Care Home: Beach Road (101)

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Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Beach Road (101) Beach Road (101) South Shields Tyne And Wear NE33 2LZ     The quality rating for this care home is:   three star excellent 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: Suzanne McKean     Date: 1 6 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. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Beach Road (101) Beach Road (101) South Shields Tyne And Wear NE33 2LZ 01914563532 01914563532 carolsmith@sjogcareservices.org.uk 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) : Saint John of God Hospitaller Services care home 4 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: Date of last inspection Brief description of the care home 4 101 Beach Road is a four storey terraced house situated in South Shields and is registered to provide personal care and accommodation to four adults who have a learning disability. The home is situated near local shops, park and sea front. An office and sleep-in room are available on the fourth floor, the remaining areas of the house provide communal and personal accommodation for the service users. Each person has a single bedroom that has a lock and key, and decor is to the taste of the individual. All of the rooms in the house meet the required measurements of the National Minimum Standards. A spacious lounge is situated on the ground floor. The dining room, large dining kitchen and laundry are situated in the basement, and all but one of the bedrooms is situated on the first floor. One bedroom is situated on the ground floor. Access to all four floors is by a central stairway. Care Homes for Adults (18-65 years) Page 4 of 29 Brief description of the care home There is a small garden to the front of the house and a courtyard that has garden furniture and a barbecue for activity in the warm weather to the rear. As well as supporting the people who live there with personal care tasks, the staff who work at the home assist residents in developing daily living skills and leisure activities. Residents are also supported to have short breaks and holidays of their choice away from the home. The service has developed a Service User Guide that informs prospective service users about the service, the aims and how these are met. A copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home range between £603.61 and £894.53 per week. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent 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: We have reviewed our practise when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Summary: This is an overview of what the inspector found during the inspection. How the inspection we carried out:- Before the visit we looked at, the information we Care Homes for Adults (18-65 years) Page 6 of 29 have received since the last visit on 18th April 2007. How the service dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The providers view of how well they care for people. The views of people who use the service and their relatives, staff and other professionals. The visit: An unannounced visit was made on 9th April 2009 this was followed by a second visit, the date of which was agreed with the service, on 16th April 2009. The visits were carried out over a total period of 5 hours. During the visit we: Talked with people who use the service, the staff and the manager. No visitors were present at either visit. Looked at information about the people who use the service and how well their needs are met. Looked at the records which must be kept. Checked the staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building and parts of the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last visit. We told the manager what we found. What the care home does well: What has improved since the last inspection? Since the last inspection the door to the residents bedroom that did not close properly was repaired. This makes sure that it is safe in the event of a fire and makes sure that the residents privacy and dignity is maintained. So that all staff know what to do in the event of a fire breaking out in the home and how to keep residents safe, all staff now take part in fire drills and receive fire instruction as directed by the Fire Regulations. Staff working night shift are given the opportunity to take part in drills by arranging them in the late evening. Improvements to the Life Plans have been made to make them more person centred approach, which further empower the residents. Care Homes for Adults (18-65 years) Page 8 of 29 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good pre-admission assessments and information available to the potential residents makes sure that the the resident can be looked after safely and the the service can be confident that they can meet their needs. Evidence: The home refers to its service user guide as The Residents Guide. The service has a comprehensive statement of purpose and a residents guide that clearly show the aims and objectives of the service. Both documents have been updated to include the changes made in the company and the change of name. The care plans and records are well written and include pre-admission assessments from the referring agencies and an assessment carried out by the home. The records include assessments from other agencies or health care professionals if they have been involved in the residents care in the past. There was also information from the adult training centre. Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: The home also carried out their own pre-admission assessment and from that, the other information gathered and observations made during visits by the resident, they are able to make a judgment that they were able to effectively address the persons needs. The information is also used to develop the plan of care and to make sure that they can have in place the things the residents need if they choose to move into the service. The service has not had a person move into the home for some time as they have not had a vacancy. Any potential new service user has the opportunity to visit the home and spend time with the other residents. There is an example of one who had moved into the home after knowing the home by visiting a friend in the service over time and this was beneficial when they made the decision to move in. Care Homes for Adults (18-65 years) Page 12 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Detailed care plans and the staffs understanding of the residents communication methods makes sure that the residents can be supported to make decisions, which at times may include taking risks and to direct their care in a way they choose. Evidence: All residents have a life plan which is the plan of care identifying the way that the people using the service is supported to spend their lives the way they wish to and that their changing needs a met. These plans are monitored and reviewed monthly and and fully re-assessed annually. They are developed with the people living in the home and all of the staff have access to them to make sure that they are fully aware of their