Care Home: Abingdon

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Abingdon 48 Alexandra Road Southport Merseyside PR9 9HH two star good service The quality rating for this care home is: 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: Debbie Corcoran Date: 2 0 0 4 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. They reflect the things that people have said are important to them: 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. 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. Internet address www.cqc.org.uk Information about the care home Name of care home: Address: Abingdon 48 Alexandra Road Southport Merseyside PR9 9HH 01704533135 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Raglin Care Limited care home 9 Number of places (if applicable): Under 65 Over 65 9 9 0 0 learning disability mental disorder, excluding learning disability or dementia Additional conditions: 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, Mental disorder, excluding learning disability or dementia - Code MD. The maximum number of service users who can be accommodated is: 9 Date of last inspection A bit about the care home Abingdon is a care home offering a service to nine people who have a learning disability. The service is managed by Gill Doyle. The home is in a residential area of Southport. It is within easy reach of Southports main shopping centre and close to local services. The home is a detached house with rooms spread over three floors. There are two large lounges, a dinning room and a games room on the ground floor. There is a large garden at the back of the house. There is a passenger lift but there are no other aids or adaptations as these are not needed by the people living at the home at this time. The fees for living at the home are £1,224 per week. 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 How we did our inspection: This is what the inspector did when they were at the care home The manager did not know that we were going to visit the home before we arrived. During the visit everybody who lives at the home was met and three people were spoken with about the home. Two members of the care staff team, the manager and the cook were also spoken with during the visit. Care plans, staff records, health and safety records and other relevant records were looked at. A tour of the home was carried out and all areas were checked. The manager returned a self assessment of the service and we have used some of the information in this help us decide how the home is doing. Surveys were sent to staff before the visit for them to make comments on the home. What the care home does well Before a new person moves into the home the manager makes sure that she gets information on what the person needs from a social worker or other professional person. This is so that the manager knows what the new person needs and can decide if their needs can be met at the home. Each person who lives at the home has a care plan. These have a lot of information in which tells the staff what they need to do to support the person. People are asked to look at their care plan with staff every few months to make sure that it is still ok or they can make changes to it if they feel they want to. People living at the home are supported to use their independent skills and to learn new skills. People are supported to get their own breakfast and lunch, do their own laundry, keep their room tidy, go to the shops. People are supported to go out for a meal, go to the pub, go shopping, attend local clubs and other interests they have. People living at the home held a meeting recently and decided on what sort of new things they would like to do in the summer and the manager is hoping to make sure that all of these take place. Staff support people living at the home to visit their doctor, dentist, nurse, optician and other important appointments on a regular basis. Staff are good at taking care of medication and support people well with their medication. The home is relaxed and people are choosing their own daily routines such as what time to get up in the morning and what time they go to bed. People are asked if they would like to take part in meetings about the home. This gives them the chance to say what they think works well and what they would like to change. Many of the staff have worked at the home for quite a few years and they have built relationships with the people living at the home. One person said the staff are very nice they support me another person said theyre great. The staff team are well trained and are confident that they can support people well. The manager makes sure that the home is comfortable, nicely decorated, safe and clean. The home has lots of space. There are two large lounges, a large dinning room and a games room. Each person has their own bedroom and these are fitted with a lock for their privacy. What has got better from the last inspection There has been more staff training in the past 12 months. Medication is now better managed and new ways of recording medication have been started. There have been improvements to the home environment and some redecoration. What the care home could do better There is information on the home called the service user guide. This could be written in different ways so that people can understand it better and it could have better information in which is more important to the people living at the home. When something has taken place at the home which could cause harm to a person then this needs to be written down in lot of detail. When people living at the home need support with their money then this is written down and the money left over each day is counted and staff sign for this. But the manager needs to start checking that all the written records for money are right. A person from the organisation visits the home once per month to check that the home is running as it should. But, there hasnt been a visit for a couple of months so these need to be started again. