Care Home: John Joseph Powell Memorial Care Centre

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What the care home does well We saw some assessments carried out on people admitted and these were thorough. They were supported by further information and assessments from professionals such as social workers and health care professionals so that a full picture of the person could be built up. Care records are completed well and included reference to a diverse range of peoples individual needs. For example one person had been assessed for risks involving smoking and the care plan facilitated times when the person could be involved in this activity. Another persons care plan had reference to needs under sexuality such as the need to maintain appearance and dignity. This shows that the home are willing to accommodate peoples individuality. We saw references on the `professional visits` sheet of GP visits as well as physiotherapy, chiropody, optician and other professional visits and appointments. A relative spoken with told us that the home had been very proactive in arranging medical appointments and ensuring that these were kept. We observed staff supporting people well and clearly recognizing people as individuals. People spoken with reported that staff were always respectful when dealing with personal care needs. This shows that staff are careful to maintain peoples dignity. One person commented: `I can`t fault the staff they look after me well`. A relative said; `The staff are lovely and look after mum very well. They always make us feel welcome and give us a cup of tea`. The general care environment is well managed and maintained. There were also some examples of good practice regarding developing the environment for people who may have some confusion and can be disorientated. We observed good use of orientation aids such as clear signage and there are `reminiscence` and themed areas around the home so that residents can walk around and feel comfortable and stimulated. The pre inspection information states that 90 percent plus of staff have achieved a National vocational Qualification [ NVQ], and most other staff are on these courses. Some staff have attended training courses around providing care for people with dementia which shows that the home are willing to support people who have a diverse range of care needs. What has improved since the last inspection? The social life for people living the home continues to be developed in a positive way. We spoke to relatives and residents who said they could join in some activity on a dailybasis although more tended to be on offer later in the week [Thursday and Friday] when there are two staff attending to the organization of activities. This helps to ensure that people living in the home enjoy some quality of life. We spoke with the manager and looked at records regarding complaints that have been made. On previous inspections some issues have not been referred appropriately such as those that needed investigation by local social service safeguarding teams. The manager is now fully aware and has developed positive contacts with social services so that any event regarding peoples safe care is appropriately investigated. We looked at some staff files and found that the checks required for each staff prior to employment had been made and that staff were recruited thoroughly. This is an improvement from the last inspection and ensures that staff who work in the home are fit to do so. What the care home could do better: The manager informed us that there should be written information in each room but we could not find a copy of the guide in any of the rooms we visited. We would recommend that all rooms are checked to ensure that up to date information is available. This helps people to orientate and settle into the home. We would recommend that residents and relatives are more formally involved in the evaluations of the care on occasions as this would be a good time to discuss the person concerned and any amendments to the care plan. We observed some handwritten entries on medication charts and we discussed the need for two staff signatures in these eventualities to ensure that accurate records of any changes are made. We did observe one area near the MAP unit laundry that was cluttered with laundry and hoist equipment blocking the passage way to a fire exit. This was reported to the manager as this area must be clear at all times. We would recommend that this is regularly checked. Inspecting for better lives Key inspection report Care homes for older people Name: Address: John Joseph Powell Memorial Care Centre McKenna`s Court 11A High Street Prescot Merseyside L34 3LD     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: Michael Perry     Date: 0 6 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 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 Older People Page 3 of 28 Information about the care home Name of care home: Address: John Joseph Powell Memorial Care Centre 11A High Street McKenna`s Court Prescot Merseyside L34 3LD 01514310247 01514310247 jjp@meridiancare.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) : Meridian Healthcare Ltd care home 45 Number of places (if applicable): Under 65 Over 65 45 old age, not falling within any other category Additional conditions: 0 The registered person may provide the following categories of service only: Care home only - Code PC, to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 45 Date of last inspection Brief description of the care home John Joseph Powell Memorial Nursing Home is registered to provide nursing care for forty-five older people. This includes people who may have needs around palliative (terminal) care. The home is located in the Prescott area of Liverpool, close to local shops and road links. The home is purpose built over two floors. There is a passenger lift to access all areas and handrails are in place in the main corridors. Recreational space comprises of a dining room, lounges and conservatory. These rooms are bright and attractively decorated. Bathrooms have suitably adapted equipment and a call