Care Home: Nevin House

Similar services:

• Polesworth Group Friary Road
• Polesworth Group Pooley Heights
• Polesworth Group 32 Station Road
• Polesworth Group 70 Long Street
• Breme
• Polesworth Group 64 Long Street
• Polesworth Group 68 Long Street
• 10 Whitfield Avenue

What the care home does well There is information about the home and everyone has an assessment, detailed care plans and regular reviews. Needs are met they way individuals want. People told us they make daily decisions about what they eat and choose to do. There is good access to health care, good medication management and competent staff. Staff are friendly and provide respectful and dignified care. People told us about their hobbies, activities and relationships, which are age and peer appropriate: "I like colouring"; "I went on holiday to Portsmouth", "I have a girlfriend..."; "I like to help cook stews"; "I visit...x...on the weekend"; "I have a job washing cars..."; and "I look after the rabbit and answer the phone at the day service". Some holidays are taken abroad, and interesting suggestions people make to improve the service have been provided, such as a sofa rather than chairs in the lounge. The owner is experienced at running a care home and has systems in place to ensure that health and safety is promoted. There are consistent staff and spot checks to ensure staff work alongside people to promote independence. The environment is homely and clean. Staff have guidance to support decision making and spot distress, and there have been no complaints. Immediate steps are taken to safeguard people when necessary. Repairs are timely and there are best practice measures to prevent the spread of infection. People have the equipment they need. Records are up to date and securely kept for confidentiality. We complimented good practice on our visit. What has improved since the last inspection? Person-centred planning improved. People have more opportunities to lead their lives like their peers, such as paid work, shopping, meals out and internet access. One person now has their own telephone. New medication policy guidelines were introduced and staff were updated. Annual quality surveys are now used and people`s suggestions have led to new furnishings, facilities, redecoration and a quiet room. Records and systems are more organized, such as cleaning schedules. An emergency alarm system was installed in people`s rooms, and equipment such as commodes and bed supports purchased. The use of temporary staff reduced. Staff were dismissed and replaced by managers undertaking shifts to ensure there is continuity while new staff are recruited. The incident reporting system was changed and a lone worker system was introduced for the safety of staff, and so that the manager can monitor shift changes. The home now has a service for legal advice about personnel, health and safety. What the care home could do better: Health promotion could improve in a variety of ways, and planning for later in life. Action was taken to immediate requirements so that a bedrail was made safe to prevent someone falling from bed. Clarification was also obtained on some medication management matters to that people are fully protected. Robust recruitment checks of staff and qualifications need to meet the minimum standards so that people can have confidence that staff are safe to work in the home, and knowledgeable about care, learning disability and management. People`s financial interests need further protection. A more critical approach to assessing and acting upon environmental risks of of slips, trips and falls is needed for the health and safety of people and staff. Nevin House needs to work with other agencies, and notify the Commission of events to keep people, their rights and interests fully protected. The home continues to learn and improve, but wider surveys and an accurate annual AQAA self - assessment should be added to the home`s quality assurance to analyse and progress towards excellence. Organisation of the home`s records could improve so they are available when needed, and staff records must be kept on the premises. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Nevin House 21 Nevin Grove Perry Barr Birmingham West Midlands B42 1PE     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: User doesnt belongs to any group     Date: 1 2 0 3 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 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. Care Homes for Adults (18-65 years) Page 2 of 38 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 Adults (18-65 years) Page 3 of 38 Information about the care home Name of care home: Address: Nevin House 21 Nevin Grove Perry Barr Birmingham West Midlands B42 1PE 01213443806/01212410774 Telephone number: Fax number: Email address: Provider web address: serenasteele@aol.com Name of registered provider(s): Type of registration: Number of places registered: Mrs Wendy Steele care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 3 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 categories: Learning disability (LD) 3 Date of last inspection Brief description of the care home Nevin House provides accommodation and support for three people with learning disabilities. The semi-detached house is in a residential area of Birmingham, close to parks, shopping and public transport. Parking on the street is limited, but there is a back entrance by the police station. There are single bedrooms on two floors, with toilets and bathroom or shower nearby on each floor. There is no lift, which may be important for people with mobility concerns. Downstairs is a lounge, conservatory / Care Homes for Adults (18-65 years) Page 4 of 38 Over 65 0 3 Brief description of the care home dining room, games room, kitchen, laundry and enclosed garden. The office is upstairs. Fees are individually determined and are dependent on support needs, as in the service user guide. Enquiries about fees should be made from management. Care Homes for Adults (18-65 years) Page 5 of 38 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 peterchart Poor Adequate Good Excellent How we did our inspection: The home was last inspected on 06/03/07. Prior to our visit the home supplied information to us from their Annual Quality Assurance Assessment (AQAA). The AQAA provides information about what has improved and is planned for the future, and current information about the running of the home. Information from this and from other sources was also used when forming judgments on the quality of the service. The home sends us notifications, and we receive reports from other sources. This year we sent 15 surveys to people, relatives and staff twice, and received none in return. One inspector visited the home twice unannounced but was unable to gain entry. The third visit was announced two days in advance. The visit took place over one day, and the morning and afternoon routine was observed. We talked to people and staff, and saw their