Care Home: Helebridge House (2006) Ltd

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Helebridge House (2006) Ltd Helebridge House Hele Road Marhamchurch Bude Cornwall EX23 0JB two star good service The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Helen Tworkowski Date: 2 2 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to:  Put the people who use social care first  Improve services and stamp out bad practice  Be an expert voice on social care  Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Internet address www.csci.org.uk Information about the care home Name of care home: Address: Helebridge House (2006) Ltd Helebridge House Hele Road Marhamchurch Bude Cornwall EX23 0JB 01288361310 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Helebridge House (2006) Ltd Name of registered manager (if applicable) Lorraine Anne Morris Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 6 1 0 0 care home 6 learning disability physical disability Additional conditions: The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD - maximum 6 places Physical disability - Code PD - maximum 1 place The maximum number of service users who can be accommodated is 6. Date of last inspection A bit about the care home Helebridge House provides residential accommodation and personal care for up to six adults with a learning disability. The house is in a rural location, thought close to public transport. There are a number of foot and cycle paths near the home. The accommodation includes four upstairs bedrooms and a bathroom. There are two further bedrooms downstairs, one of which is ensuite. There is also a lounge, kitchen, dining room, office and a futher bathroom on the ground floor. The laundry is on the first floor. Staff do not sleep at night in Helebridge House, but sleep in the adjacent house. The house is set in a spacious garden and there is ample seating space. The current fees are 350 pounds per week. This does not include toiletries, chiropody, clothes or transport to social or work activities. Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home This inspection took place on the 21st October 08 between 9a.m. and 11.00 a.m, and on 22nd between 7.30am and 12 noon. The first part of this visit was unannounced. During this inspection we spent time talking to the people who lived at Helebridge House, both over meals, and in private. We looked around the house, and talked with the manager, Mrs Morris. We looked at the records of care and focused specifically on two people. We looked at the way medication is managed, and how staff are recruited and trained. We also looked at the ways people are kept safe. We had received information from Mrs Morris, Manager, before the start of this inspection in the form of a questionaire. As part of this inspection process we spoke by telephone with someone who works at a day centre where many of the people from Helebridge House attend. We also receive a survey from a Social Worker who has contact with many of the people who live at Helebridge House. What the care home does well The people who live at Helebridge House are treated as individuals and with respect. A Social Worker who has contact with people who live at the home commented: The residents have much more control over their lives, their opportunities for doing different things has greatly increased and they have also holidayed abroad which they greatly enjoyed. One person from a Day Centre said about the home They (the people who live at Helebridge House) come in smiling and happy. Things have greatly improved, they are listened to more and are treated as indivdiuals, peoples interests are followed up. The people we spoke with at Helebridge House were happy with the way they were treated and the opportunities they had. We found that people received the support they needed and were given the opportunity to take part in activities and to develop hobbies that they found of interest. The Manager is involved in all aspects of day to day work in the home, and the people who live at the home clearly trusted and liked her. The small staff team at the home receive training to do their work. The house is clean, homely and comfortable. Where redecoration has taken place this work has been done to a hight standard. What has got better from the last inspection One of the bathrooms has recently been refurbished and some of the bedrooms have been re-decorated. One new bedroom has been created on the groundfloor, this bedroom has an en-suite shower and toilet. What the care home could do better If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Helen Tworkowski Unit D1, Linhay Business Park Ashburton TQ13 7UP 013 6465 1800 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People move to Helebridge House can be confident that their needs will be known about before they move. The information about the home, including information about the fees and terms of conditions of residence is incomplete, needing further development. Evidence: We asked the Registered Manager, Mrs Morris, about the documents that provide information about the home. we were shown a copy of the Statement of Purpose, which was in need of updating. Mrs Morris said that Service User Guide was in the process of being re-written. We discussed with Mrs Morris these documents and that they the need for them to contain the information that is specified in the Care Home Regulations and National Minimum Standards. The Service User Guide must be written in a format accessible to the people who at Helebridge House, and must contain information about the fees and the terms and conditions/ contract of accommodation. We asked to see a copy of contracts, as this had been a requirement from the last inspection. We found that there were contracts between the care home and social services, however as has already been noted no information was provided to individuals about what the service they can expect at Helebridge House. One person has moved to Helebridge House since the last inspection. We found that there was information from Social Services about the individuals needs. Mrs Morris explained that the person had come for visits prior to deciding that he or she would like to move to Helebridge House. 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 . The people who live at Helebridge House have their needs met and they are involved in decision making about their lives. Evidence: We talked with four of the people who live Helebridge House, and they were all satisfied with the help they received. Surveys had been sent to five of the six people and all five said that they were able to make decisions about what to do each day and that carers always listened and acted upon what was said. We observed the way Mrs Morris interacted with the people at Helebridge House, helping them to get ready to go out in the morning. People were asked about what they wanted and were not told. From what was observed this was not unusual but the normal style of interaction. We looked at the documentation that is provided about how care needs are to be met. Mrs Morris explained that these plans were reviewed every two months. The documents that we looked at contained general information about how needs are to be met, we discussed with Mrs Morris the importance of providing specific informationsaying exactly the actions staff are to take to meet needs. We also discussed with Mrs Morris that the review did not require total rewriting of the care plan, but only those elements that had changed. Where possible this review should be done with the individual concerned. We discussed with Mrs Morris that whilst she was aware of some of the risks people are exposed to, and was taking actions to try and minimize these risks, she did not Evidence: have a written record of this process. We discussed with Mrs Morris the importance of such documents and how they can also provide a record of the involvement of not only the individual but other professionals in this process of managing risk. 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 . The people at Helebridge House are provided with the opportunity to lead a varied and active life. They are provided with the support to maintain contact with family and friends. People are provided with a healthy diet and have the choice about where they eat. Evidence: All of the people living at Helebridge House are occupied during the day time. We were told most people attended day centres at least part of the week. There was evidence that where people were not satisfied with the service, then they would be supported to change. We were also told that the people who live at Helebridge have the opportunity to go out and be part of the local community. When we spoke to people at Helebridge House they described going out to local pubs for meals, going for walks and a recent holiday. We were told how one person had recently purchased a motor scooter so that he is better able to go out for long walks. We spoke with some of the people who live at the home about any rules, they were clear that there were no rules such as bed times. Mrs Morris explained that they encouraged choice, some people chose to eat their breakfast in their room, others enjoyed eating together. We asked some of the people who live at the home about hobbies and interests. We were shown jigsaws, and crafts. We saw that some peoples art work had been displayed on their bedroom walls. We were told that one person had recently started Evidence: to play the drums. Mrs Morris explained that whilst they respected peoples existing interests they also tried where possible to give people the opportunity to enjoy new hobbies. We were told about plans to provide raised beds in the garden, so that residents would find it easier to become involved in growing vegetables. We were at Helebridge House whilst people ate their breakfasts. This meal was informal, and people made choices about what they ate. One of the residents was involved in domestic chores. We were told that residents are involved in choosing what was eaten, we discussed with the Manager ways that residents could be provided with pictures to help them to choose meals. We were told by Mrs Morris and the people at Helebridge House about various parties and events that had been held in the home. We were shown cards and letters from relatives thanking Mrs Morris for arranging this activities. One of the people at the home told us about how he/she kept in contact with relatives, and Mrs Morris explained that visitors were actively encouraged. 