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Debbie Corcoran 33 Greycoat Street London SW1P 2QF 02079792000 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 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 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 do not move into the home without the home being aware of the persons needs and confident that they can meet these. Evidence: A statement of purpose and service user guide are available to provide people with information on the service and facilities provided at the home. The manager should review and update this information to reflect the change of name of the company now running the home. The level of information in the service user guide should be reviewed and alongside this the manager should aim to produce the guide in alternative formats more user friendly for the people using the service. A number of new people have moved into the home since the last inspection visit. Records in relation to their admission were looked at and these showed that the home had attained assessment information from the referring agency before a person moves to the home. There is also an in house assessment tool which can be used when appropriate. Along with general assessment information risk assessments are carried out and these identify potential risks to people using the service and include guidelines to inform staff on how to best manage those risks. Risk assessments have also been provided by the referring agency where this is appropriate. 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 . Each of the people using the service has an individual support plan which provides staff with guidance on what the persons needs are and how these should be met. People using the service are supported to take risks as part of living an independent lifestyle. Evidence: Care plans for two of the people using the service were looked at. These were found to be of a good standard and were clear, informative and easy to follow. The plans included information on the needs of the person in areas such as their mental health, physical health, health care and personal care. The level of information in the care plans was well pitched and this ensures staff are provided with important information on the needs of the person. One area of information noted to be missing from those care plans looked at were any areas relating to sexuality and relationships. This is an important aspect which must be included. Part of the care plans focus upon the support the person requires to develop their independent living skills. These are in line with the needs and wishes of the person concerned. It was reported that people using the service are involved in reviewing their care plan every three months. People living at the home are supported to take risks as part of an independent lifestyle. Where a person is involved in activities which pose a risk to their safety then this is recorded in a risk assessment along with information on what steps need to be taken to prevent the risk from occurring. It is recommended that the manager works closely and in consultation with the service user and relevant professionals in drawing up risk assessments and in the monitoring and reviewing of these, as appropriate to the needs of the person concerned. The manager should also ensure that incidents Evidence: which may effect the health and well being of any service user are reported to relevant professionals alongside the Commission. The staff turnover is low and as a result many of the staff have worked at the home for a significant period of time and therefore they have had the opportunity to build relationships with the people living at the home and to get to know their needs well. During discussions with people who live at the home they were very positive about all aspects of their support and appeared confident that staff were meeting their needs and providing good care and support. People said that they are making their own decisions as to their daily support and their routines within the home and they confirmed that staff support them to use and develop their independent living skills. People living at the home have the opportunity to attend meetings whereby they can discuss the running of the home with staff on a more formal basis. All personal and confidential information is stored appropriately and staff are aware of their responsibilities in this area. Staff have been provided with training on confidentiality and are required to sign a statement that they will maintain confidentiality appropriately. 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 living at the home are supported to develop their independent living skills and to be involved in their local community. People choose their own meals and are supported to use and develop their skills as appropriate. Evidence: Care plans for people living at the home included a good level of information on how to support the person with using and developing their independent living skills. From discussions with people it was clear that they are supported to develop their independent living skills as appropriate to their individual needs. For example one person confirmed that they prepare their breakfast and lunch with support from staff, they do their own laundry, keep their own room and belongings clean etc. People living at the home gave good feedback on their support with pursuing social activities. They reported going out and using community resources independently when they are able to and with support from staff when needed. Discussions with people indicated that they are being supported in activities such as attending local clubs, going for a meal, going to a pub, shopping and one person has been supported to attend a college course. People living at the home are encouraged to make choices about the running of the home and their care. People confirmed that they are making choices and they gave examples such as choosing when to get up, when to go to bed, their meals, their daily Evidence: routine, how to spend their day, and this will include going outside of the home on their own if they have the skills to be able to do this independently. People are supported to manage their own affairs when possible, for example managing their own money or their own medication. People living at the home are able to express their needs and preferences and contribute to changes at the home. They have the opportunity to attend a residents meeting on a regular basis and are given the opportunity to complete surveys to give feedback on the home. People living at the home are encouraged and supported to prepare their own breakfast and lunch. The home does have a designated cook who is responsible for the main meal of the day which is served at tea time. The kitchen was found to be well organised. The menu was varied and appeared appetising and all feedback on the food and meals was positive. The cook described how she accomodates people making choices for their meals and she was aware of the individual needs and choices of the people living at the home. In addition to the main kitchen people living at the home have a small kitchen where they can make their own food and drinks. 