Care Home: Grange House

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What the care home does well The home continues to provide a good standard of care for people who use the service. Detailed care plans are in place for people who use the service. There is a range of activities for people individualized to their needs and abilities. The home is spacious and there is an additional building for activities and staff training. What has improved since the last inspection? Care plans had been updated and the files were in the process of being re-organized. Staff had received training in the safe operation of fridge temperatures. This was verified at the Annual Service Review which took place October 2008. What the care home could do better: Health Care planning must be monitored to ensure that all appointments are followed particularly dental care. The National Minimum Standards for staffing are scored as adequate. Milbury Care must evidence that every effort is being made to recruit a permanent staff team as there is a high level of vacancies. Staff must be given the opportunity to complete a National Vocational Qualification in Care and receive the required level of one to one formal supervision. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Grange House 9 Grange Road Hayes Middlesex UB3 2RP     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: Susan Woolnough-Singh     Date: 0 2 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 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: Grange House 9 Grange Road Hayes Middlesex UB3 2RP 02088135264 02088135264 Telephone number: Fax number: Email address: Provider web address: www.milburycare.com Name of registered provider(s): Type of registration: Number of places registered: Milbury Care Services Ltd care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 5 The Registered Person may provide the following categories 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 Grange House is operated by Milbury who are a nationwide limited company who provide residential care to people with learning disabilities. Grange House is registered to provide care to five residents, and the home?s speciality is to provide for people with autism. Grange House is a detached property on a quiet residential street in Hayes. The home is a short drive from the local amenities of Hayes town centre and its public transport links. The property has five single en-suite bedrooms, one of which is on the ground floor. The communal rooms are spacious and include a through lounge, Care Homes for Adults (18-65 years) Page 4 of 28 Over 65 0 5 Brief description of the care home kitchen/diner, conservatory, and a large secure garden with a large activities room at the end. The home has its own vehicle to enable staff to take residents on outings. The fees charged range from #1,737 to #1916 per week. 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 was a Key Inspection of Grange House. The Key inspection considered the homes performance against the key National Minimum Standards for care homes for younger adults. The Inspection took place on 25th and 26th March and 2nd April. The visit on the 2nd April was to specifically meet with people on their return from College. During the Inspection we toured the premises, interviewed the Registered Manager, met with two people who use the service and a group of six members of staff. We examined a range of of care files and staff personnel files. 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 and their families have the information they need to make a choice about the home. People have their care needs assessed prior to moving into the home. Evidence: We looked at the Statement of Purpose which has been updaded since the last inspection. The Statement of Purpose contains detailed information on the service and the fees charged for this by Milbury Care Services. We looked at the files of two people who use the service. A needs Led Assessment is completed by the commissioning Local Authority prior to people moving in. People who live at the home have done so since the last key inspection therefore we did not look again at the original Needs Led Assessments. Care Homes for Adults (18-65 years) Page 9 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. A current care plan is in place which sets out the daily support that people need. People require different levels of support with decision making. Routine choice, likes and dislikes are covered in the care plan. Individual risk assessments have been completed for people were risks have been identified. One of these needs to be improved and updated. Evidence: We looked at the care records of two people who live in the home. One file was chosen at random and one was selected on the basis that the home had informed us of a number of incidents. The care plans examined were dated and reviewed in February 2009. The care plans contained the relevant sections on support needs as required. Personal care and support is covered in detail and written in the first person and gives clear guidance to Care Homes for Adults (18-65 years) Page 10 of 28 Evidence: staff on how people are to be assisted or supported with personal care. Health care, social activities, communication and information on family contact is recorded. Information on any spiritual and cultural needs is given. People living at the home require different levels of support with regard to decision making and choice. This is reflected in the care plan and risks assessments. We were of the opinion from meeting people and looking at care records that three people had low risk lifestyles needing full support in the home and in the community, from staff. The risks assessments on one persons file were examined for evidence that behavioural risks had been assessed appropriately. Although risks had been identified, in particular with regard to behaviour, a clear response and management strategy needed to be drawn up and finalized. One risk assessment was not complete. We require that a full behaviour strategy including triggers, behaviour and staff response to each area identified be put in place. Care Homes for Adults (18-65 years) Page 11 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 use the service have opportunities to engage in activities within the wider community. Family links are maintained. Varied meals are offered and people are encouraged to make a choice. Evidence: We were able to meet with four people who use the service. We were able to talk with two people and ascertain the views of one person. We asked about the home, staff and daily activities. On person indicated he/she liked the home and staff and had a good daily routine. Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: We were able to see the daily/weekly schedule for people who live at The Grange. Two people attend Southall College four days a week on a part time basis. For three people the schedule is based around the home, helping in the home, drives out, lunch out and Art Therapy one afternoon weekly. Staff also do some art work with people, some of this is on display in the kitchen. On the first day of the inspection one person was out shopping with a member of staff to purchase materials. The home has a vehicle that staff can drive to take people out to activities. We were able to see from the care plan and discussion with staff that family links are maintained were possible; people having different levels of family contact. We were given copies of the menus for two weeks. The menus looked varied with a variety of evening meals, dishes such as pasta, currey, fish and stews. We asked the staff about the menu and choice for people who use the service. We were shown an extensive selection of laminated photographs of meals and food types; we were informed that these are used to help people make a choice. Meals are taken at a large dining table in the kitchen, this creates a homely atmosphere. Care Homes for Adults (18-65 years) Page 13 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 who use the service receive the level of support they require for personal care. Evidence: We were able to see that personal and healthcare support needed is well documented in the care plan. The steps to be taken for personal care are well set out and there is reference on the care plan to cross gender care. People who use the service require diffentent levels of support. A record is made of all the health care appointments attended. We noted that people had attended appointments to monitor mental health, chiropody, opticical and general practitioner appointments. The health care plan also incorporated gender related issues and people had received a flu vaccination. We did note on each care plan that dental service support was not adequate. One person had an appointment but there were difficulties in supporting the person to go through with the consultation; it was suggested that family support could be requested but this was not followed up. One person was not registered with a dentist. We discuused this with the Registered Manager and acknowledged that for some people who use the service, there is great difficulty in attending the denstist. However, the service must ensure that this is persued to enable people to have their dental health and hygiene monitored. Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: We checked the the homes medication storage arrangements and the records of medication administration. No errors or omissions were noted. A monitored dosage system is used and the information on each persons medication requirments is clearly documented. Care Homes for Adults (18-65 years) Page 15 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. There are policies and procedures in place to ensure that people who use the service and their relatives are able to complain if necessary. Procedures are in place for the protection of vulnerable adults. Evidence: The Annual Quality Assurance Assessment provided by the home states that a complaints procedure is in place, this is provided in a user friendly format to people who use the service and their families. The Annual Quality Assurance Assessment states that a policy is in place for the Protection of Vulnerable Adults; the commissioning Local Authority Protection of Vulnerable Adults Procedure is also available. We looked at the Milbury Complaints Book and saw that the last complaint was recorded in 2006. The Complaints Procedure is visible in the entrance hall. We had not been informed of any Safeguarding Vulnerable Adults referrals during the year since the last inspection. We did not examine peoples financial records on this occasion. The Annual Quality Assurance Assessment informed us that financial records are audited on a regular basis by a Millbury Care Operational Manager. Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: We talked with the Registered Manager with regard to the care plan and risk assessment for one person and required that the risk assessment is explicit with regard to physical intervention ( restraint) and the circumstances in which this is used. We recommended that provision be made for staff to attended training on Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Care Homes for Adults (18-65 years) Page 17 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. People live in a homely and comfortable environment. Evidence: We toured the communal areas of the home with the exception of the activity room located at the bottom of the garden. The home is spacious with a large homely kitchen with room for a dining room table. The premises are well designed, well decorated and clean. We were able to see peoples bedrooms these meet the required standard. Care Homes for Adults (18-65 years) Page 18 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are supported by staff, however this needs to be improved with the recruitment of more permanent staff to the staff team. The Registered Manager needs to plan and monitor formal one to one supervision for staff. To ensure that people are supported by appropriately trained staff, National Vocational Qualification training must be offered. Evidence: The staff establishment comprises of nine full time permanent care staff. At the time of the inspection there were eight full time posts vacant. This was discussed with the Registered Manager; included in this number is one member of staff who is on long term sickness absence. Milbury Care bank(relief) staff are used to cover vacant posts and shifts. We were informed that interviews for new staff had been planned and that staff who work as bank relief workers are considered for permanent contracts if they are able to demonstrate the necessary skills for the job. Two staff had been recruited since the last inspection and one new member of staff in February 2008. A requirement was made at the last inspection that sufficient permanent support staff Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: and management staff be be employed to meet the health and welfare needs of people who use the service. This had been partially met, there remains a high level of vacancies which Milbury Care Services must endeavor to fill. We looked at the recruitment file of one member of staff who had been recruited in 2008. We were able to see that the required process had been followed and the correct documentation was in place. This documentation included a cover sheet of the various checks that had taken place, two references, identity verification (National Insurance and Passport) and Criminal Records Bureau check information with a CRB reference number. The member of staff had received training with Milbury Care Services Limited. This included an