Care Home: Meadow Acres

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What the care home does well The environment has been improved and is very welcoming.There is an effective and dedicated staff team in place to provide the home with stability and consistencyThe care plans provide good information on how to meet the residents needs. The residents are involved in the care that is provided and this ensures they have choice into how their care needs are met.There is good information about what service the home and the staff are able to provideBedrooms are decorated to meet individual choices.The staff spoken to have a clear understanding of their roles and generally receive training to keep their skills updated.There is lots of opportunity for the residents to access the local community. They have had a number of trips out including, a visit to Brighton and Bournemouth. Annual holidays will be taking place inSeptember this year to both Bognor Regis and Blackpool.Residents attend three different day centres and one person is being supported to look for a college placement.Resident`s finance records are well kept What has improved since the last inspection? Recording of people`s activities and monitoring within the activity planner and life and leisure plan has improved. Thedaily routines and jobs list is checked three times a day to make sure everything is done and nothing important is missed. Repairs to the house are now fixed much more quickly and the garden is looking better and kept tidier. What the care home could do better: The staff must make sure they fill out the charts that make the house safe and make it run well.Staff training must be kept up to date to make sure everyone working at Meadow Acres are given the right support to look after people safely and effectively.There should be access to the internet for people living at Meadow Acres. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Meadow Acres 7 Crabtree Lane Harpenden Hertfordshire AL5 5TA 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: Julia Bradshaw Date: 1 0 0 8 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. 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 Inspection report CSCI Page 2 of 34 Care Homes for Adults (18-65 years) Audience Further copies from Copyright General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 34 Information about the care home Name of care home: Address: Meadow Acres 7 Crabtree Lane Harpenden Hertfordshire AL5 5TA 01582768098 01582768268 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) : Caretech Community Services Ltd care home 8 Number of places (if applicable): Under 65 Over 65 8 8 8 8 learning disability physical disability Additional conditions: Date of last inspection A bit about the care home Situated at the end of a private drive, Meadow Acres is a bungalow that has been extended and Care Homes for Adults (18-65 years) Page 4 of 34 converted for its present use. It offers eight single occupancy bedrooms, a dining room, a lounge, a multi-sensory room, two bathrooms, two toilets and a shower. There is also a kitchen, an office and a laundry. Each bedroom has a hand basin and is personalised to reflect the character of each service user. The home is surrounded by mature gardens, parts of which have been constructed to a theme. There is also a large patio area, much used by service users the warmer Care Homes for Adults (18-65 years) Page 5 of 34 weather The home is located close to a local parade of shops and within walking distance of Harpenden town centre with its range of shops and amenities Information regarding the home is included in the Service Users Guide and Statement of Purpose, which are provided to prospective service users. Copies of the latest report on the home are available within the home. The fees range from £600 and £800 per week. Care Homes for Adults (18-65 years) Page 6 of 34 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 Care Homes for Adults (18-65 years) Page 7 of 34 How we did our inspection: This is what the inspector did when they were at the care home The last key inspection was carried out on the 20/07/07 and the last Annual Service Review was carried out on the 10/07/08 . We looked at the feedback received from questionnaires circulated to relatives, staff and people who use the service. A tour of the building took place and we talked to residents and staff on duty Care Homes for Adults (18-65 years) Page 8 of 34 What the care home does well The environment has been improved and is very welcoming . There is an effective and dedicated staff team in place to provide the home with stability and consistency The care plans provide good information on how to meet the residents needs. The residents are involved in the care that is provided and this ensures they have choice into how their care needs are met. Care Homes for Adults (18-65 years) Page 9 of 34 There is good information about what service the home and the staff are able to provide Bedrooms are decorated to meet individual choices. The staff spoken to have a clear understanding of their roles and generally receive training to keep their skills updated. There is lots of opportunity for the residents to access the local community. They have had a number of trips out including, a visit to Brighton and Bournemouth. Annual holidays will be taking place in Care Homes for Adults (18-65 years) Page 10 of 34 September this year to both Bognor Regis and Blackpool. Residents attend three different day centres and one person is being supported to look for a college placement. Residents finance records are