Care Home: St Helen`s Nursing Home

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What the care home does well The home provides a good level of care in comfortable and homely surroundings. Each person has an assessment of what their care needs are before they are offered a place at the home to make sure the home can meet their needs. A plan of care is written down and regularly updated, with individual assessments of risk and the involvement of health care professionals and other specialists as needed. People are treated kindly and with regard to their privacy and dignity. People are offered opportunities to go out on trips and to have the daily life they prefer. Staff assist people to make choices about daily living. Visitors are made welcome. The food is of a good quality and people have an assessment of their nutritional needs to make sure they receive the right diet for their health. Complaints are well handled and people are protected by safe recruiting of staff and good training in abuse awareness. The home is well staffed and staff are well trained to carry out their role. The home is very well managed by a qualified and competent manager. The manager has developed a good system for gaining feedback about the way the home is operating through audits and surveys, so that people`s opinions about the home are taken into consideration when planning improvements to the service. What has improved since the last inspection? The manager who has been in place for a year, has brought about a number of improvements to the care and environment of the home. The assessments and care plans are much improved, with an emphasis on person centred care, which places the individual in the centre of all planning. The handling of medication has improved and now better protects people from risk of error, but there are still some improvement required. Activities were not always planned with individual needs in mind but this has now greatly improved. Staff now understand individual social and recreational needs better and the home has several interesting areas where there are rummage boxes and other items to interest people as they go by. Trips have been organised and people have benefited from several outings since the last inspection. The decor and internal environment of the home is much improved. Most communal areas have been redecorated, bathrooms have been upgraded and several rooms have been refurbished. The home has a welcoming and homely atmosphere. Staffing levels have improved both at night and during the day.Staff training has improved. More staff have completed foundation training and others have begun NVQ level 2 or 3. The system for assuring a quality service has improved, personal allowances handling is also improved, with each person having a separate wallet containing their money. What the care home could do better: The manager has begun her own internal audits of the home and has identified a number of areas where the home could improve. There are still occasional gaps in the recording of medication which means people could be at risk of having medication given twice. The manager is planning more resident welfare reviews with involvement of family and residents to encourage people to have more involvement in planning their care. The manager has plans for the front areas of garden to be made secure so that people living at the home may have access to this without risk of accessing the road. A sensory garden is planned. Liquidised foods are to be put into food moulds to give a more attractive presentation for people who need this type of diet. A shower room is to be finished and brought into service, and various other improvementthroughout the home are to be made including a refurbishment of the kitchen, which is much needed. The manager is reminded of the need to register with CQC. Inspecting for better lives Key inspection report Care homes for older people Name: Address: St Helen`s Nursing Home 41 Avenue Victoria Scarborough North Yorkshire YO11 2QS     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: Karen Ritson     Date: 1 4 0 7 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 25 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 25 Information about the care home Name of care home: Address: St Helen`s Nursing Home 41 Avenue Victoria Scarborough North Yorkshire YO11 2QS 01723372763 01723501502 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) : Hamilton Care Limited care home 28 Number of places (if applicable): Under 65 Over 65 0 0 dementia mental disorder, excluding learning disability or dementia Additional conditions: 28 28 The maximum number of service users who can be accommodated is: 28 The registered person may provide the following category of service only: Care home with Nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Dementia Code DE; Mental Disorder, excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home St Helens is a care home providing nursing care for up to 26 people from the age of 65 years of age who have dementia and/or mental disorder. The home is located near the town centre of Scarborough, its amenities and facilities. There is a small garden area to the front of the house and parking for visitors on the road at the side of the house. A local bus route serves the home. The accommodation provided is in both single and double bedrooms on three floors and there is a passenger lift giving access to the upper floors. Care Homes for Older People Page 4 of 25 Brief description of the care home The home has a statement of purpose and service user guide, which provide information about the scope and nature of the care and facilities on offer. These, with CQC reports, are available on request at the home. Care Homes for Older People Page 5 of 25 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 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: The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection for this service took twelve hours. This includes time spent gathering information, examining documentation before and after a site visit. It also includes the time taken to write the report. The site visit took place on 14th July 2009 between 9:30 and 15:30. Information for this inspection was gathered from the following: 1. A visit to the home. 3. Speaking with staff. 