Care Home: Greenhill

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What the care home does well "If I had to sum it up in one word, it would be dedication" was one comment received and was fairly typical of the positive feedback that we have received about Greenhill during this current inspection. When we asked people who live in the home what the home does well, one very typical reply was "for me just about everything".There was a very relaxed and pleasant atmosphere in the home throughout this inspection visit. The rapport between members of staff and people living in the home was excellent and people in general seemed to be enjoying either living or working there. One area of the home`s provision that merits particular comment is the good standard of care for people living with dementia. Staff have received a variety of training specifically in this area of care work and this has borne fruit in many ways. People living in the home are involved in practical tasks like preparing food for the guinea pigs and cleaning them out. There are environmental adaptations and provision that has been made specifically to meet the needs of people living with dementia and the whole ethos and direction of the home appears to be in line with current best practice in the provision of dementia care. Throughout the home, not only in the Cedars wing, people living in the home appear to be well-cared for and engaged in line with their own wishes and preferences. B&M have invested in staff training and this was very much appreciated by the members of the staff team we spoke to; "We have all kinds of training - there is always training on offer". It was significant that ancillary staff, who are vitally important to the effective running of any home, have been encouraged to undertake training sometimes only available exclusively for care staff. This enlightened policy is vindicated by the standard of interaction seen between care and ancillary staff and people in the home who live with dementia. What has improved since the last inspection? The requirements and recommendations made following the previous inspection have been satisfactorily addressed. In particular significant progress has been made in improving the standard of record keeping and practice for the administration of medication and also in the completion of care plans, in particular in the way that routine reviews are carried out and recorded. The relatives` support group has been started since the last inspection and this has so far proved to be welcome and positive for those who have attended. What the care home could do better: Having improved their standard of care planning and administration of medication the future challenge for Greenhill is to maintain and take forward this improvement. This is also true for the dementia care provided in the home. If this is to be expanded, it will require an increased commitment of time and resources in order to maintain the level and intensity of training and support to staff currently provided. Equally the home`s environment will need to be subject to continued refurbishment and renewal if the current good standard is to be maintained. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Greenhill Wagon Road Potters Bar Hertfordshire EN4 0PH     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: Jeffrey Orange     Date: 2 7 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 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 Older People Page 3 of 27 Information about the care home Name of care home: Address: Greenhill Wagon Road Potters Bar Hertfordshire EN4 0PH 02084498849 02084496343 greenhill@bmcarehomes.co.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) : B & M Investments Ltd t/a B & M Care care home 67 Number of places (if applicable): Under 65 Over 65 0 0 67 0 dementia learning disability old age, not falling within any other category physical disability Additional conditions: 67 1 0 3 The maximum number of service users who can be accommodated is 67. The registered person may provide the following category/ies 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: Old age, not falling within any other category - Code OP (Maximum number of places 67) Dementia - Code DE ( Maximum number of places 67), Learning Disability - Code LD (Maximum number of places 1), Physical Disability - Code PD (Maximum number of places 3). Date of last inspection Brief description of the care home Greenhill is a care home providing personal care and accommodation for 67 people aged over 65 years who may have a physical disability and/or dementia. Set in extensive grounds, Greenhill is an old detached manor-house style property, Care Homes for Older People Page 4 of 27 Brief description of the care home which has had various extensions and to which an annexe has been added. The property has been sensitively adapted, whilst maintaining original features such as a bar and large hall with seating for several people. There is a passenger lift. The majority of the homes rooms provide single occupancy, two offer shared accommodation. Most of the rooms have an en-suite facility. There are four communal bathrooms in use. The upper rooms and gardens provide wonderful views as far as Canary Wharf, and are easily accessible. There is ample parking space within the grounds and Potters Bar Town Centre is a short car journey of approximately two miles. Information about the home is included in the statement of purpose and service user guide. Both documents and a copy of the most recent CQC (Care Quality Commission) inspection report are available in the home. Current fees range from £800 to £850 per week (May 2009). Additional charges are made for newspapers, toiletries, chiropody and hairdressing. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We last inspected this service on the 6th June 2008. This inspection was unannounced and was carried out by one inspector. Where the report refers to we it recognises that it is written on behalf of the Care Quality Commission (CQC). The inspection began early in the morning and lasted for eight hours. During that time it was possible to observe the early morning routine of the home as people who live there were being helped to get up and ready for the day ahead. We also observed the meal time experience at lunchtime and those activity sessions that took place during the day. We spoke to people who live in Greenhill and to visitors to the home. We were also able to speak to members of the staff team both care staff and ancillary staff as well as to the homes manager and members of her team. During the inspection we looked at some key records, including those for staff recruitment, care planning and the administration Care Homes for Older People Page 6 of 27 of medication. This report also draws on information contained in any surveys that have been returned to us and also to the information sent to us by the home in their annual quality assurance assessment or AQAA. The AQAA is a self assessment document that sets out how well care outcomes have been achieved for people living in Greenhill. It also contains some useful statistical information, for example about complaints and staff training. We have also made use of any information that we have received about Greenhill since the last inspection in June 2008, this could be in the form of notifications from the home or from other health and social care professionals associated with the home in any way and also from relatives and friends of people living in the home or other people who have experience or knowledge of Greenhill. 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. Care Homes for Older People Page 8 of 27 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 Older People Page 9 of 27 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People considering Greenhill as a home for themselves or someone they are responsible for can be assured that they will only be admitted if their needs have been thoroughly assessed and can be satisfactorily met. They can also be confident that they will be encouraged to visit the home before they make a final decision about moving in. Evidence: When we looked at the welcome pack and service user guide we found that they contained sufficient detail for provide people considering Greenhill as a home for themselves or someone they are responsible for to make a well-informed judgement. When we spoke to people about their experience of moving into Greenhill they told us that either they, or those responsible for them, had been able to visit the home before they moved in to get an idea about it and to see if they thought it would be satisfactory for them. In their AQAA the home told us that people are encouraged to Care Homes for Older People Page 11 of 27 Evidence: visit the home without appointment, so that they can get a true picture of how it operates and a feel for the home. People who sent survey responses to us all agreed that they had enough information about the home to help them make an informed decision and they also confirmed that they had received an appropriate contract setting out the terms and conditions of their stay. When we looked at some recent preadmission assessments for people now living in Greenhill, we found that they contained sufficient detail to allow care staff to identify the needs of the person being considered for admission and to determine how these were to be met. The AQAA informs us that each person living in Greenhill has their own contact and these were seen to be in place in the documentation that we saw during this inspection. Care Homes for Older People Page 12 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in Greenhill can be confident that they will receive effective health and personal care support, that they will be treated with respect and as an individual and that systems and records for medication are accurate and efficient. Evidence: When we spoke to people living in Greenhill they told us that they were well cared for. They are wonderful was one comment received. When we spoke to people visiting the home they told us that they were very impressed by the standard of care that they found during their visits to the home. Throughout the inspection the care that was observed was good and took account of the need to preserve the dignity of those receiving care. For example we observed a person being hoisted from their wheelchair into a more comfortable lounge chair and throughout the procedure the care workers were reassuring the person being hoisted, telling them what was going to be done and making sure they were comfortable and not being caused any distress or hoisted in an undignified way.When we looked at care plans we found that these have been improved since concerns were raised during the last inspection. Reviews are now more Care Homes for Older People Page 13 of 27 Evidence: fully recorded and include meaningful information, so that anyone reading the care plan can get a sense of how care needs have changed and how this is being reflected in the way that care is given. The home have made significant progress in broadening the personal history element of the care plan, this should enhance the ability of care staff to provide care in a way that takes proper account of the individuals preferences,background and life history. When we looked at medication records and talked to the members of care staff who have taken principal responsibility for the administration and recording of medication to those people living in the home who require assistance, we found a greatly improved standard is now achieved. There were no gaps found in records, all totals checked agreed and there was a robust system of checks and training in place to help maintain good practice. When we talked with the responsible staff they agreed that the significant improvement that has been achieved can only be maintained if the same degree of diligence and monitoring is continued. When we looked at care plans we saw evidence of the involvement of a range of health care professionals with people living in the home, either on a routine or emergency basis. Whilst we were in the home the ambulance and paramedic service were called and attended to address concerns identified with one person living in the home. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in Greenhill can be confident that they will be encouraged and enabled to exercise choice in and control over their lives including their daily activities and routines. They can be assured that they will be able to maintain and build contacts with friends and the community. Evidence: When we talked to people living in Greenhill they told us that there were usually things for them to do if they wanted to. We observed activity sessions which appeared quite well attended, and were lively and sociable occasions. When we looked in particular at the Cedars and the activities taking place for people living with dementia, we saw the very popular guinea pigs cage being cleaned and then we saw people stroking and sitting with them. We saw a number of men and women having foot spas and the multi-sensory quiet room was being used as well. We were able to speak to one of the hairdressers who provide a service to people living in the home and this seemed to be very popular on the day we were there. When we talked to the activity organiser on duty they were enthusiastic and committed to the work they do, and spoke of past events that had been organised, including trips from the home, as well as future events planned. Throughout this inspection we saw care staff engaging individuals or Care Homes for Older People Page 15 of 27 Evidence: small groups in various activities and on the Cedars unit the way the environment has been imaginatively set out, with reminiscence and rummage facilities for example, were all being well used. We were told that as fast as care staff take all the contents out of one chest of drawers in a corridor, people living in the home proceed to fold them up and return them tidily to the drawers. The care staff and activity staff all appear to have benefited from the enhanced dementia care training that has been taking place, and this is increasingly influencing the way the home operates, including in the area of activities. The garden is well-equipped and includes various areas to sit and enjoy the wild-life and well kept grounds. When we observed meals they appeared to be sociable occasions. There area variety of places where people living in the home can choose to eat and people told us that they were able to exercise choice. The content of menus and the availability of snacks were all included on service user meeting minutes and changes are made to try and meet suggestions wherever possible. In conversation with the chef and the home manager it was agreed that as well as listing peoples dislikes and particular dietary requirements, consideration would be given to high-lighting the things individuals particularly liked, so that these could be reflected in the homes menu. When we walked round the home we noted that in order to assist care workers communicate with one person whose mother tongue was French, there was a handy phrases folder to assist them to do so. When we talked to the homes manager and the activities organiser we found that whilst they felt they were supported by B&M Care in the funding of special activities and oneoffs, they would find it helpful to have a devolved budget for activities to enable them to have more autonomy over decisions about what can be provided when. During the inspection visit we saw a number of people visiting the home and also people living in the home going out with friends or relatives. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in Greenhill can be confident that if they want to make a complaint they will be able to do so and that they will be listened to and appropriate action taken.They can also be assured that staff have received training to help them protect people living in the home from abuse. Evidence: When we looked at the documentation provided to people living in or considering Greenhill as their home, we found that full details of the complaints policy is included and also provides contact details for a number of relevant organisations, this means that anyone who wants to should be able to find out how to make a complaint. When we looked at the homes complaints records, we found that they were satisfactory.We followed one complaint through and the complainants were satisfied with the way that their complaint was handled. In their AQAA, the home informed us that they had received three complaints in the past twelve months and that they had all been resolved. When we looked at staff training records we saw that this includes safeguarding of vulnerable adults and when we spoke to staff they understood what abuse is, how it can be recognised and what to do if it is seen or suspected. All of this should give confidence to people living in the home, or those responsible for them, that they are being protected from abuse wherever possible, and that were it seen or suspected, rigorous and appropriate action would be taken to address it. Care Homes for Older People Page 17 of 27 Care Homes for Older People Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living and working in Greenhill can be assured that the environment is safe, comfortable, clean and well-maintained. Evidence: When we walked round the home and with their permission went into the bedrooms of people living in the home, we found that the standard of cleanliness was high and this was confirmed in comments received from people living in the home; I think they keep it very nicely and people visiting, We have always found that the home is clean and tidy. We spoke to laundry staff and senior housekeeping staff and found that they were committed to provide a good standard of care. Some ancillary staff have also received care training at NVQ level which is a positive endorsement of their critical role in providing a good care environment for people living in the home. The bedrooms seen were personalised to reflect the personalities and interests of the people whose rooms