records. We sampled records about other people, staff and the running of the home and discussed our findings with management. Care Homes for Adults (18-65 years) Page 6 of 38 There were 12 requirements from previous inspections. We found ten fully met and replaced two. We made two immediate requirements for health and safety on our visit, which were met within 48 hours. A list of remaining requirements and recommendations are at the end of this report. What the care home does well: What has improved since the last inspection? What they could do better: Health promotion could improve in a variety of ways, and planning for later in life. Action was taken to immediate requirements so that a bedrail was made safe to prevent someone falling from bed. Clarification was also obtained on some medication management matters to that people are fully protected. Robust recruitment checks of staff and qualifications need to meet the minimum standards so that people can have confidence that staff are safe to work in the home, and knowledgeable about care, learning disability and management. Peoples financial Care Homes for Adults (18-65 years) Page 8 of 38 interests need further protection. A more critical approach to assessing and acting upon environmental risks of of slips, trips and falls is needed for the health and safety of people and staff. Nevin House needs to work with other agencies, and notify the Commission of events to keep people, their rights and interests fully protected. The home continues to learn and improve, but wider surveys and an accurate annual AQAA self - assessment should be added to the homes quality assurance to analyse and progress towards excellence. Organisation of the homes records could improve so they are available when needed, and staff records must be kept on the premises. 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 9 of 38 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 10 of 38 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. Information tells people about the home, the service and terms and conditions. There are ways to try the home to decide if it is suitable, and a regular process to assess and review peoples needs so that they are met. Evidence: Three people have been living together in the home for many years, all funded by the council. There have been no new admissions or discharges and there are no vacancies. There is no intermediate care service. There is an up to date service user guide and statement of purpose with useful information about the services, staff, facilities provided and included in the fee, and the philosophy of the service in promoting peoples independence. Some of the information is user friendly, but this could be fully accessible with symbols. The fee range is not published in the guide, but there is information about funding, terms and conditions written in Plain English, which are up to date for everyone in the home. Each person has a contract with individual fees, which is reviewed annually with the council. Care Homes for Adults (18-65 years) Page 11 of 38 Evidence: There is a pre-admission assessment process, with opportunities to visit and meet other people and staff and try the home at the persons own pace. There are thorough assessments of peoples needs, preferences and screening of key risks. Gradual introductions are also used to confirm that peoples needs can be met and that personalities are compatible, which is good practice. After admission there is a 28 day trial period and a formal review. We saw this in all three care records. Care plans, needs and progress are reviewed at least six monthly or when there are changes, and these are signed by the home with people or representatives and the council. This shows us that people are involved in care planning. There is one person who does not have family visitors or representatives. The AQAA told us that an advocate was to be arranged. On our visit we were told that the person has been on a waiting list for an advocacy service for some time. Care Homes for Adults (18-65 years) Page 12 of 38 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. People take part in setting goals, agree the care and support provided. Health and independence is promoted, but a bedrail needed to be made safe. Staff support people to make decisions, but mental capacity is not assessed. Financial interests need further safeguards. Evidence: People make decisions about goals, and each person agrees and signs written plans about personal care, manual handling, weekly activities and daily living. These are interlinked with assessments of peoples abilities, interests, needs and risks to their health, safety and wellbeing. This tells us that care planning is person-centred. The managers know people well and risk-taking is balanced with personal security. We have seen steady improvement in how Nevin House involves individuals who are not always used to making decisions about their lives. People can be confident that staff have detailed instructions so that their needs are met and about how independence should be supported. Care Homes for Adults (18-65 years) Page 13 of 38 Evidence: Each person showed us their room, spoke with us privately and told us they are happy in the home. We saw their communication diaries with photographs, demonstrating that they have accessible information. All three care records showed what people like and dislike, food that does not agree with them, allergies and their own routines. There are good medical and social histories, information about health conditions, emotional needs and medication, signs for staff to watch for, and who to contact. Healthy living is promoted. There are meaningful activities to widen interests and learning. All three people go out each weekday, and some see or stay with relatives on weekends. People told us that they take turns to go shopping and decide daily what they eat and what they do at the home, the Sytdiayl day service and college. In records of residents meetings menus, hobbies and holidays were discussed and planned. Managers are responsive to their interesting ideas, such as more television channels and a quiet room for conversations if they dont want to watch TV. This shows us that people are understood, they are offered choice and flexibility, and this is reviewed 6 monthly or when there are changes. A blank weekly activity plan was displayed in one room and we would recommend that each person has a plan with symbols and an Easy Read style so that they can check for themselves what they are doing each day. There is a noticeboard in the dining room which is changed each day about this, but it would be more confidential in peoples rooms. All care records were securely stored for confidentiality. Goals are currently identified as tasks, such as going to college, rather than peoples views of what they want to achieve, such as learning more about a subject so that they can try something new or improve an aspect of their life, such