3. Case tracking three people on the day of the site visit. 4. Reading survey forms from people living at the home and staff. 5. Looking at information provided by the manager prior to the site visit. 6. Notifications sent to the commission from the home since the last inspection. 7. Examining policies, Care Homes for Older People Page 6 of 25 procedures and records kept at the home. 8. Examining information regarding the home on the file kept by CQC. All key standards were looked at during this inspection. The manager was available throughout the day of the site visit. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations -but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? What they could do better: The manager has begun her own internal audits of the home and has identified a number of areas where the home could improve. There are still occasional gaps in the recording of medication which means people could be at risk of having medication given twice. The manager is planning more resident welfare reviews with involvement of family and residents to encourage people to have more involvement in planning their care. The manager has plans for the front areas of garden to be made secure so that people living at the home may have access to this without risk of accessing the road. A sensory garden is planned. Liquidised foods are to be put into food moulds to give a more attractive presentation for people who need this type of diet. A shower room is to be finished and brought into service, and various other improvement Care Homes for Older People Page 8 of 25 throughout the home are to be made including a refurbishment of the kitchen, which is much needed. The manager is reminded of the need to register with CQC. 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 25 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 25 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs well assessed, so that staff know what care is required. Evidence: Assessments carried out by the manager cover all areas of care in detail. This includes a life history so that staff can begin to understand the person and their interests. A photograph of each person will be kept on file, and there is an admission sheet, which lists information such as GP and next of kin. This is useful, easily accessible information for staff to use. The assessment includes all areas of physical, social and recreational needs. All risks are assessed and these are specific to the individual. The emphasis for each assessment is upon retaining as much independence as possible. This ensures peoples individual needs are well assessed, and that there is detailed information for developing a care plan. The home does not offer intermediate care. Care Homes for Older People Page 11 of 25 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 have most of their care needs met. However, medication handling does not fully protect the people living at the home. People are treated with regard to their privacy and dignity. Evidence: A care plan is drawn up, these were person centred and gave detailed instructions on how to offer the correct care for each person. The emphasis in each case is upon capacity and includes such areas as mental capacity, weight, tissue viability, continence, moving and handling, working and playing and nutrition as routine. Each person also has a personal history which is sufficiently detailed to give staff enough information to chat with people about their lives. Risk assessments are included in all areas which give concern, to ensure people can carry out their daily routines whilst being protected from harm. Daily notes give useful and relevant information about each person and this information is passed across at each new shift. Each care plan is regularly reviewed with involvement from the person living at the home, family or Care Homes for Older People Page 12 of 25 Evidence: others and health care professionals where necessary. This ensures that staff are given information about each persons changing care needs and know what care is needed. Each care plan includes advice from health care professionals where necessary and a separate record of health care professional visits gives clear information about each persons health and how this is being monitored. At the last inspection there were some gaps in recording medication and there was insufficient evidence of an audit trail for packeted medication. This inspection, the manager has begun monthly audits. A running total is now kept of all medication. The manager has noted in her monthly audits that medication is still sometimes going unrecorded and that some homely remedies had been dispensed but not recorded. As a result of this all staff are to attend a Boots medication training within the next month and medication is to be discussed at the next trained staff meeting. Such training will help to ensure medicines are handled safely at all times and that people get the medication they have been prescribed. Throughout the day of the site visit, the staff were observed treating people with care and courtesy. The home has a policy and procedure on privacy and dignity which staff cover in their induction. Visitors said that all the staff were very courteous and kind. It was clear from observing interactions between staff and people living at the home that there was a friendly and open atmosphere. One visitor said: They (staff) are all so patient even when people have difficult behaviour and language at times, they always treat each person as as you would want to be treated yourself. Care Homes for Older People Page 13 of 25 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their social and recreational needs met. Visitors