they were. When we saw the way that the environment had been modified in order to help those people living in the home with dementia we found that it reflected the expertise and knowledge gained by the manager and her staff from specialist dementia care trainers and provided facilities and furnishings that will enhance their experience of living in Greenhill and support them in their daily lives. The gardens have been laid out and equipped to a very high standard and offer a pleasant place for people living in the home to sit and enjoy any good weather we may have. Care Homes for Older People Page 19 of 27 Care Homes for Older People Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in Greenhill can be assured that they are protected by the recruitment policies and procedures followed by the home and that there are sufficient numbers of care and ancillary staff with the training, support and skills required to meet their needs. Evidence: When we looked at the recruitment files for some staff who had recently joined the staff team we found that the required checks had been completed and the information needed obtained to ensure that people receiving services and care from them are safe and that their care needs are met appropriately. When we looked at staff training records we found that these are detailed and up to date. They include routine training and updates to it, specialist training including that at NVQ level 2 and 3 in care and also a range of dementia care training which is designed to raise the standard of understanding and promote best practice in dementia care. The results of this are referred to elsewhere in the report but show the value of good quality, external specialist training for both care staff and more importantly for those who receive care from them. When we spoke to people living in the home, when we observed care throughout the day and when we monitored call bell response times whilst moving around the home, we saw evidence that staffing numbers are sufficient to maintain a good standard of care. When we spoke to care staff they were enthusiastic and Care Homes for Older People Page 21 of 27 Evidence: dedicated and all paid tribute to the training provided and to the homes management and the support they receive from them. As indicated above, all the people living in the home benefit from the dedication, skill and expertise of the care and ancillary staff at Greenhill. Care Homes for Older People Page 22 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Greenhill is a well managed and run home and people who live or work there can be confident that their best interests are at the forefront of decision making. Evidence: When we spoke to care staff, people living in the home, relatives and visitors they were all very positive about the way that the home is managed and run and about the manager and her team. If I have to use one word to describe the manager and her staff it is dedication was the assessment of one relative. Both the manager and her assistant manager indicated that they felt that they received a good level of support from B&M Care at a senior level and that they had the resources they required, although some limited additional autonomy, to avoid having to ask on every occasion funding was required for activities would be helpful. The manager is very active within the home and we saw minutes of staff, resident and relatives meetings at which she gave clear leadership and guidance. When we saw the minutes for one staff meeting the manager was recorded as giving advice to any staff who felt under stress and Care Homes for Older People Page 23 of 27 Evidence: indicating that assistance and support would be provided to them. The home only manages small amounts of money on behalf of some people living in the home and when we looked at the system for recording transactions and checked sample balances these were satisfactory. Risk assessments are in place within care plans and routine maintenance checks, including those for the fire protection system are in place and recorded. The AQAA was well completed and was an realistic assessment of the home. Throughout the inspection the manager and her team were enthusiastic and highly motivated to achieve a consistent improvement in standards in all care outcomes. When we looked at records of staff supervision and spoke to staff about the supervision and support they receive all indicated that routine, regular supervision is in place and that over and above that, they feel able and welcome to approach the manager at any time. The manager indicates in the AQAA that she has an open door policy for staff, people living in the home and visitors to the home. The management team have worked hard, under the direction of the registered manager to meet all of the concerns and requirements raised or made after the last inspection. The improved rating achieved following this inspection is testament to the success of this effort and in particular the very good standard of dementia care achieved is the result of a commitment to specialist training in providing person-centred care in line with current best practice. We noticed that the second of a newly launched relatives support group was to be held on the evening of our visit, minutes of the first meeting in February were seen and included very positive comments from those who attended.All of the above means that people who live in Greenhill benefit from living in a wellmanaged and run home. Care Homes for Older People Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 27 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 1 12 The registered provider should consider if it would be beneficial to the homes manager and activity co-ordinator and thereby benefit people living in the home if they were to have greater autonomy, for example some devolved budget for activities in the home, based upon the number of people living there. Care Homes for Older People Page 26 of 27 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). 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