well kept What has got better from the last inspection Recording of peoples activities and monitoring within the activity planner and life and leisure plan has improved. The Care Homes for Adults (18-65 years) Page 11 of 34 daily routines and jobs list is checked three times a day to make sure everything is done and nothing important is missed. Repairs to the house are now fixed much more quickly and the garden is looking better and kept tidier. What the care home could do better The staff must make sure they fill out the charts that make the house safe and make it run well. Care Homes for Adults (18-65 years) Page 12 of 34 Staff training must be kept up to date to make sure everyone working at Meadow Acres are given the right support to look after people safely and effectively. There should be access to the internet for people living at Meadow Acres. 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 Julia Bradshaw Care Homes for Adults (18-65 years) Page 13 of 34 Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 Email: enquiries@cqc.org.uk If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535 Care Homes for Adults (18-65 years) Page 14 of 34 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 15 of 34 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 can expect to have a thorough pre admission assessment which ensures the service is able to meet their individual needs. Evidence: A total of two care plans were reviewed and evidence gained regarding the initial assessments that are carried out to access if the service can meet the needs of the person. Information is held regarding the persons history and current needs. An assessment of each persons needs and aspiration are made before the person moves into the home. Competent and qualified staff complete these assessments. The service also receives and seeks external specialist support to meet the individuals needs. Whole life reviews occur to support the service users in achieving and reviewing their individual needs, goals and aspirations. The assessment process includes the gathering of information from other professionals. The organisation has its own internal assessment forms. A tenancy agreement is then drawn between the service provider and the person using the service. The agreement includes the terms and conditions within the home and the rights of the people who live at Meadow Acres. Care Homes for Adults (18-65 years) Page 16 of 34 Evidence: Care Homes for Adults (18-65 years) Page 17 of 34 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 . Care plans reflect a detailed and detailed record of peoples needs, which ensures that people using the service are assessed, reviewed and safe from risk. Evidence: Two care plans were inspected in detail and were found to provide a good insight into each individuals needs. Individual notes and guidelines for people were observed within the service. The manager and staff have worked hard to further develop these care plans into a more person centred plan format called my Plan, which can be more easily understood by the people using the service. Everyone living at Meadow Acres is supported within the whole life review framework and regular reviews occur to ensure changing needs are continuously assessed and reviewed. Ranges of risk assessments are completed within the service and action points recorded. These risk assessments are detailed and contain all the required information. However their needs to be a written consent for individuals who require either bed rails or listening devices, in order to ensure people have been consulted and their rights are protected. Activities and outings enjoyed by people living at Meadow Acres determine that people are supported to take risks as part of an independent life style. Risk assessments have Care Homes for Adults (18-65 years) Page 18 of 34 Evidence: been reviewed since the last inspection was carried out. Staff work with people to assist people to lead safe and enjoyable lives, consulting with them as appropriate, regarding decision making and offering guidance where needed. There was evidence to confirm that people had been involved in their care planning with signatures from either the person using the service or their representative. People spoken to on the day of the inspection and comments received by way of surveys were all positive about the way that care is received in terms of preserving rights and dignity. People spoken to stated, I like the staff here, they take me out and help me with my money. The Community learning disabilities team based in St Albans provides health care support. Care Homes for Adults (18-65 years) Page 19 of 34 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 . Those who use the service have their health and personal care needs carried out effectively and respectfully, ensuring that their wishes and choices are promoted. Evidence: People attend both Butterwick and Oakmere day centres, as well as the Trinity centre in St Albans, which provide a variety of activities, suitable to peoples individual needs and aspirations. The initial assessment determines the programme of choice within the day centre. Access to transport is through the on-site minibus. Staff support and encourage people to maintain and develop social, emotional, communication. People living at Meadow Acres are encouraged and supported to maintain links to the local community. The manager and staff are in the process of planning some annual holidays which will take place in September and include taking three people to Blackpool and two people to Bognor Regis. One