as having a wider circle of friends, or improving their mobility. We discussed with managers that tasks should be steps to achieve a goal, and care plan evaluations need to consider progress towards the goal, as well as achieving a task. For example, we were told that one person wants to own a car, but the reason is unclear. This should also be explored with the council, who is everyones financial decision-maker in accordance with the Mental Capacity Act. There are good personal safety assessments for inside and outside of the home, during transport and when on holiday. We saw for example, plans to prevent choking and falls, road safety awareness, seizures, and safety in the community and airports. Some staff work both at the home and at the day service. Staffing is usually arranged so that when people are in the home there is a care worker present. One person is assessed to be safe to leave alone in the home for a defined period of time. There is a Care Homes for Adults (18-65 years) Page 14 of 38 Evidence: good risk assessment about this, but the instructions do not fully match. Staff phone the person hourly to ensure they are managing safely, for a maximum of three hours. however they are assessed to be safe alone for only one hour. This ambiguity needs to be clarified. There is no concern as the person is able to use public transport and visits relatives alone. People are supported to lead responsible lives. For instance, obsessive and challenging behaviour in the past led to theft from shops and inappropriate social behaviour. Care plans detail staff monitoring and support in the community to prevent crime and about social etiquette. There have been no further incidents and challenging behaviour has ceased, which is a good outcome for people. There is a policy about sexuality but no assessments or plans about this. People can and do have privacy in their rooms. Each person has an emergency profile in case they need to go to hospital or go missing, and this includes their communication modes, which is good practice. There are no recorded mental capacity assessments. The profiles could be further developed. This is important if best interest treatment decisions need to be made by health professionals. One profile of a person who does not have visitors listed the owner as next of kin, which we queried as this not accurate. Anyone needing a statutory independent mental capacity advocate (IMCA) should have this clearly marked on their profile. IMCAs may also be available for care reviews through the council contract. This would ensure the person has independent support to consider alternatives when the home needs to make, review and record best interest decisions. We asked how restraint and restrictions are agreed and reviewed. Some people have staff escorts and other controls upon movement to make people safe or to monitor health and wellbeing. Behaviour plans use distraction techniques that avoid the need for restraint, so best practice is known and used. One person had bedrail restraint due to a history of falls from bed. When we asked if they felt safe they said no because they did not like the bedrail and a rubberized bumper stuck to their skin. When we examined the bedrail we found the fitting was loose. There was no risk of limb entrapment because national safety alerts have been followed by the home. With their permission we discussed this with management, who expected staff to check the bedrail regularly, but there were no records about this. The home assumes people can make their own choices. This is good practice however on this occasion no options to bedrails were considered or others outside the home consulted. The person may be able to express a view but not make an informed choice, and they did not know there were alternatives so did not tell staff.. People with learning disabilities may also be open to persuasion or agree to please staff. Care Homes for Adults (18-65 years) Page 15 of 38 Evidence: Serious decisions like the use of restraint and restrictions should be made and regularly reviewed in accordance with the Mental Capacity Act code of practice. The home needs a procedure and staff need new skills to do so. Appropriate action was taken to make the bedrail safe and the person comfortable following an immediate requirement. Less restrictive alternatives are now being tried after review of the risk assessment which the person is happy about, but no outside consultation is planned and the person has known incapacity to make purchasing decisions about a proposed new bed. People do not have sole bank accounts as there are joint accounts with a named manager which we queried. The owner confirmed with us when this will be changed. The home manages day to day spending and make purchasing decisions with people. Their policy includes making decisions in partnership with the council, but they need to clarify when to consult. One persons savings now appear to need proactive management that will prevent loss of welfare benefits. We recommend that care reviews with the council agree spending plans. Accounts did not tally as there was a small excess in peoples favour, but we have confidence that the homes system will rectify this by the end of the month. Care Homes for Adults (18-65 years) Page 16 of 38 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. There are opportunities for personal development, meaningful activities in the home and community. Religious worship should be regularly reviewed. Relationships with family and friends are maintained. Personal tastes in food and dietary needs are met. Evidence: Daily records show what people do each day, the care provided and their wellbeing. People have choice, such as getting up and going to bed when they want to. One person goes to bed 10 - 11 pm, and another wakes early and has a hot drink in their room. Key worker meetings and staff records show that sometimes workers have rushed people, or that there are not enough opportunities to take part in self care or daily living tasks. People said that they like particular staff because they brush my hair and they brush my teeth. It was clear after talking to managers that staff have not always worked alongside people, and people have become more dependent - this is currently being reversed. Care Homes for Adults (18-65 years) Page 17 of 38 Evidence: On our visit we were told that people wanted to stay at home to talk to the inspector, and we watched their day in the home. Each person was asked in the morning what they wanted to eat for lunch and tea. Two people chose to go food shopping with staff. One person said that they usually take turns going shopping, for food or personal needs. Two people helped to lay tables at two meals. They also prepared hot and cold drinks, and one person helped staff to prepare the evening meal by choice. They ate where they preferred - in the dining room and in the lounge. Each person has their own hobbies and relationships and told us what they