Care Home: Mount Road (104)

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What the care home does well There is good information about the home. This helps people decide if they want to move here.The manager always makes sure she finds out about people`s needs before they move into Mount Road. This helps to make sure Mount Road is the right place for them to live.Support plans are excellent. They tell staff about the best way to support the service users.There are also good risk assessments. This is important as they show how staff help service users to be independent.There are lots of activities going on, both in the home and out and about.There are always enough staff on duty to go with people on trips out.Staff training is very good.There are good recruitment policies and procedures which help to make sure only the right people are employed to work in the home.There is a good complaints procedure. Service users are protected from abuse by staff training.The home is clean.The manager is very good and works hard to make sure service users get an excellent service. What has improved since the last inspection? There are lots of pictures around the home. This is to help the service users understand information.Nearly all of the staff have an NVQ level 2 qualification in care. They have also had training in infection control.The manager and senior staff have completed extra training about medication. What the care home could do better: We did not make any requirements and recommendations at the end of this visit. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Mount Road (104) Mount Road (104) High Barnes Sunderland SR4 7NN The quality rating for this care home is: three star excellent 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: Nicola Shaw Date: 2 0 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. 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: Judgment: 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 judgment 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 36 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 36 Information about the care home Name of care home: Address: Mount Road (104) Mount Road (104) High Barnes Sunderland SR4 7NN 01915228121 P/F01915228121 mountroad@c-i-c.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) : Community Integrated Care care home 3 Number of places (if applicable): Under 65 3 0 learning disability Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Learning disability Code LD, maximum number of places: 3 The maximum number of service users who can be accommodated is: 3 Date of last inspection 0 9 0 5 2 0 0 7 Care Homes for Adults (18-65 years) Page 4 of 36 A bit about the care home Three people live at Mount road. It is a large house in a quiet street. Its close to local shops and bus stops. On the ground floor there is a comfortable lounge and a dining room. Care Homes for Adults (18-65 years) Page 5 of 36 At the back of the house is a large kitchen/diner, a utility room with laundry equipment and access to the back yard. There is also a small toilet on the ground floor. On the first floor are 3 single rooms, and a small staff sleep-in room. Everyone has their own bedroom. Care Homes for Adults (18-65 years) Page 6 of 36 On the landing there is a bathroom and a separate small toilet. The home has a car so people can enjoy trips further away. The fees charged by the home are £1131.92 per person per week. Extra charges are made for the use and running of a shared vehicle. Care Homes for Adults (18-65 years) Page 7 of 36 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: three star excellent 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 8 of 36 How we did our inspection: This is what the inspector did when they were at the care home The quality rating for this service is 3 star. This means that the people who use this service experience excellent quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations-but only when it is considered that people who use services are not being put at significant risk of harm. In future is a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Adults (18-65 years) Page 9 of 36 Before the inspection visit: We looked at: Anything we have found out about the home since April 2008. How the manager has dealt with any complaints and concerns. What the manager thinks about the home. The visit: We visited the home on the 20th April 2009. During this visit we: Looked at some of the care plans to see how well the staff meet the needs of the people who live here. Looked at other records which must be kept, like the accident book. Care Homes for Adults (18-65 years) Page 10 of 36 Checked that the staff have had good training to meet the needs of the people they care for. Talked to the staff and service users. Spent some time watching how staff communicated and supported the service users. Care Homes for Adults (18-65 years) Page 11 of 36 The manager was not on duty when we visited. So we phoned her to tell her what we found at the end of the inspection. What the care home does well There is good information about the home. This helps people decide if they want to move here. Care Homes for Adults (18-65 years) Page 12 of 36 The manager always makes sure she finds out about peoples needs before they move into Mount Road. This helps to make sure Mount Road is the right place for them to live. Support plans are excellent. They tell staff about the best way to support the service users. There are also good risk assessments. This is important as they show how staff help service users to be independent. Care Homes for Adults (18-65 years) Page 13 of 36 There are lots of activities going on, both in the home and out and about. There are always enough staff on duty to go with people on trips out. Staff training is very good. Care Homes for Adults (18-65 years) Page 14 of 36 There are good recruitment policies and procedures which help to make sure only the right people are employed to work in the home. There is a good complaints procedure. Service users are protected from abuse by staff training. The home is clean. Care Homes for Adults (18-65 years) Page 15 of 36 The manager is very good and works hard to make sure service users get an excellent service. What has got better from the last inspection There are lots of pictures around the home. This is to help the service users understand information. Care Homes for Adults (18-65 years) Page 16 of 36 Nearly all of the staff have an NVQ level 2 qualification in care. They have also had training in infection control. The manager and senior staff have completed extra training about medication. What the care home could do better We did not make any requirements and recommendations at the end of this visit. Care Homes for Adults (18-65 years) Page 17 of 36 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 Nic Shaw St Nicholas Building St Nicholas Street Newcastle Upon Tyne 0191 2333620 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 18 of 36 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 19 of 36 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 . Good assessment and admission processes ensure that potential service users needs can be met at Mount road. Evidence: One new person has been admitted to Mount Road since we last visited. Before they could move in a social worker did an assessment to see what they needed. The manager has a copy of this. She also did her own assessment to make