are made welcome. People receive a varied diet they enjoy. Evidence: Assessments include consideration of individual preferences about daily routines and how time is spent. This includes interests, social and recreational needs. The manager has organised trips out since the last inspection and people have been out to such places as the Dickens centre, where there are old fashioned shops, the sea life centre, garden centre and on short walks to the Esplanade to look at the sea and have a change of scenery. The families of people living at the home are invited to join in with outings which helps visitors to feel they are taking part in their loved ones lives. The home does not have any secure outdoor space and there are plans to make the area to the front of the building safe so that people can get out of the home to enjoy outdoor space on a regular basis. The manager has improved the environment for people with a dementia by introducing an orientation board, interesting areas in corridors, a pram, ironing board, dolls, soft toys, rummage boxes of jewellry, books and magazines. There are photographs of local beauty spots and places of interest around the home and some doors have pictorial signs to help people orientate Care Homes for Older People Page 14 of 25 Evidence: themselves around the home. The manager says that staff often stop to have short friendly conversations with people so that wellbeing is improved. However, she added that some staff needed to be reminded to act as social butterflies and not miss opportunities to chat with people. The key worker system is being developed so that staff consider personal effects, toiletries and clothing for the person they are key working. At the moment this is only working to a limited degree. Also, staff are being encouraged to enable those living at the home to make use of the interesting articles around the home, as these can only be beneficial if people engage with them. A member of staff has been allocated specific time on four afternoons each week to carry out activities with people. This might be one to one time chatting and giving a hand or foot massage, or in the case of one person a facial massage. The activities person also involves people in crafts and in particular, card making. The resulting cards are sold to create funds for improving the environment and for trips out. The home also plans open days, and a summer fete was to take place in late July to raise funds and to give family and friends the opportunity to come into the home and chat to staff and the manager. The home also invites a singer to visit the home on a regular basis, who involves people through giving them percussion instruments to play. Other visitors have included the local brownies. The home has also arranged two anniversarys with a special meal and in one case a serenade from a visiting musician. A sweet trolley has been introduced so that people can choose a snack in the afternoon when activities or film show are taking place. These efforts to improve the quality of life for each individual in the home has resulted in a warm inclusive atmosphere and a sense of calm and content throughout the building. Visitors said they were made very welcome at any time and informed about any changes in care or health. They said the manager and all the staff were approachable and friendly. Menus are devised taking into consideration personal preferences. Pureed diets are displayed attractively on plates with separate compartments and the chef has a list of all dietary requirements for each individual. The manager plans to introduce the use of moulded foods which would improve the presentation of pureed foods further. Those who require assistance with feeding and who may be distressed by eating in the dining area are helped in a quiet lounge where staff have the time to focus on each individual. Other residents eat in a pleasant and light conservatory. The home carries out a nutritional analysis for each person to ensure each person gets the nutrition they need. Likes and dislikes are recorded so that people are given meals they enjoy. Care Homes for Older People Page 15 of 25 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their complaints properly dealt with and they are protected from abuse. Evidence: The home has a complaints procedure and policy. The procedure was followed after a formal complaint by a member of the public, and the matter was dealt with appropriately. Staff have all received abuse awareness training during induction and again at foundation level. Many staff have also covered this in their NVQ training. The manager has been briefed in the Deprivation of Liberty Safeguards and is planning a training session for staff. She described how one person had commented she wanted to get out of the home more often. Her Power of Attourney was approached and funds made available for privately funded carers to accompany this person on trips out. As it was within her capacity to arrange this the manager considered it a potential deprivation of liberty not to pursue funding to make the trips out possible. People are kept safe by the good recruitment practices in the home, which ensures only suitable staff are taken to work at the home. Care Homes for Older People Page 16 of 25 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 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 safe well maintained environment Evidence: The manager has made many improvements to the environment of the home. The home smells pleasant and the entrance hall is inviting. Most communal areas have been redecorated to a good standard and are homely and attractive. The patio area beyond the conservatory has been fenced. Baskets and tubs have been placed out here to give people something pleasant to look out onto when they are dining or sitting in this area. The corridor at the rear of the ground floor has been redecorated and two large toilet rooms have been created here. The laundry, which is reached through this corridor is now protected by