enjoy: I like colouring; ...holiday to Portsmouth, I... a girlfriend I like to see at the day centre; ...to help cook stews; and visit.ing..x...on the weekend. One person proudly showed us a training certificate about a food safety course they completed alongside staff and passed the exam. Another person is completing a first aid awareness course. This is good practice if they get regular opportunity to use their skills. There were other examples of how people are encouraged in their personal development and to achieve their goals. Some people keep their room clean and tidy, or make their bed. No one cares for their own laundry. One person had a job in the past has now has work experience at the day service and told us how they look after the rabbit and answer the phone. The owner told us about their salary, which will not affect their welfare benefits. One person said that they have a job washing cars at the day service. The home has a cat and fish, but people are not involved in feeding them, although this was tried in the past. At present people are content to go out every weekday to the day service or college. As they grow older some may want more flexibility, and the home needs to plan how staffing can be provided at short notice. One person told us that they get bored on Sundays and that they used to go to church with a worker no longer at the home. In care records every ones religion is recorded. We queried this and were told that no one is currently interested in attending services. We recommend this is regularly reviewed as interests change. There are age, peer and culturally appropriate activities and use of community facilities such as parks, pubs, cinemas and meals out. Holidays and outings are usually taken together. Outings are not occurring as frequently as some people would like and this is because of current staffing arrangements which will change. Two people need staff escorts to go out, and one person uses public transport on their own after assessment. Everyone has a travel pass. Holidays have been taken abroad in the past, Care Homes for Adults (18-65 years) Page 18 of 38 Evidence: and we heard about exciting trips to Egypt and Jamaica. This year a holiday was delayed due to the loss of passports and staff changes. The owner confirmed that a 5 day holiday was taken in Scotland during December 2008. Healthy lifestyles are promoted, for example records note that one person was supported to stop smoking and has kept this up since 2000. Another person gained weight and was referred to a dietician, and has now lost weight. We checked expenditure and saw that meals out and take away food is occasional. Two people told us about relatives who visit them and relatives they stay overnight with. One person has two mobile phones and a safety plan about taking them out of the home. Staff help people to keep in touch with friends and relatives. On occasion the home has had to safeguard people, and they have done so in a way that maintains their right to continue relationships they choose. This is good practice. People liked the food, which was nutritious. All staff prepare food and have food safety training. We watched staff support each person differently at meal times. Meals were unhurried, and some staff ate with people. This is good practice that creates a homely atmosphere conducive to eating well. We sampled food monitoring records, menus for four weeks and checked the kitchen. The food on offer is varied and large stocks are not kept. Dietary needs are met, for example a low fat diet. People told us that they can get or make drinks and snacks when they want. Food at the day service is provided free of charge. There was a concern during 2008 that the diet may not be sufficiently varied for lunch. The home cooperated with an adult protection investigation which was unfounded, but agreed to review peoples diet and said that nutrition and health training would be planned. We found there were mainly frozen and tinned vegetables in the fridge and cupboards, however after shopping there was salad for lunch and a cooked meal for tea. There was no plan for nutrition training. We recommend that government advice about healthy eating is promoted in more depth by monitoring fresh fruit and vegetables. Care Homes for Adults (18-65 years) Page 19 of 38 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. Personal care and health needs are met in the way people prefer and need, with dignity and risks managed. Health is promoted but exercise needs review. The medication system is managed and checked by competent staff which protects people. Evidence: Personal support is agreed with people, and provided the way they want and need. Currently there is only female staff so the men do not have choice of gender for help; recently there were male staff. Managers now monitor how staff support people, after finding that policies and care plans were not being followed. On our visit people had good personal hygiene and discreet prompting of continence for dignity. Their appearance and clothing was appropriate for the temperature, their age, culture and tastes. Everyone needs support or assistance to bathe, and most bathe daily. Assessments include peoples abilities to participate, such as choosing clothing. Staff have detailed instructions to prompt or assist with washing, dressing, oral care and this is adjusted and recorded on a daily basis according to peoples cooperation and mood. A new format for daily records from 10/03/09 makes it easier to spot changes in peoples wellbeing and health conditions. We sampled older and new formats and Care Homes for Adults (18-65 years) Page 20 of 38 Evidence: found these are kept up to date. There are also good communication systems so that care can change rapidly. Staff accurately told us about peoples needs, how risk-taking is managed, what people prefer (such as baths or showers) and how care is safely provided. There are plans about night-time, sensory needs and mobility, which are regularly reviewed. There is an emergency call system which people told us they use and staff always come quickly. Care plans show staff how to recognize non-verbal signs of wellbeing, discomfort or pain, which is good practice. Physical and emotional needs are met. There are health plans, for example about high blood pressure, and staff support people to attend appointments and bring monitoring records. Everyone has annual health checks, including flu jabs, but we did not see any well men checks. Records show that checks with dentists and opticians are kept and chiropody for one person takes place regularly. One person needing eyeglasses was wearing them, and told us that they will be seeing the dentist soon about a partial denture. The advice of health and social care professionals is incorporated into care plans. Two people are having treatment for epilepsy and have guidelines about this, including emergency measures and have been seizure free for many years. We were told there is