Care Home: Silverpoint Court Care Home

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What the care home does well The manager provides people with excellent up to date information about the service and people receive a thorough assessment of their needs before they move in, which ensures that the home can meet their needs. People are offered the opportunity to visit the home and spend some time there to make sure that they like it. The care planning system is detailed, thorough and person centred; the night care plans provide staff with excellent information about peoples preferences. The home ensures that risk assessments have been carried out for all areas of identified risks and has in place plans on how staff are to manage them. The home offers people an excellent range of activities including a variety of regular entertainers and it displays forthcoming events prominently on the noticeboard in the reception area to enable relatives and visitors to join in if they wish to. People get a good choice of healthy foods and the menus are regularly changed to suit the requirements of the people living in the home. The manager deals with concerns and complaints effectively ensuring that a record of the complaint and how it was dealt with is kept in the home. All staff have had training in safeguarding adults and they know what actions to take if they suspected abuse. There is a stable staff team that are experienced and well trained and the recruitment process is robust ensuring that all prospective staff have the appropriate employment checks before starting work at the home. The manager is very experienced and has good leadership skills; he has made many improvements to the home including the provision of a new conservatory and the landscaping and securing of the gardens. What has improved since the last inspection? The care planning and risk assessing processes have improved considerably since the last inspection and the care plans now contain much more detail on the level of assistance that people need in all areas of their care. There are now management plans in place for all areas of identified risk ensuring that staff are more confident in supporting people to take risks. The medication system has been improved upon to ensure that the risk of medication errors is minimised and the manager has put in place regular checks to ensure that medication practice is safe. All complaints including minor ones are now recorded in the homes complaints log. The manager has replaced the worn stair carpet. What the care home could do better: The manager must ensure that he continues with his regular checks on medication that is brought into the home in its original packs and bottles to ensure that it is administered safely. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Silverpoint Court Care Home Silverpoint Marine Canvey Island Essex SS8 7TN     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: Pauline Marshall     Date: 2 4 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Silverpoint Court Care Home Silverpoint Marine Canvey Island Essex SS8 7TN 01268515564 01268510404 silverpoint.court@nellsar.com 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) : Nellsar Ltd care home 36 Number of places (if applicable): Under 65 Over 65 36 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 Silverpoint Court provides residential accommodation for thirty-six older people. The home is a purpose built property with accommodation on three floors with a passenger lift allowing access to each floor. The homes facilities include two large lounge areas on the first and second floors and the main dining room on the ground floor. There are thirty single and three double bedrooms and several toilets and bathrooms. The home is situated in a residential area of Canvey Island and close to the seafront. A large conservatory was built last year and the garden is landscaped and has a raised flowerbed; there is a gazebo and two patio areas with tables, chairs and parasols. A copy of the homes Statement and Purpose and Service User Guide is available on request and is provided to all people with an interest in living at Silverpoint Court. Current fees range from £383.00 to £520.94 per week and there are additional variable charges for hairdressing, chiropodist and newspapers. Care Homes for Older People Page 4 of 27 Care Homes for Older People Page 5 of 27 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 Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection that lasted for eight and a half hours. All of the key standards were inspected; we checked a random sample of policies and procedures and examined some of the records that the home is required to keep. We looked around the building and we spoke to most of the people living in the home, to some of their visiting relatives, to the staff, to the manager and to the providers representative. We checked the progress of the requirements that were made at the last inspection on 27th June 2008 and all had been met. The manager completed the annual quality assurance assessment (AQAA) and returned it to us within the required timescale; it was detailed and informative and provided us with good information about the service. The AQAA is a self assessment document that Care Homes for Older People Page 6 of 27 the manager is required by law to complete; we have used the information provided in the AQAA throughout this report. We sent surveys to ten people using the service, six health and social care professionals, ten relatives, two advocates and twelve of the homes staff to obtain their views on the service that the home provides. We received three completed surveys, one from a person using the service, one from a relative and one from a health and social care professional; no other completed surveys were received by the due date. The views were mainly positive and comments from these have been included in the body of this report. What the care home does