person spoken to during this inspection stated that they had been on a day trip to Brighton and another person stated that the staff were endeavouring to support them in enrolling in a college course. The home Care Homes for Adults (18-65 years) Page 20 of 34 Evidence: does not currently have access to the internet and this is obviously a disadvantage to both the staff team and particularly to one person using the service who has raised this issue with both the manager and senior management. However the manager stated that the service will have internet connection by the end of this year. The service has further improved the recording and monitoring of daily activities by introducing an activity file and monthly planner for each person living within the home. This has improved the overall monitoring of activities and ensures people are offered a range and variety of activities on a regular basis. People also enjoy trips to the local pubs, cinema, meals out and also regular shopping trips. The service also provides a range of in-house activities that include, karaoke, make up sessions, hand massage, music sessions and video sessions. There is also a summer BBQ planned as a fundraiser to raise enough funds to purchase some new garden furniture and summer bedding plants. Menus were inspected and offer a range of diverse meals that are representative of the cultural needs and wishes of the people currently living at Meadow Acres. People are assisted with choosing their meals using pictorial aids. One person is on an individual diet plan as part of their overall healthy eating plan, with the community dietitians support and guidance. Care Homes for Adults (18-65 years) Page 21 of 34 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 . Those who use the service have their health and personal care needs carried out effectively, respectfully and safely ensuring that their wishes and choices are promoted. Evidence: The medication cupboard is located within the main office of the home. Medication that had been received into the home has been recorded accurately. All staff have been trained and inducted in the administering medication. There is currently no controlled medication held in the medication cupboards, however there is a robust procedure in place for the administration of these medications, if required. All non- blister pack medication has a date of opening recorded. The new contract pharmacist has provided the home with some useful patient information leaflets, that also give information on the common side effects of medication being administered to the people within the home. Health records are maintained within the main care plan and ensure that peoples holistic care is being monitored and maintained. Files checked confirmed that everyone living at Meadow Acres has regular health checks including out patient appointments. The main care plan provides information on peoples last wishes, with the exception of Care Homes for Adults (18-65 years) Page 22 of 34 Evidence: one person who the manager is still endeavouring to obtain consent for. Care Homes for Adults (18-65 years) Page 23 of 34 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 . People living in this service can be assured that they will be protected from abuse and that they will be listened to if they raise any concerns or make a complaint about any aspect of their care. Evidence: The service has a detailed complaints procedure in place. A record is maintained in the service of any complaints made detailing actions and outcomes as necessary. One person spoken to stated that they knew who to talk to if they had reason to complain. The recent AQQA stated that one complaint had been received since the last inspection was carried out and resolved to a satisfactory conclusion for both parties involved. A detailed procedure is in place to ensure that people using the service are protected from abuse and harm. Staff receive suitable and adequate safeguarding training. Staff employed within the home are all subject to enhanced Criminal Records Bureau disclosure. Care Homes for Adults (18-65 years) Page 24 of 34 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 service provides a safe, clean and well-maintained environment for those who live and work there and people who live at Meadow Acres can be assured that they can personalise their rooms to reflect their own tastes and personalities. Evidence: Several areas of the service have been re-decorated since the last inspection took place, including a completely newly fitted kitchen. All communal areas of the service are brightly decorated. All health and safety monitoring was up to date, including fire records and hot water temperatures. Bedrooms appear clean, bright and have been created to provide and reflect a very individual private space, with peoples hobbies and interests reflected throughout. Several bedroom flooring has been replaced with more suitable and practical alternatives including laminate floorboards. There are adequate communal areas and the service also benefits from having a well equipped sensory room. The service has a variety of specialist equipment and all service records relating to this equipment were up to date. On the day of this inspection there had been a flood caused by a leaking tap on the outside of the building which had damaged the flooring in one of the bedrooms and damage to one of the toilets/flooring. However these repairs have now been completed and caused Care Homes for Adults (18-65 years) Page 25 of 34 Evidence: minor inconvenience to the people living within the home. Care