sure Mount Road could meet their needs. We talked to the staff about how this person was admitted to the home. They told us that there were many trial visits. This included day visits and overnight stays. This was so that the new person could meet the other service users and staff and decide if it was the right place for them to live. Care Homes for Adults (18-65 years) Page 20 of 36 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: Judgment: People using this service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service . Service users support plans provide staff with excellent information about how each individuals care needs are to be met. Service users are supported to take risks and make choices in their daily lives. This enables service users to lead independent lifestyles. Evidence: The care plans we looked at have been developed based upon a detailed up-to-date assessment and contain excellent information. The support plans are person centered and focus upon the individuals strengths and personal preferences. They are regularly reviewed and these reviews involve the key worker and service users. Mount Road has a can do attitude. This was evident in the way the support plans are written with an emphasis upon each persons strengths and how staff should support and encourage independence. For example; in one persons plan it was clearly recorded what they are able to do for themselves regarding their healthcare needs. Care Homes for Adults (18-65 years) Page 21 of 36 Evidence: Some of the people who live at Mount Road have complex communication needs. Good information about each service users communication needs is included in the support plans. This is important so staff know the best way to help people to make decisions and choices for themselves. For one person this involves the use of pictures and cards. They use these to communicate to staff what they need or want. There is also a picture communication board. During our visit the staff continually included the service users in making decisions and choices. For example; what to have for tea, what music they would like on and where they would like to eat their meal. Staff recognize that service users may make choices which involve a degree of risk. For example, for one person it has been identified that when out in the community, crossing the road may pose a risk. There is a risk assessment about this so that they can safely enjoy community activities. Care Homes for Adults (18-65 years) Page 22 of 36 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Opportunities for service users to take part in a range of activities both inside and outside the home are excelllent. Service users are assisted to maintain links with their family and to have a community presence. This enables them to lead a full and enjoyable life. Service users are provided with a healthy, varied diet which helps to promote their general health and well being. Evidence: In the care plan there is a section about each service users interests and hobbies. From this information a weekly timetable of activities has been developed. During our visit one service user was at a day center, whilst the remaining two attended a cookery class. Other regular activities include ten pin bowling, going to the cinema, shopping and attending a local social club. One service user has an interest in Care Homes for Adults (18-65 years) Page 23 of 36 Evidence: gardening and a small green house has been purchased so that they can develop this interest. There are also lots of activities for the service users to enjoy in the home, for example, sewing, jigsaws and books. Each year service users are supported to enjoy a holiday of their choice. This year two service users are going abroad for their holiday, whilst the third has chosen a short break at Alton Towers. The home has its own transport so that service users can enjoy day trips further away. Relatives are able to visit the home whenever they wish. Staff said that sometimes, if the weather is bad, and they are unable to visit, staff provide transport for the service user so that they can still maintain contact with their relative. There is a list of important people and special occasions in each service users support plan. Staff use this information to support the service users to send birthday cards. During our visit staff interacted with service users. Everyone sat together either in the lounge or around the dining table. Service users were included in the conversation that took place. The service actively encourages and provides opportunities for service users to develop independent living skills. For example: in each service users support plan there is a section about independent living skills. This tells staff about what support each person needs with a range of activities, such as tidying wardrobes, hovering, and changing their bedding. The menu has been developed based on the service users likes and dislikes and special needs, which is recorded in their support plans. Service users can choose to have their meals in the kitchen or dining area. In the support plans there is a food preparation and diet section. This tells staff about each service users abilities in this area and what support they need to remain independent. We sat with service user during their evening meal. The table was nicely presented with a table cloth and napkins. Staff sat with service users, eating with them, offering support where this was needed. The meal looked and smelt appetizing with plenty of fresh salad available. There was also plenty of fresh fruit in the home which service users can help themselves to. Service users said they liked the food. Care Homes for Adults (18-65 years) Page 24 of 36 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 arrangements for meeting the personal and health care needs of people using the service are good. And service users receive the support they need from staff to ensure that their personal, physical and emotional needs are met. The service users are protected by the homes medication policies, procedures and practices. Evidence: There is detailed guidance available in the support plans so that staff know the most appropriate way to support service users in the way they prefer. Personal health care needs, including specialist health and dietary requirements, are clearly recorded in each service users support plan. They give a comprehensive overview of each persons health needs. Service users have access to a range of health care professionals including dentists, opticians, chiropodists, district nurses and the complex needs team. Each service users weight is monitored monthly. Care Homes for Adults (18-65 years) Page 25 of 36 Evidence: Wherever possible, service users are encouraged to manage their own health care. And this is recorded in their support plan. However, in one persons support plan it was not clear the assistance they needed with their health care. We spoke to the manager about this who agreed to develop this support plan further. Where service users have complex needs, in terms of their behaviour, there are behaviour care plans in place. These are regularly reviewed and up-dated. All staff who administer medication have been provided with training in this area. We looked at the Medication Administration Records ( MAR). These were clear with no gaps indicating that service users have received their medication as prescribed. A random check of medication in stock