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 using the service are well supported with their personal, emotional, physical and health care needs and medication is well managed. Evidence: Each of the people living at the home has a care plan and these include a good level of information on how to support the person with their emotional and physical health and well being. During discussions with people living at the home they felt that staff support them well in this area but that they are also encouraged to use their independent skills. Records showed that people living at the home are well supported to remain healthy and to attend health related appointments on a regular basis. For example they are supported to see a GP, district nurse, dentist, optician etc on a regular basis. People are also supported to see other health professionals as appropriate to their needs. Each person living at the home has a health action plan and care plans also include a good level of information on the persons needs with health care. Regular reviews take place in relation to the persons physical and mental health needs. Medication storage was checked and a random sample of administration records were checked. These showed that medication is safely managed. There was one medication administration record which needed to be amended to read that the medication was to be administered as required. Staff have been provided with medication training. People are encouraged to manager their own medication when this is appropriate. Each service user file has information on their medication which includes the details of their medication, description of it and reason it is prescribed and any possible side effects. The manager reported that medication is audited on a monthly basis. 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 . Policies procedures and practices are in place for dealing with complaints and for aiming to protect service users against abuse or neglect and systems are in place for dealing with allegations of abuse. Evidence: The home has a complaints procedure which is time scaled appropriately and includes contact details for the Commission. However, this needs to be reviewed and updated so that it informs the reader that a complaint can be forwarded to the Commission as opposed to how it reads that any complaint will be reported to the Commission. The contact details for the Commission should be updated as part of this review. A copy of the complaints procedure is available to people living at the home and is on display in the main hallway. The home has an Adult protection procedure. This includes information on responsibilities for contacting relevant authorities. Care staff have been provided with training in adult protection. The manager was asked how she would respond to an allegation of abuse and she was able to provide an appropriate response to this. A record of key events is maintained for example incident reports and accident reports. These were looked at and it was evident that some incident reports required a lot more detail as to what exactly took place especially if restraint of any form has been used. The manager needs to audit incident reports and those which identify the use of restraint in an aim to further reduce the number of incidents occurring. The manager must ensure that staff record exact information when restraint has been used including clear information as to what happened beforehand, details of what alternatives have been employed and the exact type and duration of restraint if this has been used. The manager must ensure the use of alternative strategies whenever possible in supporting people who present with challenging behavior. The system for recording service users monies was checked. A random sample of records for this showed that the system does aim to safeguard the people living at the Evidence: home. However, whilst balance checks take place on a regular basis there was no evidence that the records and money are being audited. This was discussed with the manager and is a practice which must be addressed. 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 living at the home are provided with a comfortable, safe and well maintained home environment. Evidence: A tour of the home was carried out. Accommodation is provided over 3 floors. The ground floor comprises of two large lounges, a dinning room, a games room and an office. Bedrooms and bathrooms are located on the first and second floors. Each person living at the home has their own bedroom and a sample of these were looked at and found to be well presented. Furnishings and fittings were also noted to be of a good standard. Bedrooms were personalised with peoples own belongings and each room is fitted with a lock so as to ensure the persons privacy. When asked about their rooms people said that they were happy with them. The home has a large rear garden which is well maintained and provides a good amount of outdoor space for peoples use. The home is comfortable, clean and well maintained. The home has health and safety practices and procedures which are aimed at ensuring the home is clean and free from hazards to the health and safety of people living at the home and staff. 