Homes for Adults (18-65 years) Page 26 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . A loyal and experienced staff team ensures people using this service are provided with levels of support that meet their individual needs and supporting documentation confirmed people are protected. However inadequate staff training could place people at risk. Evidence: The registered manager has been in post for a period of five years and has completed their registered managers award since the last inspection was carried out in August 2008. The rotas were checked and confirmed that the service provides adequate staffing throughout both the day and night. On the day of this inspection there were four staff on duty, which appeared adequate to meet the needs of the people using this service. The staffing structure within this service consists of one manager, one deputy manager, senior support workers, support workers and full time driver. The deputy post was recently vacated by a member of staff who transfered to another home, however this has now been filled with the promotion of an internal member of staff. The service still has two full time support worker vacancies and a one part-time night care post vacant. Training records were inspected and unfortunately both food hygiene training and infection control training for staff were both out of date.The manager stated that training had been previously booked but cancelled by the organisation. However recent Care Homes for Adults (18-65 years) Page 27 of 34 Evidence: training has included, first aid, fire awareness, health and safety, medication and safeguarding training. The manager is providing staff supervision on a regular basis. Staff spoken to on the day of this inspection confirmed that they felt both well supervised and supported by the manager. The manager also co-ordinates the staff meetings which are held monthly ( last minutes seen were dated the 31st July) to ensure that all staff have the opportunity to be involved in the running of the service. The staff team appeared loyal and committed and very caring in their approach to the people using the service. The fire records were checked and found to be accurate with the latest fire drill being carried out on the 28/7/09. The last weekly checks were carried out on the 7/8/09 and the annual fire check was completed on the 20/5/09. The recruitment records of 3 staff including the latest recruit were viewed; evidence demonstrates that there are good recruitment procedures within this service, which means that people living at the Meadow Acres can be reassured they are protected by the effective recruitment systems in place. Care Homes for Adults (18-65 years) Page 28 of 34 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 . People living at Meadow Acres can feel confident that they are living within a service that is well managed and they are safeguarded from harm by effective policies, procedures and accurate record keeping. Evidence: The manager has been in post for a period of five years and is effective in their administration and organisational skills in managing this service. All documentation relating to the health and welfare of the people using this service was accurate, up to date and had been reviewed regularly, to ensure people are kept safe and are protected. People are safeguarded from harm by the by the services recruitment procedures, safeguarding and complaints procedures. The manager ensures that supervisions are held regularly and staff confirmed that they feel supported and respected by the manager. However the manager must ensure that all staff are provided with the required and necessary training, in order to carry out their role effectively. People living within the service are provided with information that can easily be understood although this could be further developed throughout the service. The Care Homes for Adults (18-65 years) Page 29 of 34 Evidence: service manages peoples personal monies effectively and appropriately. A random check of two peoples monies was found to be accurate and reconciled with the individual ledger. Quality assurance systems should be further developed before the next inspection takes place, to include recorded weekly, monthly six monthly annual quality assurance audits as currently these are carried out but only on an informal basis and therefore evidence of these checks was unavailable. These should include checks to the environment, care plans, medication and infection control standards. Care Homes for Adults (18-65 years) Page 30 of 34 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 Care Homes for Adults (18-65 years) Page 31 of 34 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 7 15 There needs to be a written 30/10/2009 and signed consent form for the use of bed rails and listening devices used within the home. To ensure service users rights are protected 2 35 18 30/10/2009 The manager must ensure that all staff receive the mandatory training required, in order to carry out their role effectively. To ensure staff are supported and are able to offer the best care possibly to the people living at Meadow Acres. 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. Care Homes for Adults (18-65 years) Page 32 of 34 No Refer to Standard Good Practice Recommendations 1 38 There should be an effective system in place that can evidence that Quality Assurance checks are carried out regularly and efficiently. Care Homes for Adults (18-65 years) Page 33 of 34 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. 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