well: What has improved since the last inspection? What they could do better: The manager must ensure that he continues with his regular checks on medication that is brought into the home in its original packs and bottles to ensure that it is administered safely. Care Homes for Older People Page 8 of 27 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 27 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive excellent information about the service and they know that their needs will be met. Evidence: The manager regularly reviews the homes Statement of Purpose and Service User Guide and displays both documents prominently in the reception area. The information contained within them was up to date and when spoken with, a relative of one of the people living in the home said I am able to keep up to date with information as these guides are situated next to the visitors book, so it reminds me to look at them. The manager said that both the Statement of Purpose and the Service User Guide can be translated into other languages when required. There were full pre-admission assessments on all of the four care files that we looked at, these were informative and detailed and included all areas of need such as social, Care Homes for Older People Page 11 of 27 Evidence: physical, spiritual and psychological. People spoken with said that the manager carried out a full assessment of their needs prior to their admission. The manager said in his AQAA prospective residents are given the opportunity to spend time in the home and an individual member of staff is allocated to give them information and special attention to help them to feel comfortable in their surroundings and enable them to ask any questions about life in the home. People spoken with confirmed that together with their relatives they had the opportunity to visit the home and spend some time there before making the decision to move in. Care Homes for Older People Page 12 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal care in a way that suits them and ensures that their health care needs will be fully met. Evidence: We looked at four care files and we found that the information in them was detailed and person centred. Each of the care files that we examined contained a personal profile that looked at the likes and dislikes of the person both now and in the past. It looked at what they enjoyed doing and provided a detailed history of events that had taken place throughout the persons life. All of the care files that we looked at included fully completed health charts, and there were records to show that regular health appointments had been made and kept and the outcomes of the visits were recorded. Each of the care files that we looked at contained a night care plan that included information on individual preferences such as if people preferred their en-suite door open or shut, if they preferred the curtains open or shut, which night-time drink they preferred and their choice of night clothes. People spoken with confirmed that they had Care Homes for Older People Page 13 of 27 Evidence: been asked about their preferences and said that staff always adhered to them. The care plans were signed by people living in the home and their relatives, where necessary and people spoken with, including the relatives of people living in the home, confirmed this. We spoke to many of the people living in the home throughout the day and all of their comments were positive and included I am very happy here, it is marvelous, the staff are kind and caring and nothing is too much trouble and I have been here a couple of years and I am involved in my care plan. The home has recently changed its medication practice; it is now provided in a monitored dosage system for seven days at a time. We checked a random sample of the monitored dosage system and the corresponding medication administration sheets (MARS) and all was found to be correct. There were protocols in place explaining why, how and when to administer as and when prescribed medication. There was a list of the signatures and initials of all staff that administers medication; an observation of the medication round showed that it was correctly administered. All staff that administers medication have had medication training and there was evidence on the staff files that their competence had been regularly assessed. The medication for two people that had been admitted within the last three months was not included in the monitored dosage system and the senior carer said that this was because they were prescribed midway through the medication ordering period, so their medication was still in the original packets. We carried out a random check of this medication and it was not possible to determine if it was correct as there appeared to be too many tablets in one pack and not enough in another. As a result of this the manager has since put in place measures to ensure this does not reoccur. The manager is a qualified nurse and will now carry out regular checks on all medication to ensure that it has been correctly ordered, administered and recorded. The manager said that he will also ensure that all medication that is brought into the home in its original packs and bottles is changed into the monitored dosage system at the earliest opportunity. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are well supported to live a lifestyle that meets their identified needs and preferences. Evidence: The home employs an activities co-ordinator for five afternoons each week. People are offered a range of activities such as seated exercises, quizzes, bingo, music sessions, BBQs, fetes, reminiscence, dominoes, darts, film shows, church services, drives into the local community and eating out. In addition to this, regular external entertainers visit the home and have already been booked on a monthly basis for the forthcoming year. There was a large activities notice board in the reception area that clearly showed the planned activities and one person spoken with said there is plenty to do at Silverpoint Court if you want to, and the singers are really good and they come here a lot. The home is a member of the National Association for Physical Activities for older people (NAPA), which is a charitable organisation that promotes high quality activity provision for older people. Each of the care files that we looked at contained information to show that people are involved in their care planning and when spoken with people confirmed that the home Care Homes for Older People Page 15 of 27 Evidence: not only involves them but also involves their families if they wish them to. There was notes of regular residents meetings taking place and people said when spoken with that they were always consulted on what they liked, disliked and wanted from the service. Silverpoint Court operates a four week rolling menu that offers people a good choice of home cooked food. People spoken with were very complimentary about the food and one person said if I dont like what any of what is on offer, the staff will always cook me something different and the food is really great here. We observed staff assisting people with their meals and they did so in a discrete and sensitive way and they were helpful and patient, allowing individuals sufficient time to complete their meal. The manager carries out regular food surveys to ensure that people are happy with their meals and when spoken with one visiting relative said I am always made to feel welcome and can have a meal with my relative whenever I want and it is a lovely atmosphere here, I am so pleased that my relative is happy at Silverpoint. Another visiting relative said the food is so good, it is served like you get in a hotel, the staff cater to my relatives every need and I have no worries now my relative lives here. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be protected from harm and abuse. Evidence: The complaints procedure was reviewed recently and is available in a variety of formats such as large print and easy read and there are copies displayed around the home; there was a copy on the notice board by the visitors book. There has been five complaints since the last inspection and the records showed that they had all been dealt with appropriately. One relative of a person living in the home said when spoken with, if I have any concerns, I raise them with either the staff or the manager and I am confident that they are dealt with, and if possible they are often resolved straight away. Staff spoken with confirmed that when people living in the home or their relatives share any concerns with them they will try to resolve the issue immediately, if possible. People said in their surveys the home sorts any problems straight away if they can and I dont worry about things as I tell staff straight away if I have any concerns. The manager said in his AQAA we do a review of the number and nature of complaints and we use the information as part of our quality assurance procedures. The manager said that information from these complaints will be included in his next quality assurance report, which is due to be completed in the next few weeks. All staff have received training in safeguarding adults and when spoken with, staff showed that they had a good knowledge of safeguarding and they knew what actions Care Homes for Older People Page 17 of 27 Evidence: to take if they suspected abuse. The manager said in his AQAA the home is clear when an incident needs to be referred to the Local Authority as part of the local safeguarding procedures. Staff spoken with were aware of the Southend, Essex and Thurrock guidelines. The manager said that staff have a regular annual update to their safeguarding training and the training matrix confirmed this. Care Homes for Older People Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, comfortable safe environment. Evidence: Silverpoint Court was purpose built in 1995 and is situated just off Canvey seafront; some of the bedrooms and both lounges have beautiful sea views. We looked around the building and it was well decorated with good quality furniture and fittings and all worn carpets have been replaced since the last inspection. Each of the bedrooms contained many personal belongings and they were individually furnished. People spoken with said they were very happy with their rooms and one person said the view from this room is beautiful and I have all that I need around me, I brought quite a lot from home so it feels homely. This person was watching their own flat screen TV in their bedroom and staff had ensured that the nurse call buzzer was appropriately placed within easy reach of their armchair; the person said that staff always check that they can reach the buzzer. The manager said in his AQAA we have purchased a new hoist, new tumble dryer and a new fridge and a new freezer is on order; we now have an aquarium on the middle floor. People spoken with said that staff looked after the fish in the aquarium and that it was very relaxing watching the fish swim. There was a large flat screen TV in the Care Homes for Older People Page 19 of 27 Evidence: middle lounge and people spoke about the film shows that they have and the activities co-ordinator confirmed that some people preferred to watch an old movie from time to time so this was scheduled into the activities plans. There is a large conservatory that leads out into a large well landscaped secure garden that has seating areas with tables, chairs and parasols, there is a gazebo and the garden has a brick built path to allow for wheelchair access. There was raised flowerbeds that make it possible for people in wheelchairs to plant small flowers and plants and people spoken with said that they had enjoyed doing this and liked to see the colouful display of flowers. The garden and conservatory were in full use on the day of the inspection as people living in the home had requested a BBQ for their lunch. Silverpoint Court has an ongoing plan for redecoration and employs a part time handyman to carry out routine repairs. The maintenance records showed that all repairs are dealt with in a timely manner and people spoken with confirmed that repairs are done quickly. Four domestic staff are employed and the home was found to be spotless; it was clean and hygienic and there was no malodorous smells. The relative of one of the people living in the home said, I visit regularly at various times of the day and in the evening and I can honestly say that this home is always clean and fresh. The manager said in his AQAA twenty of the homes staff have had infection control training and he said that more training is planned for later in the year; the training records confirmed this. Care Homes for Older People Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by a competent, well-trained and supervised staff team, who are safely recruited. Evidence: We looked at the staff duty rosters over a three week period and we found that there had been sufficient care staff on duty to meet the needs of the people living in the home. The rosters showed that a senior carer, five care assistants, two domestic staff, a cook, a kitchen assistant and a laundry worker works on the morning shift. The roster showed that generally there was one senior carer and four care assistants working on the afternoon shift; it also showed that an additional care assistant worked at times when needed. The roster showed that one senior carer plus two care assistants work at night. The manager said in his AQAA that seventeen staff have an NVQ qualification and when we looked at the staff training records they confirmed this. Staff spoken with confirmed that their NVQ training had proved useful in their work and that it had made them more aware of the need to record their actions. One staff member said when spoken with I am currently working on my NVQ level 3 as I have already done level 2 and it really helps me in my work. Care Homes for Older People Page 21 of 27 Evidence: We looked at four staff files, which included that of the most recently employed staff member and we found that they contained all of the documents that are required in the regulations including a completed application form, two written references, evidence of induction and criminal records bureau (CRB)checks. The manager said in his AQAA we have a highly developed recruitment procedure that has the needs of the people who use the service at its core and the service is highly selective, with the recruitment of the right person for the job being more important to the filling of a vacancy. Staff spoken with said that the recruitment process was rigorous and that they had a thorough induction when starting work at the home and that they were supervised until its completion. The manager said in his AQAA the home ensures that all staff receives relevant training that is targeted and focused on improving outcomes for residents. We looked at the staff training certificates and they confirmed that in the past year training has taken place on dementia, safeguarding adults, communication, challenging behaviour, fire, health and safety, medication, infection control, first aid, moving and handling and the deprivation of liberties. The manager keeps a training matrix displayed on his office wall, which shows the planned training for the coming year. Staff spoken with said that the training was very good and that they had been provided with training in care planning and risk assessment which had helped them when devising and reviewing peoples care plans. Staff spoken with and observed demonstrated a good understanding of the various differing needs of the people living in the home, and they used a person centred approach when delivering care. Care Homes for Older People Page 22 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well run home that is run in their best interests. Evidence: The registered manager has worked at the home since February 2007 and has completed the registered managers award; he has many years experience, is a trained registered mental health nurse and has owned and managed a care home in the past. Staff spoken with said that the manager supports them well and provides them with clear leadership. The provider makes regular monthly visits to Silverpoint Court and there was copies of their reports kept in the home. There was records to show that the manager keeps a regular monthly check on accidents and falls and the manager said that by monitoring these the home reviews the delivery of care to eliminate or minimise the risk of falls. The manager completed his annual quality assurance assessment (AQAA) fully and returned it by the due date and it contained all of the information that we had asked Care Homes for Older People Page 23 of 27 Evidence: for. The home does not hold any monies for the people that currently live there but has policies and procedures in place should this be the case in the future. We looked at four staff files and all but the most recently recruited member of staff had evidence that supervision had taken place. Staff said when spoken with that they had regular supervision now, and the senior care staff now supervise the care assistants. A random sample of safety certificate were checked and we found them to be in place and up to date. There was a current fire risk assessment in place and as a result of the last fire officers visit the manager has purchased two special carrier chairs for staff to use to assist people living on the top floors of the building to vacate the home in the event of a fire. Care Homes for Older People Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 27 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 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 Older People Page 26 of 27 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. 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