Care Home: Spout House Support Services

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What the care home does well Spout House is a small home, that continues to provide an individual service that is person centred and needs led. This approach respects the skills, abilities and individual wishes of the people concerned. The five people living at the home have all been there for a number of years and have good relationship with each other as well as staff. The staff work well as a team and a key worker system is in operation that ensures a close professional relationship with each person to ensure their individual potential. Staff spoken with confirmed that they feel confident about their skills and abilities and have received sufficient training for the support required to be provided. A new member of staff is completing an intensive induction programme with the support of other staff. There are relaxed and friendly interactions taking place between the people being supported as well as staff. Privacy and dignity is maintained at all times and measures are in place to reduce anxiety and encourage independence. The majority of staff have worked at the home for a number of years and this provides consistency and stability to persons who benefit from a familiar face. Various strategies are in operation to assist with the support provided including the use of pictures. The people living in the home help with domestic chores such as cleaning, washing and cooking and are encouraged and supported to participate in activities and outings of their choice. Relatives are encouraged to visit the home and support the care provided where this is helpful for the individual concerned. Liaison takes place with other professionals as necessary. All staff undertake the Learning Disability Award Framework (LDAF) training programme that is specifically targeted at supporting people with a learning disability. Three staff have obtained a National Vocational Qualification (NVQ) at level 2 or above in Care and three other staff have registered to undertake NVQ training. Three staff have been registered for the LDAF training programme. What has improved since the last inspection? Changes have been made to one of the care plans by including pictures and symbols within the documentation to make it more user friendly. This has taken some time as the person requiring this support has to recognise what the pictures and symbols represent. Each staff member has a training log that details the training received and any gaps. The induction process takes place over several weeks as necessary until the individual concerned becomes confident. The home continues to be refurbished and changes have been made in order to extend the lounge space by the removal of a pool table and there are now two lounges, both with a TV. The lounge has been painted and there are new light shades. The landing and stairs have been re-carpeted. One of the bedrooms has been decorated accordingto the wishes of the person residing in the room. New tiles have been fitted in the kitchen area and there has been a new cooker and boiler. The fridge has been put on wheels in order that it can be cleaned underneath. The bathroom has been upgraded with a new shower. The office has been decorated with a new carpet. Outside a derelict building that was considered a hazard has had the roof removed and metal railings installed in front to prevent access. One of the people living at the home places the staff rota made up of photos of the staff on the wall the day before. This helps with her anxiety about the support to be provided and who is available. There are also photos of activities to be undertaken each day by one of the people living at the home who benefits from this approach. What the care home could do better: Staff would benefit from being updated on the latest information and strategies in Safeguarding/Protection of Vulnerable Adults and ensure that they familiarise themselves with the reporting procedures. There is a need for the registered manager to ensure that there she is allocated sufficient time within the staffing rota for management duties and completing vital documents such as the AQAA in order to comply with legal obligations. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Spout House Support Services Spout House Bay Horse Lancaster Lancashire LA2 9DE     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: Susan Dale     Date: 2 1 0 1 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. the things that people have said are important to them: They reflect 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 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.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 27 Information about the care home Name of care home: Address: Spout House Support Services Bay Horse Spout House Lancaster Lancashire LA2 9DE 01524792261 F/P01524792261 joanne@spouthouse.wanadoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Miss Joanne Helen Swindlehurst Type of registration: Number of places registered: Mrs Pamela Joyce Broxup care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The registered person may provide the following category/ies 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 - Code LD The maximum number of service users who can be accommodated is: 5 Date of last inspection Brief description of the care home Spout House is a small care home registered to accommodate up to five people of either sex who have a learning disability and associated needs. The home is set in a very rural environment, is not purpose built but, provides a homely environment with enough space for individuals to be private as they wish. The homes aim is to provide a domestic environment, which consolidates existing skills and abilities and endeavours to develop the lifestyles and potential for each person provided with the service. The current fees vary and depend on the individual being cared for. Further information over fees can be obtained from the registered manager of the home. Care Homes for Adults (18-65 years) Page 4 of 27 5 Over 65 0 Care Homes for Adults (18-65 years) 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: 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 site visit took place at short notice and information was obtained prior to the visit via an Annual Quality Assurance Assessment (AQAA) that is completed by the home about how well they are meeting the Care Home Regulations. Various documents were examined belonging to the people provided with the service as well as staff records. The registered manager was spoken with as well as other staff on duty and the people living at the home. A tour of the home took place and the outside garden area. The last key inspection took place on the 8th February 2007. Care Homes for Adults (18-65 years) Page 6 of 27 What the care home does well: What has improved since the last inspection? Changes have been made to one of the care plans by including pictures and symbols within the documentation to make it more user friendly. This has taken some time as the person requiring this support has to recognise what the pictures and symbols represent. Each staff member has a training log that details the training received and any gaps. The induction process takes place over several weeks as necessary until the individual concerned becomes confident. The home continues to be refurbished and changes have been made in order to extend the lounge space by the removal of a pool table and there are now two lounges, both with a TV. The lounge has been painted and there are new light shades. The landing and stairs have been re-carpeted. One of the bedrooms has been decorated according Care Homes for Adults (18-65 years) Page 7 of 27 to the wishes of the person residing in the room. New tiles have been fitted in the kitchen area and there has been a new cooker and boiler. The fridge has been put on wheels in order that it can be cleaned underneath. The bathroom has been upgraded with a new shower. The office has been decorated with a new carpet. Outside a derelict building that was considered a hazard has had the roof removed and metal railings installed in front to prevent access. One of the people living at the home places the staff rota made up of photos of the staff on the wall the day before. This helps with her anxiety about the support to be provided and who is available. There are also photos of activities to be undertaken each day by one of the people living at the home who benefits from this approach. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 27 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 9 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, 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. A person centered approach is undertaken to assessment that ensures individual requirements are met as safely as possible and encourages independence. Evidence: There have been no new assessments for a number of years as all the current people living at the home having been living there for at least six years. The records showed that an individual approach is taken at the initial assessment and liaison takes place with family, friends as well as other professionals. With regard to equality and diversity, the individuals background and preferred lifestyle is taken into account at all times. Numerous risk assessments were seen to have been recorded on every aspect of physical and personal care needs as well as those connected with outside pursuits, hobbies and interests. Care Homes for Adults (18-65 years) Page 10 of 27 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. The individual needs and choices of the people living at the home are met in as safe a way as possible through the trained staff who provide support and guidance. Evidence: Three care plans were examined and found to contain very detailed information about the individual concerned including their background, physical and emotional requirements. A person centered approach is taken at all times and the wishes, choices, hobbies and interests of the person concerned is taken into account at all times. Currently one of the care plans is being compiled in pictorial form with symbols for one of the people living at the home who benefits from this approach. This strategy is taking some time as the person requiring this approach has to become familiar as to what the pictures and symbols represent. Care Homes for Adults (18-65 years) Page 11 of 27 Evidence: Although the persons seen living at the home are not able to voice their feelings regarding the care received, from observation, the interaction between them and staff was excellent. Risk assessments and guidance were recorded for daily routines, activities and outings. Staff are trained in breakaway techniques and restraint and not allowed to carry out such procedures until they had received appropriate training. Freedom of choice about daily living is promoted as much as possible taking into account any risk factors and how they can be overcome as safely as possible. A key worker system is in operation and staff were seen to provide guidance in a kind and caring manner. Each person has their own bank account and a corporate appointee assists with financial affairs for four out of five of the current people living in the home. Independent advocates to act on an individuals behalf have been provided as required. Care Homes for Adults (18-65 years) Page 12 of 27 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. Individual lifestyle choices are supported within a safe framework to ensure a good quality of life. Evidence: Each person has their own individual care plan that sets out their individual daily routines and activities. Currently none of the people living at the home undertake paid employment although there has been some voluntary work. One person attends a local Church and others go out to lunch once a week or to the local pubs and cafes. Staff are able to have timeout and go out with the person they are allocated to for example shopping or to a cafe. The home is situated in a very rural area but staff are able to accompany the people living in the home and use the bus or take them in their car. Activities include board games and DVDs, a foot spa, facials, arts and crafts, a Care Homes for Adults (18-65 years) Page 13 of 27 Evidence: hairdresser attends the home for one person. The people living at the home participate in the daily routines of the home. For example one person puts the staff rota on the wall ready for the next day using photographs of the staff. In order to provide structure with activities, photos of each daily activity are placed on the wall for one person living at the home who benefits from this approach. The people living at the home also take turns making an evening meal of their choice, the menu is recorded for others to view in advance. Changes are then made to the menu if other persons at the home do not like what is to be provided. Specialist diets are catered for and a record is kept of food preferences. According to ability, independence is encouraged as much as possible and the people living at the home tidy up and wash their clothes and put them to dry outside. The emphasis is that this is the persons own home and staff support and encourage. During the visit, one of the persons living at the home who exhibits very challenging behaviour was being encouraged to hang her washing out on the line. The care plans showed a number of preferred individual pursuits and activities including College and swimming. Family and friends are welcomed and risks are minimised as much as possible when visits are made to see family and friends. Care Homes for Adults (18-65 years) Page 14 of 27 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. There are good systems in place to ensure that the health and personal care of the people living at the home is supported. Evidence: The care files contained numerous evidence of liaison with health professionals including, GP, District Nurse, Pharmaceutical service, CPN, Dietician, Dentist and Optician. Following consultation, a special exercise has been conducted over one of the persons in the home to see if a particular diet had an effect on their behaviour. Escort is provided to visit health professionals as necessary. There was evidence that staff ensure support is provided in a way to reduce anxiety as much as possible. One of the methods used is by the use of photographs to enable the person to point to the things she requires rather than ask for them verbally. Medication records were examined and found to be accurately maintained and secure. The manager ensures oversight and checks the medication administration records on a Care Homes for Adults (18-65 years) Page 15 of 27 Evidence: regular basis. All staff have been provided with medication training. Care Homes for Adults (18-65 years) Page 16 of 27 