no need for emergency medication or epistasis training. Two people are noted as experiencing long term medication side effects; regular reviews by doctors take place. Recently one person appeared jaundiced. Management researched their medication with the GP and asked for referral to a specialist with a view to reducing one persons medication. This is proactive health promotion. Screening and monitoring to prevent falls, malnutrition and pressure sores is regularly reviewed and uses best practice guidance. People are weighed and body mass index measurement is used, and changes are acted upon. Care plans address nutrition and skin care. There are guidelines if people experience heartburn or bloating, and the likely cause such as dairy products or tight clothing, which shows how well people are known. No one is at risk of pressure sores. Some people have prescribed creams and gels for their skin, which they apply under staff observation. We confirmed that there have been no falls in the past year, and no hospital admissions. There are people with decreased mobility and who are unsteady when walking. They have screening assessments to prevent falls day and night. One persons room is on the ground floor. Another person has shoes provided by a specialist and no longer needs a walking stick. There is a bath hoist and staff have clear instructions and training to use this. People with arthritis have prescribed pain relief, those with varicose veins have support stockings, and one person needs a wheelchair on outings. Care Homes for Adults (18-65 years) Page 21 of 38 Evidence: The home needs to plan for the future as peoples mobility will eventually make it difficult to use the staircase. One person has regular exercise. We recommend exercise is monitored and reviewed to promote everyones health and agility so that people will retain their mobility as long as possible. One person self administers medication on weekends when they visit family. There is a detailed system of creative support to help by phone. We queried why the person does not self administer in the home if they are capable of doing this. No one has medication disguised in food. All staff complete accredited medication training and update their learning, and those we spoke to were knowledgeable. Competence is tested, observed and confirmed regularly; staff records not available to us were sent after our visit. There is a safe monitored dose system but we queried the quality of pre-printed labels and medication administration records (MAR) from the pharmacist, as it was not clear if one medication was prescribed for occasional or regular use. The home has since checked with a doctor and a repeat prescription now has clear instructions. There is a system to check medication when it is received and disposed of so that it does not go missing. Occasional use medication carried over from a previous delivery was not always added to new medication checked into the home on the MAR, which could hamper audits. We discussed using the MAR rather than the MDS box to record receipts. We were satisfieinformed that edication procedures were updated after our visit and this will now be added on the MAR. Medication is stored in appropriate cabinets in each persons room and there is good key security. We queried a homely remedy oil that was open and undated, which is used to calm someone at night. As the shelf life could not be determined; the owner threw it away. Temperatures are not taken to ensure drugs remain stable and effective, but rooms were not excessively warm. We saw safe containers and records for medication transferred to day services or for holidays and visits to family. No one needed medication stored in a fridge, or controlled drugs and there is no cabinet or controlled drugs register. There were no gaps in the MAR, which shows that people have medication as prescribed. Audits are regularly conducted by managers. Audit findings and professional advice have been used to improve for instance, guidelines for occasional use psychiatric drugs. Medication is well managed and recorded so that people have medication as their doctor intends for their health and wellbeing. Care Homes for Adults (18-65 years) Page 22 of 38 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 know who they can report a concern to and they can have confidence it will be taken seriously and acted upon. Staff are trained to recognise and report abuse and they provide immediate safety, but the home is not working with other agencies to fully safeguard people. Evidence: People told us who they would turn to if they were unhappy, and were confident this would be acted upon. We checked the homes log and confirmed no complaints were made since the last inspection. We asked about their equipment and how people spend time. Two people told us about things they did not like or wanted improved and we discussed this with managers with their permission as they had not raised this before our visit. We saw that there are good relationships with managers, who responded quickly and appropriately. We were notified after the inspection that the outcome for one person resulted in less restriction, to their satisfaction. People with learning disabilities do not always want to make formal complaints, and some people need staff to note their distress or discomfort. Safeguarding is taken seriously at Nevin House and there is a whistle blowing policy that is known by staff. Staff have training to recognize and report abuse and poor practice inside and outside the home. There are clear guidelines about peoples communication and what to watch for so that staff can enquire further. Complaints and adult protection procedures are readily available, and they match national guidelines and local council protocols, Care Homes for Adults (18-65 years) Page 23 of 38 Evidence: however we found they are not always used. Staff we spoke to had understanding of abuse and recent experience of the local protocol. The AQAA was not accurate and told us there had been no adult protection concerns. The Commission was aware of one unfounded matter which involved the homes cooperation with a multi-agency investigation. We were also notified by the home about a burglary on other premises, affecting peoples valuables kept there. We checked and found that peoples valuables and records were replaced, and now have safekeeping in the home, and were told that the council required changes to the recording of transactions and receipts, and are now satisfied that peoples money is accounted for transparently. We were satisfied through checks that financial decisions have been appropriately made by the home, in keeping with peoples needs and lifestyle, but peoples financial interests need additional safeguards and sole bank accounts, as already discussed. We were told during our visit of a third matter resulting in dismissal of a worker for neglect of duty, having left the premises and a person alone before the next worker arrived. Robust