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 . The people who live at Helebridge House are given the support and care they need to maintain their physical and mental health, in a way that suits them. Evidence: We looked at information about peoples health care needs in their care plans. There was a record of appointments that were attended. We discussed with Mrs Morris a referral to a Speech and Language therapist, and that the plan of action to identify a list of words an individual used, needed to be followed up. All of the people we saw were well dressed and in a manner that reflected their own taste. People made choices about their hairstyles and what they wore. We were also told that some individuals chose to go to church and they received the support they needed to do this. Mrs Morris explained that there are pressure mats in place that are switched on in the evening. These allow her to be alerted to if anyone is entering or leaving the house, and then for her to check and see if there is a problem. We discussed with Mrs Morris that information about such alarms system needs to be in the Statement of Purpose or Service User Guide. If such alarms are being fitted to monitor and provide surveillance on individuals then it should be clear in the care plan why this is needed and agreed through a multi-disciplinary team meeting. We looked at the medication system. This was in good order and there was a record of medication administered. 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 . The people who live at Helebridge House are listened to and staff are aware of how to protect people from abuse. The current system of managing money needs changing so that there is a clear separation of moneys belonging to the an individual and charges made to the individual by the service. Evidence: We talked to the people who live at the home about whether they could raise any concerns, they said they could. One of the visiting professionals said that the service always responded appropriately to any concerns raised. As part of this inspection we saw that staff had received training in relation to protecting people from abuse, and that in discussions with Mrs Morris she demonstrated a good understanding of the right and needs of the people she supported. We looked at the way that the way money belonging to the people who live at Helebridge is managed. We found that there were good accounts of cash held on behalf of people, with receipts kept where appropriate. We discussed with Mrs Morris the way that benefits are managed and charges are made. We were told that the system used is the one that was inherited from the previous owners. Currently benefits are paid into the Helebridges account, and any personal allowance is paid to the individuals by Mrs Morris. We discussed with Mrs Morris that money (income support, mobility allowance or other monies) belonging to the people living at the home should not be paid in this way. It should be paid into their own account, or the account of someone they choose. Helebridge House may then charge the individual for any service it provides, as specified in the contract or terms and conditions. This means that there is a clear separation of monies which belong to the individual and those belonging to the service. This will provied a clear audit trail for any charges, and if an individual were to move then any changes to benefits may be less complex. 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 people at Helebridge House benefit from comfortable and clean accommodation. Evidence: As part of this visit we were shown around the house, some of the people living at the home were happy to show us their rooms. The house was generally clean and in good order, there were no unpleasant smells. Each of the bedrooms reflected the occupants preferences in terms of decor and tidiness. Mrs Morris explained that many of the rooms had been re-decorated, and that they were gradually working through the home improving standards. There was a clear distinction between areas which had been redecorated and areas that were yet to be upgraded. The people who live at Helebridge House feel comfortable enough to leave their own personal items around in communal areas, such as family photos. We looked at the laundry on the first floor and discussed with Mrs Morris issues related to control of infection. We discussed hand washing facilities in the laundry and the use of paper towels and liquid soap in communal toilets and bathrooms. Helebridge House has a large garden, there is a patio area with some good quality garden furniture, that could be used all year. There is also a vegetable garden, Mrs Morris said that they are hoping to provide raised beds, so that people can be more involved in gardening. 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 . There are sufficient, competent staff to provide support to the people who live at Helebridge House. Recruitment records and staff records are limited, and need to be improved to demonstrate that staff are fit to work at the home. Evidence: Mrs Morris explained that the home is staff by a combination of paid and unpaid staff. We looked at the recruitment files of paid staff. We found that not all of the information that is required by regulation was present. Mrs Morris explained that she knew staff before they started to work, and whilst we recognized that she ensured that only staff she could trust worked at Helebridge House there was no evidence of proper checks to confirm this. We found that there were copies of criminal records bureau (CRB) checks, however there was no full employment history and there were no references. We found that no formal checks had been made in relation to people who worked in the home in an unpaid capacity. We discussed with Mrs Morris that anyone who works at Helebridge House, whether paid or unpaid should be subject to the checks that are specified in the regulations. We looked at the record of training for a member of staff who had recently started work at the home. We found that they had received an induction and a range of training such as training in relation to fire, food safety, medication, health and safety, and the Protection of vulnerable adults. Mrs Morris told us that there was always at least one person on duty. At night she was available on call if any help was needed. Mrs Morris said that the alarm systems were linked to where she slept in her house, a few yards away. We discussed this situation with Mrs Morris, and considered that any risks to people were properly managed, however there was no written risk assessment of this situation. We asked to see a rota to show who was on duty at any one time. Mrs Morris said that Evidence: she was in the process of drawing up a rota. We discussed with Mrs Morris that there should be a rota that accurately reflects the hours planned and actually worked within the home. We talked to people living at Helebridge House during this visit about how they were treated and were told that they were happy. 