in-house induction to look at practice, policies and procedures and Common Induction Standards; this being done by staff on the computer with an accompanying workbook. The member of staff had also completed training in Non Violent Physical Intervention and Restraint (physical intervention techniques). The Annual Quality Assurance Document completed in August 2008 states that three staff have National Vocational Training and it is identified on the AQAA that this needs to be improved. This improvement is required by Care Quality Commission to meet the required standard of at least 50 of staff to have obtained an NVQ. We looked at the supervision records and dates of two members of staff and were able to see that the requirement made at the last inspection had not been fully met. One member of staff had not received adequate one to one supervision and supervision for one member of staff had not been recorded for 2009. We discussed this with the Registered Manager as a requirement had been made at the last inspection with regard to supervision not meeting the required standard. We recommended that a forward planner for all staff supervision be prepared for at least six month possibly a year. As art of this inspection we will be making three requirements in relation to the staffing standards, for Milbury Care Services Limited to forward an action plan to improve recruitment, NVQ training and supervision. We spoke with six members of staff as a group. Staff confirmed that they had received induction training and training in the administration of medication. Staff reported that a minimum of five people were on duty during waking hours. When asked staff said they felt supported in managing challenging behavior and that a ratio of two staff to one person is available on activities in the community. Staff confirmed that people Care Homes for Adults (18-65 years) Page 20 of 28 Evidence: make choices in regard to clothes and food. Care Homes for Adults (18-65 years) Page 21 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. The home is administered by an experienced manager who has identified areas for improvement. The views of people who use the service are taken into account, There are systems in place for the health and safety of the home and the people who reside and work there. Evidence: A Registered Manager is in place who is currently working toward the Registered Managers Award. The Registered Manager remains responsible for a two person supported living scheme known as Ross Cottage in addition to the management of Grange House. The Registered Manager does not have access to the necessary information technology to enable him to work efficiently. A computer is available for the staff Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: training package, there is no email or internet facility. The Manager gave the example of the Local Authority requesting some information to be emailed and this was not possible. The internet is also essential for information on the care sector and legislation. We strongly recommend that this facility be made available to the staff at Grange House. An Annual Quality Assurance Assessment was completed by the Registered Manager and returned to the Commission for Social Care Inspection. This clearly states the areas identified as being good and areas identified for improvement. We received a copy of the Annual Service review completed for 2008, this was completed by an Operational Manager. Areas for improvement have been identified and people who use the service/relatives and staff have been consulted with regard to their satisfaction with the service. We looked at a sample of records relating to health and safety in the home. A weekly check of fire alarms and hot water is made. A fire fire safety audit had taken place in February 2009 and a household health and safety check. Fire extinguishers had been serviced in April 2008, Gas safety and electrical equipment testing had taken place in 2008. The Annual Quality Assurance Assessment stated that staff had received training in infection control. Information was forwarded to verify that staff had received fire safety training. Care Homes for Adults (18-65 years) Page 23 of 28 Are there any outstanding requirements from the last inspection? Yes R 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 1 32 18(1)(c) Every effort must be made to 01/05/2009 increase the percentage of NVQ qualified staff employed in the care home to 50 . The registered person must ensure that all staff are appropriately supervised. Restated from the previous inspection report as the timescale of 01/11/06 was not met. 01/09/2007 2 36 18(2) Care Homes for Adults (18-65 years) Page 24 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 9 15 The Registered Provider and the Registered Manager must ensure that behavioural risk assessments are detailed and complete and set out a behaviour management strategy for staff. Care staff need clear guidance on how to respond to and manage challenging behaviour. 19/06/2009 2 19 13 The Registered Provider and the Registered Manager must ensure that people who use the service attend regular dental checks. People who use the must be supported to access dental health care provision. 11/06/2009 3 32 18 The Registered Provider and the Registered Manager must ensure that the training resources are 26/10/2009 Care Homes for Adults (18-65 years) Page 25 of 28 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 available for care staff to undertake NVQ training. Training to NVQ standards provides care staff with the knowledge required to work in the care sector. 4 33 18 The Registered Provider and the Registered Manager must be able to evidence that care staff vacancies have been advertised to recruit a full staff team. People who use the service will benefit from a permanent staff team and constant care. 5 36 18 The Registered Provider and 30/06/2009 Registered Manager must ensure that all staff receive one to one recorded supervision six times a year. The Registered Manager and care staff must meet to discuss practice and the welfare of people who live in the home. 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 03/08/2009 1 23 We recommended that staff attend training in the Mental Capacity Act 2005 and Deprivation of Libnerty Safeguards. Care Homes for Adults (18-65 years) Page 26 of 28 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 2 36 We recommend that the Registered Manager completes a supervision planner to ensure that all staff supervision is set for at least six months. We recommend that Milbury Care Services provide The Grange with the Information Technology to ensure efficient communication and access to social care knowledge. 3 37 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. Care Homes for Adults (18-65 years) Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!