action was taken by the owner to prevent recurrence; however this was never reported under the council protocol or to the Commission as required under regulation 37 and our current guidance about safeguarding. A previous requirement about this was not met. A report had not been considered to the national barring list, so we requested this was reviewed and we were satisfied with their decision. The home also told us about action taken to safeguard people in the community and in their relationships, which we complimented as excellent practice. Incidents and history are clearly recorded and appropriate risk assessments are in place. However these too were not reported / notified. There were no serious consequences for people of any of the matters we queried, because of immediate action taken by the home. However these matters show us that the home is not working in partnership with other agencies to safeguard people fully, and others in the care industry. We saw good practice - the environment and care planning balances peoples needs for security with their rights to privacy, risk-taking and access to the grounds and community. There are least restrictive plans about personal safety and behaviour management concerning: self harm, wandering, preventing crime, community safety, road safety awareness, use of public transport and safety if left alone at the home. Staff are not trained to use physical restraint, but no one has such needs apart from a bedrail. Multi-professional decisions are made about medication. Care Homes for Adults (18-65 years) Page 24 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Nevin House is homely, clean and comfortable. Peoples have privacy and security in their rooms, and the equipment and facilities they need and want. Repairs are timely and regular health and safety checks are made, but management need to prevent slips, trips and falls. Evidence: The home is in a quiet cul-de-sac, just off a busy main road but there is public transport nearby. It is an ordinary house that is not distinguishable as a care home. The appearance of the front of the house would be improved if the front door bell was fixed. The home and grounds are secure so people do not wander into the road. Furnishings are comfortable and the standard of decor is adequate. The premises are regularly maintained and refurbished, and repairs are timely. There is a homely and welcoming atmosphere. Lighting in the home could do with review, as it appeared dark, which can strain peoples eyesight. There is sunlight in a conservatory/dining room where meals are usually taken. There are sufficient communal areas for quiet conversation, eating and noisy activity. In the large lounge is an area for the computer, and a large screen TV appropriate for people with sight impairment. The garden has been made more secure since the last inspection. Toilets and bathing facilities suit peoples needs, including an Care Homes for Adults (18-65 years) Page 25 of 38 Evidence: assisted bathtub and hoist, and have door locks for privacy. People are happy with their rooms, which suit their tastes, age, culture and lifestyle. They chose the colour schemes and bedding. There is sufficient storage space for personal belongings, such as music collections, TV or radio and an emergency call system. Some people have photographs of family and friends on display. Each person has a lockable tin for their valuables and the key. One person said they had lost their key but had not told staff, which we advised managers about. People have privacy when they want because each door has a lock. This can be opened by staff in an emergency. Everyone has a travel pass for public transport, and there is a vehicle used by staff. Access to upstairs rooms is by staircase and some people in the home have reduced mobility, so this may need consideration as they grow older. The AQAA told us that equipment and the hoist are regularly checked and maintained. One person uses a wheelchair outside the home, and another was assessed to need a bedrail. The bedrail fitting did not pose risk of limb entrapment because a national safety alert was followed, but the care plan and daily records did not include instructions to check the fitting. The rail was loose, posing risk of collapse, and the person was not comfortable in bed. The owner tried but it was not possible to remedy this, so an immediate requirement was agreed, and this was met quickly for the persons safety and comfort. Safety checks of hot water were not available on our visit, but were provided so that we can confirm that people are protected from scalds. We saw window restrictors on the first floor, and security from intruders downstairs. One person said they do not like their ground floor window being knocked in the morning by staff. There are fire drills twice a year, and the owner confirmed that the fire evacuation plan and homes risk assessment had been reviewed about health and safety. We were told that the council Environmental Health report made a recommendation about the worktops, and the entire kitchen was refurbished. Nevan House is clean and smells fresh. There are best practice infection control and food safety measures in place. All staff are trained in infection control and safe food handling. There is a health and safety culture and safe working practices, the environment needs a more critical assessment. We discussed three hazards with the owner and agreed feasible timescales to address them to prevent slips, trips and falls. The front porch has holes in the concrete where peoples feet can get caught, but because of damp proofing protection for the building, the owner said she will need to have flush grates made. The new kitchen flooring buckled, which is a design fault for which they have received compensation. An order was placed in January 2009 and delivery is Care Homes for Adults (18-65 years) Page 26 of 38 Evidence: expected. Lastly, the step down into the kitchen came as an unexpected surprise. Staff and people living in the home may have become used to it. We advised that an arrow or sign might warn everyone, including visitors. Care Homes for Adults (18-65 years) Page 27 of 38 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. Competent and consistent staff have clear roles, training and knowledge of peoples needs. A robust recruitment process must ensure staff are safe to work in the home. Qualifications and supervision do not meet minimum standards but clear guidelines and spot checks protect people from inexperience and lack of knowledge. Evidence: The home is staffed by two carers and two managers so that peoples needs are met at all times they are in the home, by a lone worker. The manager is always on-call. Four staff were dismissed for various reasons in October/November 2008 and one worker has been suspended for some time pending renewal of a work permit. There is consistency because temporary staff are not used. New staff are being recruited. Another work