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 living at the home are supported by trained and well supported staff. Staff recruitment and selection practices aim to safeguard the people living at the home. Evidence: The manager records and plans staff training well and ensures that staff are provided with mandatory training. Staff files showed that they have been provided with training in topics such as medication management, supporting people with challenging behaviour, food hygiene, health and safety, infection control, confidentiality, supporting people who have epilepsy, first aid, stress awareness. Additional training noted on some staff records included training in mental health issues, equality and diversity, person centred planning, introduction to autism and supporting people who self harm. In addition to this staff have been provided with training specific to the needs of some of the people they support. This has been provided by relevant professionals. There are a total of 17 support workers and all but 3 of these have attained a relevant qualification. Staff turnover is low and therefore staff get to know the needs of the people they support well and have the opportunity to build relationships with them. There has been only one new member of care staff employed at the home over the past 12 months. The recruitment and selection procedures for this person were looked at. These showed that all relevant pre employment checks had been carried out prior to the employment of the person in order to safeguard the people living at the home. The only area for improvement was that one of the references was a hand written note on a plain piece of paper and it was advised that this is not best practice. The manager reported that that the practice for references has changed since the employment of this person and the company now require two professional references and these are followed up with verbal confirmation. Evidence: New staff undergo a period of induction. The manager reported that that a new induction process has been started and this involves one weeks induction training. During discussions with staff they reported feeling well supported and staff surveys which were retuned included comments such as training is excellent all mandatories covered and specialist training provided relating to any new service users who move in. Very caring, staff dedicated to residents. Very good with interacting with service users and meeting all their needs. Supporting them so they can go back into the community. Discussions with a number of the people living at the home and indicated that staff are supporting the aims and objectives of the home in encouraging people to make choices, develop their independent living skills, and use their local community. People living at the home gave positive feedback about the staff. One person commented theyre very good and they make sure I am supported. Staff are provided with supervision meetings and team meetings take place. The frequency of supervision meetings needs to be increased in order to meet the national minimum standards. These meetings provide an opportunity for staff to explore their practice, explore new ways of working and to make and communicate decisions as to how to develop the service. 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 home is well managed and is run in the best interests of the people living there. Practices are in place which protect the health, welfare and safety of people living at the home. Evidence: The manager has been in post for almost 7 years and has attained the Registered Managers Award. The home is well organised and all required information was readily at hand. People who live at the home contribute to daily decision making in the home and alongside this they are also invited to comment on the home through service user meetings and through completing surveys on the home on annual basis. The home is visited by a representative from the organisation on a monthly basis and reports of these visits were available. However, it was noted that the last monthly visit was carried out in January 2009. This needs to be addressed in line with Regulation 26 of the Care Home Regulations. The home has numerous policies and procedures in relation to the health and safety and staff are provided with training in core health and safety related skills. A sample of records of fire and health and safety checks were looked at and found to be up to date. A safe working practice risk assessment is in place but this needs to be reviewed. Are there any outstanding requirements from the last inspection? Yes  No  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 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 Description 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 Description Timescale for action 1 1 5 The statement of purpose and service user guide must be reviewed and updated. 22/06/2009 So at to ensure that people are provided with correct and up to date information on the service. 2 22 22 The complaints procedure must be reviewed and updated. 11/06/2009 To provide people with accurate information on making a complaint and for passing complaints information on. 3 23 13 Incidents where restraint has 11/06/2009 been used must be clearly and accurately recorded. To safeguard people living at the home and staff. 4 39 26 The home must be visited on 11/06/2009 an unannounced, monthly basis, by a representative of the organisation. To assess the quality of the service being provided. 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 9 Risk assessments should be carried out, monitored and reviewed in consultation with relevant professionals as appropriate to the needs of the person. Any incidents which effect the health, safety and wellbeing of any person living at the home should be reported to relevant professionals alongside the Commission. 2 9 3 23 Incidents where restrictive techniques have been used should be audited in an aim to reduce these incidents further. A system should be introduced to ensure the records of money belonging to people living at the home are regularly audited. The safe working practice risk assessment should be reviewed. 4 23 5 42 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. - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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