system with an Care Homes for Older People Page 4 of 28 Brief description of the care home alarm facility is operational for the residents. The home has garden areas, a large pond and a secure entrance to the car park. The home was acquired by Meridian Healthcare Limited in July 2005. Meridian Healthcare owns other care homes in the area, Leeds, Tameside and Scunthorpe. Mrs Dorothy Pye is the registered manager. The current fees are 516.88 pounds weekly Care Homes for Older People 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 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: Before we visited the home the manager filled out a form (Annual Quality Self Assessment, or AQAA) we sent and returned this. It had a lot of information about the home and how the people are supported to live their lives. We visited the home without telling the staff we were coming so that we could see how things work normally. We spoke with many of the people who live there and watched how they spend their day and how the staff support them. We also spoke with visitors. We looked at the records kept on people who live in the home and other records to do with how the home is run. Care Homes for Older People Page 6 of 28 We looked around the home to see if it was clean and a nice place to live and some of the people living in the home showed us their bedrooms. What the care home does well: What has improved since the last inspection? The social life for people living the home continues to be developed in a positive way. We spoke to relatives and residents who said they could join in some activity on a daily Care Homes for Older People Page 8 of 28 basis although more tended to be on offer later in the week [Thursday and Friday] when there are two staff attending to the organization of activities. This helps to ensure that people living in the home enjoy some quality of life. We spoke with the manager and looked at records regarding complaints that have been made. On previous inspections some issues have not been referred appropriately such as those that needed investigation by local social service safeguarding teams. The manager is now fully aware and has developed positive contacts with social services so that any event regarding peoples safe care is appropriately investigated. We looked at some staff files and found that the checks required for each staff prior to employment had been made and that staff were recruited thoroughly. This is an improvement from the last inspection and ensures that staff who work in the home are fit to do so. 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 Older People Page 9 of 28 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 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 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 are assessed and admitted to the home appropriately so that care needs can be effectively planned. Evidence: The pre inspection self assessment completed by the manager [AQAA] tells us that the home complete detailed assessments prior to people being admitted to the home so that the home are sure that any care needs can be met. We saw some assessments carried out on people admitted and these were thorough. They were supported by further information and assessments from professionals such as social workers and health care professionals so that a full picture of the person could be built up. From this information a care plan can be drawn up. We spoke with a relative and also people in the home and. They felt that staff assisted them to settle into the home but were unaware of any written information such as the Care Homes for Older People Page 11 of 28 Evidence: service user guide. The manager informed us that there should be written information in each room but we could not find a copy of the guide in any of the rooms we visited. We would recommend that all rooms are checked to ensure that up to date information is available. This helps people to orientate and settle into the home. Care Homes for Older People Page 12 of 28 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. Health care needs are well monitored by the home and staff ensure peoples personal care so that privacy and dignity are mainatined. Evidence: We looked at the care records for three of the people in the home. These were fairly comprehensive and we were able to follow the care of the people concerned. The care records include a care plan which details the care needed for each person so that staff can carry out the care with some consistency. These were completed well and included reference to a diverse range of peoples individual needs. For example one person had been assessed for risks involving smoking and the care plan facilitated times when the person could be involved in this activity. Another persons care plan had reference to needs under sexuality such as the need to maintain appearance and dignity. This shows that the home are willing to accommodate peoples individuality. The care plans are evaluated monthly and these were written so that we could get an understanding of the persons progress. There was no evidence in the care plans seen Care Homes for Older People Page 13 of 28 Evidence: of relatives involvement in the care planning process. The manager said that this varied but relatives are informed of the care informally. We saw that residents and relatives sign to say they have initially discussed the care plan but there is no further evidence of involvement. Those people spoken with said that they had had not involvement with the care plans although they were pleased that staff kept them up to date with any changes to the care. We would recommend that relatives are more formally involved in the evaluations on occasions as this would be a good time to discuss the person concerned and any amendments to the care plan. The care records contained very good references to peoples health care needs. We saw references on the professional visits sheet of GP visits as well as physiotherapy, chiropody, optician and other professional visits and appointments. A relative spoken with told us that the home had been very