contents. The residents were aware of the contents of their plans and understood why a record was kept about them. Two residents are relatively independent and are able to verbally make their needs known while others rely on more support to communicate effectively. To support Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: residents to take the lead in their care, effective communication between residents and carers is encouraged and the individual communication needs are recorded in detail in their Life Plans. Where the resident is unable to communicate effectively the staff have developed skills to interpret different facial expressions and body language. This information is recorded and it makes sure that staff can be aware of their preferences when supporting them to make decisions. Although the four residents have a diverse range of needs, all are treated equally with regards to the opportunities they are offered. This is particularly evident when looking at their life choices. This was shown by the way the staff were discussing the plans they had for the future both long term, for such things and holidays, and short term around the choices of meals. The staff were observed working with the residents in a way which supported them all to take part in the conversation and in the day to day activities and care. During the visit one resident was choosing clothing from a catalogue which she had been sent following a visit to a department store. Both staff and other residents were joining in with the discussion. They were all being encouraged to develop their independence. Clear risk assessments are in place followed by clear risk management Care Homes for Adults (18-65 years) Page 14 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are being given good support to take part in an extensive range of leisure and community based activities and the varied choices they are offered live fulfilled, satisfying lives. Evidence: The residents have individual weekly activity programmes that are evident in their Life Plans. These are varied according to individual preferences but confirm well-organised and active lifestyles. As part of their weekly routine two residents attend day centres on certain days of the week. Discussions with them confirmed that although they enjoy attending the centres they also enjoy a wide range of activities in the local community. The activities the residents take part in are reflected in the daily notes where comments also reflect the outcome of the activity. It was noted that since the last Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: inspection residents have been given further opportunities to try new activities, for example photography classes, and as a result there has been an increase in the use of local community facilities. One resident referred to a health group that they had taken part in where they took part in activities in the gym and swimming pool, as well as enjoying the activity of walking. Other activities enjoyed include, line dancing, 10pin bowling, water aerobics, shopping, beauty therapy and going to a local community based disco. One resident said: I always have something to do. The staff said that they enjoy taking part in the activities with the residents. The Cultural and Spirituality section in the Life Plans record how the person prefers to live their life and includes the special things and people to them. Records include reference to family members, pets, daily routines and programmes watched on the TV. This acknowledges the individual lifestyle the individual prefers to live. Residents eagerly discussed a holiday in Tunisia they had taken and said that this year they planned to holiday in this country. Staff confirmed that all residents have holidays planned to different destinations depending on individual preferences. Risk management plans ensure that residents are safely supported to take part in their chosen activity and when necessary identifies when limitations might have to be set. This is an area that has been successfully addressed since the last inspection. Risk assessments why two residents do not have keys to the front door are in place. A varied nutritious menu is offered at the home. A picture diary is used so that residents can assist in the planning and choosing of different menus. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents personal and healthcare needs are fully met in a flexible but consistent manner, ensuring a healthy lifestyle for the people living in the house. Evidence: The residents are given the necessary support to register and attend healthcare practices in the local community as and when necessary. The visits to the persons General Practitioner, dentists, opticians and other health professionals are recorded in the individual persons care files and the outcome of the visit is identified. Staff work closely with healthcare staff involved in the lives of individual service users. The individual healthcare needs are clearly recorded in the care files and if necessary there is a care plan developed to make sure that the staff are aware of the support needed. Any health or behaviour changes that are observed by staff are clearly recorded in the care files and if needed action is taken to gain specialist healthcare advice. It was noted that residents generally looked fit and healthy and happy with their lives. Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: Two of the residents were spoken to in private, one said: it is really nice living here and everyone is great while another said I can do anything I want and they will help me The observation of the way that the staff and residents behave toward each other shows that personal support is given privately and in a respectful manner. Risk assessments are in place in relation to the self-administration of medication resulting in all residents that take medication needing support with this. Medication is stored and administered appropriately. Staff and records confirmed that staff only administer medication after receiving specialised training. Care Homes for Adults (18-65 years) Page 18 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate arrangements are in place which protect residents from abuse and to manage complaints and concerns effectively. Evidence: The home has a Complaints Procedure that is also in picture format, a copy of which is kept in the residents care files. Residents know how to complain and who to go to if they are not satisfied with any aspect of the service. One resident who was asked about how they would have any concerns dealt with said I dont think there is anything wrong but I tell them if Im not happy. There has been one complaints recorded since the last inspection the records of this was examined and found to have been fully investigated and the outcome was clear and well documented. Staff are given safeguarding awareness training. The manager confirmed that staff have attended training in relation to the local authoritys POVA (Protection of Vulnerable Adults) procedures, a copy of which is available in the home. The outcome of individual risk assessments carried out in relation to the selfCare Homes for Adults (18-65 years) Page 19 of 29 Evidence: management of residents finances showed that each resident needs staff to support them with this task. Care records show that individual residents are encouraged to take responsibility for their daily finances with support from the staff. The guidelines and practices in place follow the homes comprehensive policies that aim to protect the residents from financial abuse. Care Homes for Adults (18-65 years) Page 20 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The accommodation is homely, comfortable, clean, safe, well decorated and furnished to a good standard, giving the people living there good private and communal spaces in which to live. Evidence: 101 Beach Road is a large terraced house on a residential street. It is close to the seafront and the town centre and is a busy but pleasant area of the town. There is good amenities and it is on a bus routes. The house has a small garden area to the front of the house and there is a courtyard to the rear that has garden furniture and a barbecue for the people living in the home and the staff to enjoy in the warm weather. The decor and furnishings inside the house are of a good standard. All residents have single bedrooms that are individually decorated. Two resident were keen to show their bedrooms and said they loved the way that it had been done also that I chose the colours and the curtains. The choice of neutral colours gives a calming effect throughout the home and the choice of good quality furniture reflects the needs of the residents. Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: The communal areas of the home are comfortable and well decorated. They are furnished with good standard domestic furniture which gives a very pleasant place for the people living in the home to spend their time. The kitchen area was mainly being used during the visit although it is evident that the residents spend time in the lounge and the other rooms according to the activities they are involved in. The residents confirmed that they were consulted about the choice of colours and that in the past they have been involved in majoy decisions about the home. The bathroom has a bath and a shower cubicle so residents have the choice and there are plans to further improve the bathroom although these plans are not yet agreed. All areas of the home were exceptionally clean and tidy, reflecting effective cleaning routines. Staff confirmed that they have attended training regarding infection control. There are plans to carry out the work that is needed to the building as a result of wear and tear and the maintenance person for the organisation has put together a list of the work that is needed so that an action plan can be developed. Care Homes for Adults (18-65 years) Page 22 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good recruitment & selection procedures and regular training opportunities makes sure that residents are appropriately supported and protected by a skilled, competent and qualified staff team. Evidence: On the first day of the visit there was one resident in the home for the short duration of the visit. The second visit all of the residents were in the home and there was a good opportunity to look at the way the residents were living. There were more staff on duty as they had been going to have a staff meeting and the inspection visit coincided with it. The staff rota showed that there is a an appropriate number of staff on duty to effectively address the needs of the residents. The manager confirmed that it is the homes aim to give all residents 1:1 support at some time during the week. Residents and records confirmed this. This staffing ratio enables residents to take part in interesting and valued lifestyles. The organisation has a training contract with a training agency and the manager accesses other training from both training providers and the local authority. This means that she can be confident that she can access appropriate training for the staff and can meet the needs of the residents. Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: A training matrix confirmed that all staff are up to date regarding mandatory training. Other training courses recently attended include diabetes, personal hygiene, epilepsy and the Learning Disability Award Framework (LDAF) that is compulsory for all staff and part of the Induction Course. Records confirmed that further training is planned. The company provides new members of staff with a filofax type folder that includes information about the home and explains training requirements and opportunities. Staff are employed using robust recruitment procedures. A sample of staff files demonstrated that the necessary documents were in place, for example an application form, 2 written references and a satisfactory CRB check. This makes sure that the staff who apply to work at the home are suitable to work with vulnerable people. Care Homes for Adults (18-65 years) Page 24 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager, who is well supported by her staff team, provides very good leadership and runs a service that has a very effective monitoring system that are focused on the best interests of the people living there. Evidence: The manager of this service is fully qualified as a registered manager. She has achieved the Registered Managers Award, NVQ4 in Care and the NVQ Assessors Award. She is also up to date with mandatory training and attends training relevant to her role. Recent training includes issues around the Deprivation of Liberty, Stress Management, the Mental Capacity Act, Presenting Training and Report Writing. Both residents and staff confirmed that they felt valued by the manager and the company and felt that their opinions mattered. This has created an atmosphere of openness and respect, that reflects on the quality of care and the quality of life experienced by the residents. Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: This service has a quality assurance system in place that monitors and records all aspects of the service delivered. As well as seeking the views of the residents, the manager confirmed that satisfaction surveys are sent out to the residents relatives, staff at the day centres and other professionals including the General Practitioners of the people living in the home. The quality of the service is also effectively monitored during the monthly providers visits. Following such visits a detailed report is produced and issues addressed during the visit are related to the National Minimum Standards. Recommendations for the registered manager to address are made when appropriate. The manager makes sure that the checks around health and safety in the home are carried out and that there are records in place to show this. Training for staff around health and safety, fire safety is provided and that the staff are supervised to make sure that their practices are safe and in the best interest of the residents. Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 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 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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