permit will need renewal in May 2009. New staff have an induction to safe working practices, followed by a longer Skills for Care induction. There are clear roles. We were told that new staff work with more experienced staff until they are confirmed as competent. Only one out of the four staff have NVQ qualifications, which does not meet the minimum standard so that people are protected from lack of knowledge and inexperience. Four places have been booked for enrollment in NVQ2 in September 2009, if staff are recruited. Quality audits and spot checks by managers have been recently introduced to ensure that staff Care Homes for Adults (18-65 years) Page 28 of 38 Evidence: performance is sustained and improved, peoples health and wellbeing is monitored, and specialist advice is sought when necessary. Staff do not have qualifications specific to learning disabilities. The deputy is currently working on an NVQ 3 qualification, and has had additional training to understand disability and dementia. The owner explained that they were unable to complete an NVQ 4 in care and management, and must re-start. The deputy attended the pilot leadership and management course but was unable to complete this due to workload commitments. Although management qualifications are not yet satisfactory, the home is well managed and peoples outcomes are good. Mandatory training and refreshers are up to date. There is no training to manage behaviour, although no one in the home is currently presenting challenging behaviour. Some staffing records are not kept on the premises or available to us on our visit. This was discussed with the owner who said changes would be made to comply with the law, and missing records were provided following our visit. The job centre provides staff new to the job of caring, already checked with the police and government lists for working interviews. No international checks are done to make sure they are safe to work in the home. Paid work trials are by short contract and staff work under superivision. After a new contract, induction and training commence after vetting by the home. This does not match the regulations so that people are fully protected. Management need to ensure they have sufficient information about new staff before they commence any work in the home, including authentic reference checks before new staff are confirmed in post. We queried action taken in 2009 about a missing character reference managers noticed were missing from employment confirmed in 2007. One long-standing staff file had a very useful recruitment checklist which demonstrated good practice; no one could not explain why this has not been used for new staff. We were told that regular staff meetings were held when there was a larger staff team, to discuss standards and to learn together. Formal staff supervision, notified after our visit took place just below minimum standards. Performance and learning needs are appraised annually by observation, which is good practice. Care Homes for Adults (18-65 years) Page 29 of 38 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. Experienced management and systems benefit people and provide safe working practices. Views of people are used to develop the service. Systems need development to maintain a safe environment, and the home needs to work with other agencies to promote peoples rights. Evidence: Nevin House is effectively managed, and peoples welfare is of priority. The owner is experienced in care but no one has care and management qualifications.. A deputy supporting the owner since 2007, is gaining experience and qualifications, and now has specific responsibilities such as care plan evaluations and running staff meetings. Both managers try to keep up with new laws and ways of working, for instance person-centred planning, and both are attending council training on the Deprivation of Liberty Safeguards. This is a new law with legal duties from 01/04/09 and management will need a new policy and procedure that promotes and protects peoples rights. We saw that managers and staff have good relationships with people. The owner Care Homes for Adults (18-65 years) Page 30 of 38 Evidence: responded quickly and effectively to our requests and any concerns we noticed or reported. The homes registration and liability insurance certificates are up to date and on display. The AQAA was returned on time but only the dataset was updated. The AQAA therefore was not used as an opportunity to evaluate the service this year. Recruitment was described as a challenge, to find staff with the right attitude. The owner was disappointed by staff who tend to do things for rather than alongside people, and noticed that they have become more dependent as a result, which both managers are now reversing. This means that people living in the home have experienced a lot of staff changes and conflicting approaches since the last inspection. There appears to be confusion about staff names. Following the induction of new staff, managers are now conducting regular spot checks. Supervision dates and appraisal records were confirmed by letter following the inspection regarding current staff. People told us that they are happy in the home, but they also described being able to go to the cinema only if the owner had time to take them, and another is bored on Sundays. Both managers now undertake daily shifts at the day service and at the care home for staff continuity, while they are trying to recruit new staff, and the owner is on-call most days. This has taken its toll on the owners health recently. There is a recruitment strategy, assisted by negotiations near conclusion with the council about funding levels. Proactively, four places have been secured to commence NVQ 2 training in September 2009, if staff are recruited. The owner is now seeking other recruitment options, as well as using the job centre. Human resource processes were robust to manage dismissals of four staff for various reasons, and we were told an Employment Tribunal application was unsuccessful as due process was followed by the home. Notifications to the Commission, to the council under the adult protection protocol and reports to the government barring list must be timely and the home needs to work with other agencies to promote and protect rights.. Since the last inspection, a quality assurance system was purchased, and annual surveys seek peoples views to develop the service. Results are not published, but there are regular resident meetings where suggestions and actions taken are discussed. For example, after peoples suggestions the home replaced the computer, tv and computer games, and are now planning a lending library from the day service resources. This is good practice. We recommend that views are also sought from relatives and professionals, the AQAA Care Homes for Adults (18-65 years) Page 31 of 38 Evidence: and inspection report are used to inform the homes development plan. A number of changes will need to be anticipated