proactive in arranging medical appointments and ensuring that these were kept. We observed staff assisting people to walk and also encouraging people with their diet. Staff also used moving and handling skills to assist some residents. We did see that some people who where moved in wheelchairs did not have the appropriate footrests in place to ensure safety from injury. We discussed these and although one person was assessed as appropriate for this, others were not and were therefore at risk. We would require that all people are moved with footrests in place unless otherwise assessed. We observed varying levels of staff interaction but none of these were negative or adverse. Staff supported people well on these occasions and clearly recognized people as individuals. People spoken with reported that staff were always respectful when dealing with peoples personal care needs. This shows that staff are careful to maintain peoples dignity. One person commented: I cant fault the staff they look after me well. A relative said; The staff are lovely and look after mum very well. They always make us feel welcome and give us a cup of tea. We looked at how medicines were managed and found these to be safe and based on individual needs. For example medicines that needed to be given prior to or after food where observed to be given correctly. The medication records were easy to follow and accurate. We observed some handwritten entries on medication charts and we discussed the need for two staff signatures in these eventualities to ensure that Care Homes for Older People Page 14 of 28 Evidence: accurate records of any changes are made. Care Homes for Older People Page 15 of 28 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. The social life of people living in the home continues to be developed so that they feel relaxed and engaged in the daily life. Evidence: The social life for people living the home continues to be developed in a positive way. We spoke to relatives and residents who said they could join in some activity on a daily basis although more tended to be on offer later in the week [Thursday and Friday] when there are two staff attending to the organization of activities. During the rest of the week the activities tend to be more one to one. For example on the day of the inspection one of the residents was being encouraged to join in some physical exercises. This helps to ensure that people living in the home enjoy some quality of life. We observed the various peaces of art work on display around the home and spoke to a relative who has become involved in the maintenance of the pond which forms part of the garden facility of the home. Relatives reported that they are free to visit at any time and that they are always made welcome. This helps ensure that relatives and visitors feel involved in the care. We spoke to people about the general routine and were told that this is quite flexible. Care Homes for Older People Page 16 of 28 Evidence: One person said that she likes a lie in and this is accommodated. Meal times can be taken in the well appointed dining room or residents own bedrooms. We observed that the dinner time meal which was a pleasant and social occasion. People clearly enjoyed the food and said that there was choice available. We were advised that drinks and snacks are available throughout the day. We observed staff assisting people to eat and the meal was well paced and relaxed. Care Homes for Older People Page 17 of 28 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. There are policies and procedures and staff are trained so that peoples concerns are listened to and reported and they are protected Evidence: There is a complaints procedure available for people in the home. Those spoken with were very relaxed around staff and said that they were listened to so that any concerns could be addressed. The complaints procedure is displayed in the entrance foyer as well as being available in the information supplied in each bedroom so this is easily accessible. We looked at the complaints recorded. There were three complaints recorded since the last inspection visit. These had been well managed and the complainants had been appropriately responded to so that redress was evident. One complaint is currently ongoing but the manager has been responding appropiatle and has refered issues to the relevant people as part of the investigation process. We were shown policies and procedures around the recognition and management of allegations of abuse. Copies of the locally agreed procedures were available and the manager was able to discuss and show evidence of working with the local socila service safgaurding team. This shows that the home are continuing to act in the best interests of residents. One previos inspections matters have not always been refered Care Homes for Older People Page 18 of 28 Evidence: appropiatly so this an improvment. Staff spoken with have received training in how to recognize and report abuse and were knowledgeable about identifying abuse and said were confident about reporting this to the manager. This helps ensure that people living in the home are protected. Care Homes for Older People Page 19 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, 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally well maintained and clean so that people living there enjoy comfortable surroundings. Evidence: We toured the home and visited some residents in their bedrooms and spoke to other people living in the home. We found the home to be relaxed and welcoming and residents spoken to and observed were clearly at home and enjoyed the positive atmosphere. Areas seen were clean and well maintained. We were invited to look at some of the residents bedrooms and found these to be very personalized and generally well maintained so that individual lifestyles were reflected. Those people spoken with said that privacy was respected. The external grounds are accessible. We spoke with one resident who has difficulty with mobilizing and the home have made it possible for this person to move freely around the home by providing level