I want to live on my own now. Comment from a resident. Ive lived here a long time, I like it here. Comment from a resident. We have improved by working in a more person centred way and ensuring that people are given the opportunity to re-evaluate their lives and make plans for future ventures. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit the homes acting Manager told us that no new residents had moved into the home for almost two years. All six people living in the home had lived together for between two and fifteen years. Care Homes for Adults (18-65 years) Page 9 of 28 Evidence: As part of this inspection we reviewed the care and support of two people who had both lived in the home since it opened in 1994. We did not see the original information provided when people moved in, but we saw evidence that peoples current care needs were regularly assessed and reviewed. The residents, their families, staff working in the home and other agencies were involved in the assessments and reviews, as part of the homes care planning procedures. Care Homes for Adults (18-65 years) Page 10 of 28 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can be confident that staff will work with them to assess and record their care and support needs in a plan that is easy for them to understand. Peoples care plans will include a comprehensive risk assessment that is reviewed regularly. Evidence: I talk to the staff about the support I need and they help me. I can do most things for myself though. Comment from a resident. All the staff help me. Comment from a resident. We have support plans that are regularly updated to ensure that needs are being met and that we are aware of changes in peoples lives. There are also regular key working days where the residents are given the opportunity to express their wants, needs and desires. Regular reviews also take place to ensure that placements are meeting the Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: needs of the residents. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit we checked the care and support plans for two people living in the home. Both people had lived in the home for more that 10 years. For one person we saw that their support plan gave staff a good overview of the help and support the person needed. We also saw that staff had worked well with this person to make sure that their views and experiences were included in the plan and the plan had last been reviewed in January 2009. The second persons support plan also included good information about the persons needs and how these would be met in the home. Staff must make sure that all plans are signed and dated to make sure that plans are reviewed and updated regularly. Staff should also make sure that the care needs assessments they complete with residents are used to develop and agree goals and actions plans that residents and staff can work to. We discussed this issue with the interim manager who told us that this would be included when the residents care plans were transferred to the new providers person centred care planning systems. We also saw evidence that both peoples risk assessments had been reviewed and updated during 2008. The risk assessments highlighted potential risks to each person and included guidance for staff on how these should be minimised. Care Homes for Adults (18-65 years) Page 12 of 28 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home have the opportunity to develop skills, including social, communication and independent living skills. The home respects the human rights of people with fairness, equality, dignity, respect and autonomy underpinning the care and support provided. Evidence: I go out every day by myself, but the staff will help me if I ask them. Comment from a resident. I like my dance class. Comment from a resident. Its my room, I can do what I want to here. Comment from a resident. Care Homes for Adults (18-65 years) Page 13 of 28 Evidence: At Canning Road all residents have comprehensive support plans to ensure that access to the community is priority and that day centres are still appropriate for that individual. Where a person expresses a wish to attend college or participate in a hobby or leisure activity then we will ensurer that support plans reflect that and these needs are looked at monthly to ensure that they are still what people want to do. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit we checked the support plans and daily care notes for two people living in the home. We saw evidence that staff asked people about their interests and included these in their support plans. Staff also had access to information about local events and amenities. The daily care notes we saw were clear evidence that people were supported to take part in activities independently or with support from staff where this was needed. One person told us that they went out each day independently and staff had supported them to buy and learn to use a mobility scooter. We saw good evidence that people made use of local day services, as well as other community amenities. We also saw that peoples bedrooms were very individual and each person had their own belongings, including TVs, DVD players and music systems. Both of the residents we spoke to said that they liked to spend time in their rooms and they could do this at any time. The support plans we saw included good information about each persons relatives, friends and other significant people, together with information for staff about how residents should be supported to stay in touch with these people. Residents and staff told us that the home had a weekly menu that residents were involved in writing. People were supported to choose their own meals and these were recorded by staff each day. Care Homes for Adults (18-65 years) Page 14 of 28 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home receive the personal and health care support they need. Staff make sure that residents are