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 . Helebridge House is a well managed home, that is run for the benefit of the people who live there. Evidence: We asked a Social Worker about the quality of service at Helebridge House. He said Since taking over the ownership of Helebridge Lorraine has greatly improved the quality of care and support available to the residents. As part of this inspection we looked at the way the home was managed. Mrs Morris is not only the manager but provides much of the care and support herself. It was clear from our discussions with both her and the people who live in the home that she knew what was going on and was taking an active role in improving the service. At the last inspection a recommendation had been made that the recommendations should reflect the change of ownership. Mrs Morris showed us copies of policies and procedures that they had revised to reflect current ownership. Mrs Morris said that whilst they had a Quality Assurance policy they had not yet sent out questionnaires to people as is required by this policy. We discussed with Mrs Morris ways of receiving feedback from people who live in the home. It is clear that Mrs Morris has daily contact, however we discussed with Mrs Morris having residents meetings where people could share their ideas about what happens in the home. We asked about Environmental Risk Assessments, and were shown risk assessments that had been developed by the previous providers. We discussed with Mr and Mrs Morris that these risk assessments need to be improved so the hazard was clearly Evidence: identified, as were the actions taken to reduce the risk to a manageable level. There were no risk assessments in relation to preventing infection from Legionella or in relation to the risk of scalds from hot water. These risk assessments need to be developed. We asked about a Fire Risk Assessment and were told that because the home employs so few people it is not required to have a written Fire Risk Assessment. We saw that checks on the fire system were being completed. We would recommend that a written Fire Risk Assessment is completed. Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 23 20 Monies belonging to individuals living at Helebridge House must not be paid into any account relating to the business, unless it is as a charge for a service provided. 01/02/2009 There must be a clear separation of monies, providing an audit trail. 2 34 19 Prior to a person starting work (paid or unpaid) at Helebridge House proper recruitment checks must be completed. These must include two written references. There must also be a complete work history. 01/01/2009 Vulnerable people need to be protected by good recruitment procedures, which include written evidence. 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 1 The Statement of Purpose and Service User Guide must be updated so that they contain all of the information as specified in the regulations and National Minimum Standards. Each person must be provided with clear information about their terms and conditions of residence, including the fee, how it is paid and what it covers. Care or Service User Plans should contain details of the actions staff are to take, to meet peoples needs. These should be completed with the individual concerned where ever possible. Written risk assessments should be completed for each person so that there is a clear record of the decisions around risks and the actions taken to reduce any risk. The use of any monitoring or surveillance device must be identified in care plans, where it relates to individuals. There must be a record of a discussion and multidisciplinary team agreement. Control of infection procedures and practices should be reviewed, as per the advice of relevant professionals such as the Health Protection Agency. This should include considering the provision of hand washing facilities in the laundry and the use of liquid soaps and paper towels in communal toilets. A written rota showing who is working when should be kept, so there can be no confusion about who is providing care and support. A risk assessment should be completed in relation to staff providing support at night time from within the adjacent house rather than from inside Helebridge House itself. Environmental Risk Assessments should be developed so that there is written evidence that risks, such as those related to Legionella or scalds from hot bath water, are eliminated or managed. The Fire Risk Assessment should be written down, so that there is evidence of this process available at all times for inspection. 2 5 3 6 4 9 5 18 6 29 7 33 8 33 9 42 10 42 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone : 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web:www.csci.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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