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. The policies, procedures and staff training ensure that the people living in the home are protected from harm. Evidence: There is an appropriate complaints procedure and the people living in the home are aware of who to go to if they have any concerns. There have been no complaints since the last key inspection and the Commission for Social Care Inspection (CSCI) has not received any concerns. The manager dealt correctly with a recent incident that was reported to both Social Services and CSCI. The incident has resulted in additional refresher training in restraint and a review carried out on one of the people living in the home with particularly challenging behaviour. Social Services are satisfied with the handling of the incident and the measures put in place afterwards. Staff have received training in the protection of vulnerable adults and a recommendation was made that in light of the recent incident, staff should receive some additional training to familiarise themselves with the subject and the recent changes to safeguarding procedures. Care Homes for Adults (18-65 years) Page 17 of 27 Care Homes for Adults (18-65 years) 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, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a pleasant, homely, safe place to live for the people living in the home as well as the staff. Evidence: A tour of the home took place and all areas were clean, tidy and warm. The bathroom has been upgraded with a new shower. One of the bedrooms has been re-decorated according to the wishes of the person residing in the room. The office has been decorated and has new carpet. The pool table has been taken out and the dining tables moved to extend the lounge area and so there are now two lounges with a TV in each. The lounge has been painted and there are new light shades. New carpet has been fitted on the landing and stairs. The kitchen has been refurbished with new tiles on the floor to replace some that were missing. A new boiler system has been installed and the fridge is now on wheels so that it can be cleaned beneath. The bedrooms were individual and personal possessions in evidence. There were no toiletries/cleaning products on view that could be ingested. Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: The home does not employ a cleaner, the people living in the home help to clean all areas assisted by staff and do their own washing and ironing where possible. On the outside of the home a roof has been taken down from an outbuilding to make it safer and railing placed in front to stop anyone going too near. Care Homes for Adults (18-65 years) 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, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living at the home are cared for by well trained staff who benefit from the training received and the support of the manager and senior staff. Evidence: There were sufficient staff on duty for the number and needs of the current people living at the home. One of the persons in the home has been assessed as requiring additional staff support and has been granted 2-1 funding. Staff are provided with training that meets the needs of the people requiring the service and undertake the LDAF training programme that is appropriate for people with a Learning Disability. Each member of staff has a booklet that records all the training received including Induction Training and this ensures that there are no gaps. Some training is provided in-house and cascaded down from the manager or senior staff; other training that takes place outside the home includes, Moving and Handling, Health and Safety, First Aid, COSHH, Drug Administration and Food Safety. There are eight support staff and three have a National Vocational Qualification at level 2 or above in Care and three other staff have registered to take the qualification. Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: Three members of staff have been registered for the LDAF training programme. The recruitment procedures were examined and staff files examined. There was evidence that security checks had been undertaken prior to new staff commencing. The checks included the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults Register (POVA). As recommended at the last key inspection, there is now written evidence that a POVA check has been undertaken. One member of staff spoken with had only recently commenced and was gradually being inducted and was being shadowed by other experienced staff. She stated that she felt comfortable in the role and was gaining in confidence gradually. Staff work as a team and a team approach is taken at all times. Staff spoken with expressed their satisfaction with the support provided by the manager and senior staff. One to one supervision does take place although not as regular recently and the manager hopes to establish supervision on a more frequent basis. Staff meetings take place frequently and the manager has found that the meetings are more successful if she does not chair the meetings. Care Homes for Adults (18-65 years) Page 22 of 27 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. The home is well managed for the benefit of the people living at the home as well as staff. Evidence: The registered manager is well qualified and has lengthy experience in the care of people with a Learning Disability. The manager has obtained the Registered Managers Award and NVQ level 4 in Care. Additional training has been undertaken including Health and Safety in the Workplace, Time Management and Conducting and Appraisal. The home is well managed although the manager also has to be part of the staffing rota and this can make it difficult to have the time to complete necessary records and be pro-active in planning for the future. Vital information that is legally required for registered establishments for example, the Annual Quality Assurance Assessment (AQAA) needs to be completed on time and contain sufficient information about the home for a judgement to be made. Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: Feedback is obtained directly from the people being provided with a service about how content they are with the service provided. No formal quality assurance systems are in place as it was thought not necessary in such a small home. External feedback is sought from other professionals, visitors and relatives at the annual review for individual people in the home. Other reviews were seen to have been carried out on an almost daily basis as necessary. Adequate records had been kept on the maintenance of the home and staff are trained in Fire Safety. Records are kept of any accidents and incidents. Care Homes for Adults (18-65 years) 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 Adults (18-65 years) 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 1 23 All staff should undertake some refresher training in the Protection of Vulnerable Adults and become aware of the latest legislation and local procedures with regard to Safeguarding Adults. The registered manager should be allowed adequate time within the staffing rota for the management of the service including time to complete documents such as the AQAA within expected time limits that meet necessary legal obligations. 2 37 Care Homes for Adults (18-65 years) Page 26 of 27 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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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