a key pad entry system so that residents cannot access this area which may be dangerous. Visitors said that there were no problems with the laundry. Laundry was labelled and organised so that the clothes for each person were kept separate. The inner lounge which was poorly lit with no natural light is still being used as a lounge but has been redecorated and the lighting improved. Staff still walk through this area on route to other parts of the home but now often use these occassions as an opportunity to have a few words with the people sitting here. The use of this room is still not ideal. The manager has plans to change this into a sensory room which would be a better use as there is no way of getting natural light into this room. Nine of the bedrooms have been refurbished to a good Care Homes for Older People Page 17 of 25 Evidence: standard and look bright and attractive. Others will be refurbished when funds allow. The cleanliness of the home has improved a great deal. The home now employs three cleaners and their attention to the home has had good results. Most staff have now also had infection control training and the two members of staff spoken to were very knowledgable about infection control procedures. This ensures people live in a clean and pleasant environment and they are protected from risk of infection. Care Homes for Older People Page 18 of 25 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 good 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 well recruited and trained staff in sufficient numbers. Evidence: The home is better staffed than at the last inspection. There are now three night staff on duty, six during the morning and five during the afternoons. This allows staff to spend time with people without rushing. Visitors said the staff always had time to chat and were all kind. One person wrote I feel confident about (the) care which is obviously important to me. All the staff are so friendly and helpful and I always feel reassured that they are doing their best for mum. Staff are well recruited, with a Protection of Vulnerable Adults check and a Criminal Records Bureau check carried out. This makes sure people who are unsuitable to work with vulnerable people are not recruited. Two references are also taken up. Staff receive a good induction, and foundation training is regularly updated. There are some areas of foundation training where staff are due for updates but this is planned for the near future. Many staff have achieved or are working towards NVQ at level 2 or 3. This means staff have the skills necessary to offer good care. The home also employs a good proportion of trained nurses. The manager has created team leaders who are not necessarily nurses but who have a good standard of practice and can lead by example. Staff do not work short handed, but agency staff are used to cover gaps in the rota when necessary. Most agency staff are regulars to the home and know the people living there. Any Care Homes for Older People Page 19 of 25 Evidence: problems or issues with care are discussed at the regular meetings. This gives staff the opportunity to discuss any concerns and get valuable feedback from colleagues and the manager. Staff spoken to were well motivated and were enthusiastic about offering good care. The manager operates a carer of the month award which recognises the achievement of carers who show they are committed to doing a good job. A photograph of the carer is displayed in the entrance hall so that visitors can see. This helps acknowledge good work and lets people know the home values its staff. Care Homes for Older People Page 20 of 25 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 benefit from a well managed home. Their health and safety in protected. Evidence: The home is well managed by Ann Greaves who took up post a year ago. Since then she has developed a strong working relationship with her staff team and has provided excellent support in achieving improved care standards. She is well qualified for her role and has continued to access training throughout the year. She is a trained nurse, has a management qualification, has attended a course in risk assessment in health care and has completed a three month dementia training course. Staff said that she was a fair and supportive manager who had made good changes in the way the home was run over the year. Because she has high standards this had clearly inspired those staff with a similar desire to create the best care possible for people living at the home. Staff all receive regular supervision and the manager has an open door policy where any concerns can be aired on a daily basis. The manager has begun comprehensive audits on areas of care and health and safety topics. These inform an Care Homes for Older People Page 21 of 25 Evidence: annual business plan for improvement in the home. Surveys hace been distributed to people who come into contact with the home and a number have been returned. Comments from these will be taken into consideration when planning improvement for the coming year. The home looks after the personal allowances of a number of people. These are suitably kept and accurately recorded to keep peoples money safe. The manager protects the health and safety of people through good staff training and risk assessment, good care plans and a thorough knowledge of each person. Maintainance records and servicing of equipment are kept up to date. The manager is reminded of the need to register with CQC. Care Homes for Older People Page 22 of 25 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 23 of 25 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 9 12 Staff must not leave gaps in recording of medication. To protect people from risk of errors in administration. 21/07/2009 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 31 The manager should register with CQC. Care Homes for Older People Page 24 of 25 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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