access to most areas including the garden. This shows that the management have considered people with physical disability and have taken time to ensure they can access facilities in the home and also externally. Care Homes for Older People Page 20 of 28 Evidence: We saw good provision of bathing facilities and these variable so that some choice is provided. Likewise there is good provision of tiolet facilities. We did observe one area near the MAP unit laundry that was cluttered with laundry and hoist equipoment blocking the passage way to a fire exit. This was reported to the manager as this area must be clear at all times. We would recommend that this is regularly checked. There were some good examples of good practice regarding developing the environment for people who may have some confusion and can be disorientated. We observed good use of orientation aids such as clear sinage and the manager is keen to develop themes further particulaly with staff education. There are reminiscence and themed areas around the home so that residents can walk around and feel comfortable and stimulated. There are plans to develop other areas along similar lines. Care Homes for Older People Page 21 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 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. Staff are recruited and trained appropriately so that the care needs of residents can be met. Evidence: At the time of the inspection visit the home had 44 residents. Staffing consisted of two trained nurses and seven care staff. These were supported by the manager who is supernumerary and ancillary staff cover such as administrators, kitchen staff and domestic and laundry staff. There is also an activities organiser employed. Staff reported that the home is generally settled in terms of consistency and that this has improved since previous inspections although occasional shortages still do occur. Overall this means that there is good continuity of care for residents. Staff spoken with felt that they were supported by the management and that there was enough staff to carry out the care needs of the residents. Staff spoken with clearly understood the care needs of the people in the home and could explain their role in providing support. We observed the staff to be warm and supportive in their interactions with the residents and this was confirmed as consistent by speaking to residents. Care Homes for Older People Page 22 of 28 Evidence: Most staff are involved with some training. The preinspection information states that 90 percent plus of staff have achieved a National vocational Qualification [ NVQ], and most other staff are on these courses. Staff files seen and staff spoken with evidenced ongoing support around training which is monitored through supervision sessions so that staff can be supported. Some staff have attended training courses around providing care for people with dementia which shows that the home are willing to support people who have a diverse range of care needs. Overall this shows that the staff have the basic skills to care for people in the home. We looked at some staff files and found that the checks required for each staff prior to employment had been made and that staff were recruited thoroughly. This is an improvement from the last inspection and ensures that staff who work in the home are fit to do so. Care Homes for Older People Page 23 of 28 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. There are systems in place to ensure continued monitoring of the standards in the home so that the home is run in the best interests of the people living there. Evidence: The manager is Dot Pye. We spoke at length and she was able to give a clear outline of the current needs of the service in supporting residents with elderly care needs and also outline how future developments would fit in with best practice with particular reference to palliative care and also dementia care. We asked how the service promotes peoples views and suggestions and was told about meetings with relatives so that they can air any views or concerns. The service also canvases opinions of residents through surveys so that people can provide feedback about the service and feel more involved in the running of the home. The manager discussed the various internal audits that are carried out including Care Homes for Older People Page 24 of 28 Evidence: regular environmental checks and also visits by the service managers for the company who also complete a regular inspection and report [Regulation 26 report] which provides further feedback for the manager. We found that the management of health and safety in the home was good. The pre inspection information completed states that all safety certificates are up to date and some of these were spot checked on the inspection. This ensures that the environment for people is safe and maintained. The Health and Safety policy is available. Staff receive basic training in Health and Safety and this was confirmed by the available training records as well as staff interviews. Care Homes for Older People Page 25 of 28 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 26 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 1 8 13 All people moved in 01/06/2009 wheelchairs must have the appropriate fotrests in place. This will ensure that they are free from risk of injury. 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 2 1 7 A copy of the homes service user guide should be available in each of the bedrooms a per homes policy. We would recommend that residents and relatives are more formally involved in the evaluations on occasions as this would be a good time to discuss the person concerned and any amendments to the care plan. We observed some handwritten entries on medication charts and we discussed the need for two staff signatures in these eventualities to ensure that accurate records of any changes are made. Equipment should be stored appropaitly and not left in corridoor areas. 3 9 4 19 Care Homes for Older People 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. 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