against records showed no discrepancies. The manager and senior staff have completed level 5 training in managing medication systems at Teeside University. Care Homes for Adults (18-65 years) Page 26 of 36 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 . Arrangements are in place through the complaints process to promote the safety and protection of service users. Policies and procedures are in place, supported by staff training, which ensure that service users are protected from abuse and neglect. Evidence: There has been one complaint received by the home since we last visited. This was dealt with appropriately through the homes complaints procedure. The manager told us that she has given each service user a copy of the complaints procedure and has talked to them about it. She has also sent a copy of this to each of the service users relatives. Staff knew what to do if they received a complaint. And service users told us that if they were not happy they knew who to speak to. Staff told us that when they first started working with the company they were provided with training in safeguarding adults. They are also provided with refresher training every three years. They were clear in what they should do should they witness or suspect abuse. There is a copy of the local authority safeguarding procedures in the home. There have Care Homes for Adults (18-65 years) Page 27 of 36 Evidence: been no safeguarding referrals made. This is a result of lack of incidents rather than a lack of understanding about what incidents should be reported. We looked at the personal allowance for one service user. There are clear records of all purchases made on behalf of the service user. And two staff signatures are maintained on the transaction sheet, which is good practice. Each week the manager checks that the money is correct. And the staff also do a daily check of this during the handover. Care Homes for Adults (18-65 years) Page 28 of 36 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 environment provides service users with a safe, well maintained place to live. Evidence: The building throughout was very clean, smelt fresh and was well maintained. There is a communal lounge and separate dining area. These are bright comfortable places. There is a small yard at the back of the home. All bedrooms are single occupancy and service users have a key to their room. One service user showed their room, which was personalised with photographs and ornaments. They said that they liked their room. Although staff have responsibility for domestic tasks, service users are encouraged to help. The support they need with this is recorded in their support plans. There are enough bathrooms and toilets for the three people living here, which meet their needs. Six staff have had training in infection control. Protective gloves and aprons are available for staff to use. Care Homes for Adults (18-65 years) Page 29 of 36 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 . Service users benefit from skilled staff and the good staffing levels ensure that the service users needs are readily met. Service users are protected by the homes recruitment practices. Evidence: On duty on the day of the inspection were two staff, which is enough to meet the needs of the three service users. During the night there is one sleep-in member of staff. Staff told us that they felt this was sufficient. They said they were confident that, should the needs of the service users change, then the manager would review and increase the staffing levels as needed. There has been a low turnover of staff since we last visited, which is good for continuity of care. Staff told us that training is very good. Five out of the six staff have completed an NVQ 2 qualification in care or above. In addition to this, specialist training has been provided in the mental capacity act. And at the moment all staff are completing training in equality and diversity. The manager is also arranging for training in age and learning disability and Makaton, (this is a form of sign language for people who have a learning disability). This is so staff can meet the diverse needs of the service users. Care Homes for Adults (18-65 years) Page 30 of 36 Evidence: The manager has a training needs analysis to help her plan future training needs. The company operates a good recruitment and selection procedure, including interviewing potential staff and taking up two suitable references. Staff are not able to start working in the home unless the manager has obtained an Enhanced Criminal Records Bureau (CRB) check for them. Every three years the company does an additional CRB check to make sure that staff remain suitable to work with vulnerable adults. Staff said they loved working in the home. There was clearly a good relationship with the staff and service users. Staff knew about the needs of service users and could describe in detail each individuals health and personal care needs. Service users said they liked the staff. Care Homes for Adults (18-65 years) Page 31 of 36 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Overall management systems are excellent and ensure that the health, safety and welfare of service users is promoted. Evidence: The registered manager has many years experience of working with people with a learning disability. She has attained the Registered Managers Award and NVQ level 4 in management. She has been the manager of this home for over 7 years. Other training she has completed, to up-date her knowledge and skills, includes level 5 in managing medication systems, a course about disciplinary procedures as well as training about dementia. Staff said about the manager that the service users were her number one priority. And it was evident that she provides an excellent role model for staff. This was demonstrated through the culture of the home. For example, the way staff encourage service users to do as much for themselves as possible. The manager finds out about what the service users think of the home through regular keyworker meetings, annual surveys and house meetings. The surveys are in picture Care Homes for Adults (18-65 years) Page 32 of 36 Evidence: format to help the service users understand the information. She also carries out regular checks to make sure that staff are following the homes policies and procedures. And the service manager also carries out a monthly audit of the service. There is full and clearly written recording of all safety checks and accidents. During our visit a member of staff was completing a health and safety check of the building. She told us that this was a regular weekly task delegated to staff. We received the annual quality assurance assessment (AQQA) when we asked for it. This provided us with information about what the service does well as well as how they could do better. It also included information about equality and diversity issues and how the home includes the views of service users in what they do. The manager told us in the AQQA that health and safety training for staff meets the statutory requirements. Care Homes for Adults (18-65 years) Page 33 of 36 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 34 of 36 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 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 Care Homes for Adults (18-65 years) Page 35 of 36 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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