encouraged to be independent, have regular appointments and visit local health care services. Evidence: If I need to see the doctor, the staff will help me if I need them to. Comment from a resident. We encourage service users to be as independent as possible with tasks in relation to their personal care needs. When doing shift plans, every effort is made to ensure that staff who work well with individuals will work with that individual to ensure best outcomes. Extract from the providers Annual Quality Assurance Assessment (AQAA). As part of this visit we reviewed the support and health care plans of two people living in the home. We saw that staff had talked to each resident about the support they needed with their personal care and how this would be provided in the home. We also saw the support plans emphasised what people could do for themselves and Care Homes for Adults (18-65 years) Page 15 of 28 Evidence: encouraged people to be as independent as possible. Peoples health care needs were also well recorded in the plans that we reviewed. We saw that one person had little contact with health care professionals, but where appointments were needed, these were well recorded by staff. The other person whose care we reviewed had more complex health care needs. We saw from this persons support plan that there had been good joint work with health care professionals, including the persons GP and hospital staff. Both of the files we checked included good evidence that people were supported to make and keep appointments with opticians, dentists, chiropodists and other health care professionals. As part of this inspection we also checked the homes arrangements for managing residents prescribed medication. The interim manager told us that the provider was changing the arrangements for managing residents prescribed medication and we saw evidence that this transition was being well managed. The home provided secure storage for prescribed medication. We checked the Medication Administration Record (MAR) sheets for each person living in the home. We saw that the MAR sheets were well completed by staff and there were no errors or omissions. Staff should make sure that they record the opening dates on medicinal creams to make sure that they are disposed of within recommended timescales. Care Homes for Adults (18-65 years) Page 16 of 28 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are supported safely. Staff have had the training they need to keep people safe and they follow agreed local procedures when necessary. Evidence: I feel safe here. If I was worried Id talk to the staff or the manager. Comment from a resident. All staff have received training on safe guarding adults from abuse. All staff are aware of the reporting procedures for allegations of abuse. All staff are aware of the policy around whistle blowing. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit we checked the homes complaints and safeguarding adults records to make sure that people living in the home were cared for safely. We saw that the home had already started to use the new providers complaints procedure. We saw that staff had displayed copies of an easy read leaflet that outlined the complaints procedure in communal areas of the home. The leaflet made good use of pictures and Plain English to make the information easier for some residents to understand. The homes records showed us that there had been one recent complaint from a social care professional. We saw that the interim manager had responded promptly and appropriately and the complaint was well recorded. The person who made the complaint was also told of the Care Homes for Adults (18-65 years) Page 17 of 28 Evidence: outcome of the managers investigation. We saw that staff had access to a copy of the local authoritys safeguarding adults policy and procedures. The interim manager told us that all staff working in the home had completed safeguarding adults training. We know that there have been two recent safeguarding investigations involving people living in the home. The interim manager had followed the agreed procedures appropriately and the local authority had kept us informed of progress with both investigations. Care Homes for Adults (18-65 years) Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a physical environment that is appropriate for the specific needs of the people who live there. The well maintained environment provides equipment that residents need. The home is a pleasant, safe place to live. Evidence: I like my room, Ive got all my things here. Comment from a resident. Canning Road is clean, homely and welcoming. we are close to local shops and the residents can access the community and public transport easily. Our gardens are well kept and the residents are actively encouraged to plant things in the garden. Extract from the providers Annual Quality Assurance Assessment (AQAA). 93 - 95 Canning Road is a two-storey detached house in a residential area, close to shops and public transport routes. There is level access to the ground floor and garden, but there is no access to the first floor for people in a wheelchair or those people unable to climb stairs. On the ground floor there is one wheelchair accessible bedroom and a shower room and toilet that are also accessible. There is a large kitchen / dining room and a separate lounge. On the first floor there are four single bedrooms, a bathroom, laundry room and staff office / sleep in room. Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: During this visit we saw all communal parts of the home and two residents bedrooms, with their permission. All parts of the home that we saw were clean and hygienic. All rooms were bright, spacious, well decorated and comfortably furnished. Residents bedrooms were very individual and people had personalised their rooms with their own possessions, furniture, pictures etc. Residents told us that they liked spending time in their rooms and the large, well kept garden. Care Homes for Adults (18-65 years) Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have confidence in the people who care for them. The staffing structure is based around delivering outcomes for residents. Evidence: Most of the staff are good and they help me when I need it. Comment from a resident. I like all the staff. Comment from a resident. Regular team meetings are held to enhance care practise at Canning Road. There is a small well-matched staff team at the home and this shows with the team dynamics as everybody works well together for the benefit of the service users. Extract from the providers Annual Quality Assurance Assessment (AQAA). When we arrived for this unannounced visit, the interim manager was on duty with one Support Worker. A second support worker was sick and unable to work. During the afternoon, three Support Workers were on duty as one resident had 1:1 support. This level of staffing was sufficient to meet the care needs of the existing residents. Care Homes for Adults (18-65 years) Page 21 of 28 Evidence: During our visit, we saw that the staff worked well together to respond to residents and visitors requests for information or support. Staff supported each person living in the home to spend time out of the home during the day. Two residents who spoke with us told us that they liked the staff and had all of the help and support they needed. One person added some staff dont always listen, but they are usually busy. The interim Manager told us that staff records were kept in the providers head office but he saw copies of application forms, employment references and Criminal Record Bureau (CRB) checks. The provider must make sure that a record of staff CRB checks is kept in the home for inspection. The Manager and staff who spoke with us also confirmed that staff had access to training they needed to do their jobs effectively. Care Homes for Adults (18-65 years) Page 22 of 28 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a need to register a permanent manager for the home and appoint a new deputy manager. Staff have access to the polices and procedures they need to work effectively and standards of record keeping are good. Evidence: I like the manager, hes very good. Comment from a resident. Staff ask me about how I think the home could be improved and I tell them. Comment from a resident. Our plans for improvement in the next 12 months are for the management structure to be more robust and stable. For the recruitment of a deputy manager to be a priority as this will increase the consistency of management and also increase the management presence within the unit. Extract from the providers Annual Quality Assurance Assessment (AQAA). Care Homes for Adults (18-65 years) Page 23 of 28 Evidence: During this visit the interim manager told us that he had been appointed for a two month period in October 2008 and this had been extended to the end of March 2009. He told us a new, permanent manager had been appointed by the provider and she would start work in the home at the end of March 2009. The provider must make sure that the new manager submits an application to the Commission for registration as a fit person to manage the home. The previous and current interim managers had completed the Annual Quality Assurance Assessment (AQAA) and returned it to us. The AQAA contained clear and relevant information that was supported by a range of evidence. The AQAA told us where the provider needed to make improvements and how they were going to do this. The management of the service and the employment of staff working in the home transferred from Harrow Mencap to Support For Living (SFL), a voluntary organisation, on the day before our visit. During the day, SFLs Chief Executive and Care Services Manager visited the home to talk to residents and staff and leave information about the transfer. The interim manager had made sure that all of SFLs policies and procedures were available for staff reference and staff had also had a brief induction to the new provider and their policies and procedures. During this visit we checked a selection of care records kept by staff in the home. All of the records we saw were well completed and up to date and standards of record keeping were good. The interim manager told us that all required safety checks were carried out regularly and we saw no health and safety concerns during this visit. We saw that representatives from the provider organisation had carried out monthly monitoring visits to the home from June 2008 - February 2009 and copies of reports were sent to the home following each visit. Care Homes for Adults (18-65 years) Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 25 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 34 19 The provider must make sure that a record of staff CRB checks is kept in the home for inspection. This will evidence that the staff are suitable to work with vulnerable adults. 30/06/2009 2 37 9 The provider must make 30/04/2009 sure that the new manager submits an application to the Commission for registration as a fit person to manage the home. This will make sure that the residents and staff in the home have the management support they need to provide good outcomes. 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 Care Homes for Adults (18-65 years) Page 26 of 28 1 6 Staff should make sure that all plans are signed and dated to make sure that plans are reviewed and updated regularly. Staff should make sure that the care needs assessments they complete with residents are used to develop and agree goals and actions plans that residents and staff can work to. Staff should make sure that they record the opening dates on medicinal creams to make sure that they are disposed of within recommended timescales. 2 6 3 20 Care Homes for Adults (18-65 years) Page 27 of 28 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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