as people grow older. We saw shift plans, cleaning schedules, and detailed guidance for staff day and night. Manager spot checks sustain safe working practices. All staff work alone during hours people are in the home, and there is a loner worker and on-call system for safety. Most records are kept up to date and secure for confidentiality. Care documentation has been streamlined so that changes affecting people and issues affecting staff can be easily identified. There is still room for improvement. Managers could not easily locate essential records we requested, which extended the inspection process. This means they are not readily available when needed in the home. Some staff recordsare not held in the home because staff are often work in two services. The owner said this would be changed after we advised on the law. Records sent after our visit howed that people are protected from scalding hot water because temperatures are within the safe range. There is a health and safety culture that also balances independence and risk taking for peoples benefit.. We sampled policies which reflect best practice, current national guidance and local protocols. We were told that the homes fire safety plan, and health and safety risk assessment were reviewed. This needs a more analytical approach as there are hazards we noticed that need attention to prevent slips, trips and falls. Staff are inducted, trained and refreshed in safe working practices, including manual handling. Fire drills are held twice a year. There is an emergency fire pack and the emergency alarm system is regularly checked. We were told that other regulator reports were acted upon. Care Homes for Adults (18-65 years) Page 32 of 38 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 Adults (18-65 years) Page 33 of 38 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 20 20: The registered person must not act as the agent of a service user or have their name on service user bank accounts, so far as practicable. There should be a working agreement with the council appointee about financial decision-making in best interests. The rights and financial interests of people with incapacity need to be lawfully safeguarded. 12/08/2009 2 20 13 13(2): All homely remedies 31/07/2009 and oils should be dated when opened so that their shelf life can be determined. This is to ensure peoples health. 3 23 13 13(6): The registered 12/08/2009 person must ensure that suspected abuse or neglect is reported under the council adult protection protocol at Page 34 of 38 Care Homes for Adults (18-65 years) 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 the time an incident comes to light. Where paid staff or volunteers are dismissed or leave as a result of abuse, reports must be made to the Independent Safeguarding Authority for their decision about barring. Agencies need to work together to keep people safe. 4 24 23 23(2)(b): The premises 11/09/2009 must be safe and in a good state of repair. Hazards in the front porch and kitchen must be risk assessed and action taken to minimise risk of slips, trips and falls as far as is possible. This is to promote the health and safety of people living in the home. 5 34 19 19, Schedules 2 and 4: 12/08/2009 There must be records about staff kept on the premises, demonstrating a robust recruitment process. People need to have confidence that staff are safe to work in the home. 6 42 37 37: Notifications to the Commission must be made in accordance with current guidance. 12/08/2009 Care Homes for Adults (18-65 years) Page 35 of 38 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 The home needs to work with the Commission to protect people. 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 7 The system to prevent falls needs more balance so that least restrictive alternatives are considered in best interests to manage risk and specialists can be sought at early points, if necessary. Where best interest decisions are needed, anyone with incapacity represented only by paid staff may have rights to an Independent Mental Capacity Advocacy service, arranged by the home in accordance with the council contract. Emergency files and the missing person procedure could be further developed to include: a photo, mental capacity; accurate next of kin or representative, whether/when an IMCA may be needed, religion and relevant cultural and emotional support. Sexuality and sexual needs should be assessed in accordance with the homes policy, ensuring rights to privacy, equality and diversity are responded. It is recommended that each person has a weekly activity plan with symbols and an Easy Read style to keep in their rooms so that they can check for themselves what is planned, and have more confidentiality. Spiritual needs and religious observance should be regularly reviewed as peoples interests are subject to change. Diet should be monitored to ensure that government advice is followed about healthy eating, such as sufficient fresh fruit and vegetables. Opportunities for regular exercise should be reviewed and Page 36 of 38 2 7 3 9 4 9 5 10 6 11 7 17 8 18 Care Homes for Adults (18-65 years) 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 monitored so that health and maintaining mobility is promoted. 9 10 18 20 Well mens checks should be sought through GP surgeries so that health is promoted. The purchase of a thermometer is advised and daily recorded checks to ensure that medicines are stored in accordance with their product licence to maintain their stability for peoples health. Fifty percent of staff should have NVQ2 qualifications completed so that people are supported by staff with sufficient knowledge of care. Consideration should be given to involving people in staff selection and appraisal. Formal supervision for staff should take place a minimum of six times per year. The manager in charge of the home should complete care and management qualifications so that they are up to date on management roles and responsibilities and further develop leadership skills. Surveys could be sought from relatives and other professionals so that the service can continue to develop and learn with feedback from all sources. The AQAA should be accurate and the opportunity to self assess the service against the national minimum standards and KLORA should be used to inform the homes development plan. The recording of mental capacity and best interest decisions, policy and procedures should reflect Mental Capacity and Deprivation of Liberty codes of practices, and CQC guidance available on the Commissions website. Critical review of the homes health and safety risk assessment should minimise environmental risks. The owner would benefit from council environmental health leaflets. 11 32 12 13 14 34 36 37 15 39 16 39 17 40 18 42 Care Homes for Adults (18-65 years) Page 37 of 38 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. Care Homes for Adults (18-65 years) Page 38 of 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!