Care Home: St Josephs

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What the care home does well People living in the home shared their experiences of what it is like for them, living at St Josephs, they told us, they are able to spend their time as they wish and that they were happy living there. They also told us, "staff in whatever capacity they are employed in, show kindness patience and a desire to help each other and every resident. This in turn creates an atmosphere of friendliness, generosity and security. The manager or a senior member of staff will always be available and usually an answer will be found to any request or problem. I have found staff to be helpful at all times, including the cleaning staff, all staff have an excellent attitude towards residents and relatives, and provide excellent personal care, and the food is good and nicely presented". We also spoke to people visiting the home, who told us, "all staff are friendly and approachable, my relative has settled in really well and this makes me feel very confident" and "the staff look after my relative really well, they are nicely settled and they have made acquaintances within the home". Other comments included, "my friend has been here nearly two years, it is like living in a hotel with carers around you" and "we are extremely satisfied with the service, my relative feels safe and well supported and the staff provide an all round service of excellent care, with patience and compassion". Comments included in the residents, `Have Your Say` surveys reflected, "I consider the home to be a warm and happy environment, `Home` is exactly what it feels like, with beautifully kept gardens, building and interiors". Feedback from health professionals, who visit the service, told us, "the staff provide an excellent quality of life to the people who live there" and "the service looks after the social, physical and mental health needs of people in the home well, they would be well placed to develop a nursing side to the service". What has improved since the last inspection? The service is further developing information about the home using technology to make this information more widely available, via the internet. A short film about the day in the life at St Josephs is to be included on the website and a DVD is in the process of being made to send to all prospective enquirers to the home. Improvements have been made to ensure the change over of monthly medication is booked in more efficiently and returns are sent back to the pharmacy more promptly, so that medication not required, is not stored unnecessarily. The homes AQAA reflects they have responded positively to feedback from residents, relatives and staff about the provision of the breakfast service in the dementia unit. Concerns were raised that residents appeared to be increasingly isolated at this important meal time. A trial breakfast service in the dining room has been well received, which has improved the residents social and nutritional well being. The manager advised us they are in the process of re designing the quality assurance surveys, into a more suitable format to ensure these are more user friendly. As recommended, in the previous inspection report these should include feedback from people who have contact with the home in a professional role, and those residents whoare unable to complete a survey, or fully communicate their views of the service. What the care home could do better: Feedback received in residents surveys, reflected where little improvements could be made, to improve the service. These included, in spite of clothes being labeled, some laundry does go astray, and more help and supervision in the dining room at lunch time, is needed, as more residents require help and encouragement to eat their meal and the television is often left on with sometimes unsuitable and violent programmes and more tea tables in the sitting room, would be helpful. Inspecting for better lives Key inspection report Care homes for older people Name: Address: St Josephs The Croft Sudbury Suffolk CO10 1HR     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: Deborah Kerr     Date: 1 3 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 39 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 39 Information about the care home Name of care home: Address: St Josephs The Croft Sudbury Suffolk CO10 1HR 01787888460 01787888469 careforehomes@aol.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) : Carefore Homes Limited care home 60 Number of places (if applicable): Under 65 Over 65 26 0 33 0 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: 6 1 0 2 To offer care and accommodation to 1 named person within the category of MD and DE, as per application V29740. Date of last inspection Brief description of the care home St Josephs is owned by Carefore Homes Ltd, and are registered to provide residential care for up to 60 people, from 55 years of age and over. Although the home can care for a maximum of 60 people, they have the flexibility to take up to 33 frail older people, up to 26 older people who have a diagnosis of dementia, and up to 6 people within the age range of 55 - 64 years, who have a physical disability or dementia. The home (part new build, part listed) opened in August 2005, and is located within walking distance of the town of Sudbury, which offers a range of amenities. These includes rail and bus links, shops, restaurants, hotel, banks, post office and public Care Homes for Older People Page 4 of 39 Brief description of the care home houses. In December 2006, following the conversion of the convent building next door which is now linked to the home, they were registered for an additional 9 places. People can access the home by stairs or passenger lift. Some residents, due to their mobility needs, may find some areas of the home easier to access than others, therefore staff will discuss this on an individual basis, prior to allocating a room. All 60 bedrooms are of single occupancy with an en-suite toilet and wash hand basin. Some also have an en-suite shower. The home is divided into 3 main areas, and includes a specialist dementia care unit (Gainsborough), which has restricted access and a sensory room. Each of the 3 areas has their own lounge, dining rooms, assisted bathrooms and access to landscape gardens or patio. The home has been decorated and furnished to a high standard throughout. There is a hairdressing room, and limited car parking is available at the front of the home. Fees are currently £740 per week, for stays of over 4 weeks, which includes all personal care, accommodation and meals. The home also offers short-term (respite) care, currently priced at £115 per day for stays at the service under 4 weeks. Care Homes for Older People Page 5 of 39 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 a key inspection, which focused on the core standards relating to older people. The inspection was unannounced on a weekday, which lasted nine and a half hours. This report has been written using accumulated evidence gathered prior to and during the inspection, including information obtained in thirteen residents and six staff and health professionals Have Your Say surveys and the Annual Quality Assurance Assessment (AQAA) issued by the Care Quality Commission (CQC). This document gives the provider the opportunity to inform CQC about their service and how well they are performing. We also assessed the outcomes for the people living in the home against the Key Lines Of Regulatory Assessment (KLORA). Care Homes for Older People Page 6 of 39 A tour of the premises was made and a number of records were inspected, relating to people using the service, staff, training, the duty roster, medication and health and safety. Time was spent talking with six people living in the home, two visitors and two staff. The manager was present during the inspection and fully contributed to the inspection process. What the care home does well: What has improved since the last inspection? The service is further developing information about the home using technology to make this information more widely available, via the internet. A short film about the day in the life at St Josephs is to be included on the website and a DVD is in the process of being made to send to all prospective enquirers to the home. Improvements have been made to ensure the change over of monthly medication is booked in more efficiently and returns are sent back to the pharmacy more promptly, so that medication not required, is not stored unnecessarily. The homes AQAA reflects they have responded positively to feedback from residents, relatives and staff about the provision of the breakfast service in the dementia unit. Concerns were raised that residents appeared to be increasingly isolated at this important meal time. A trial breakfast service in the dining room has been well received, which has improved the residents social and nutritional well being. The manager advised us they are in the process of re designing the quality assurance surveys, into a more suitable format to ensure these are more user friendly. As recommended, in the previous inspection report these should include feedback from people who have contact with the home in a professional role, and those residents who Care Homes for Older People Page 8 of 39 are unable to complete a survey, or fully communicate their views of the service. 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.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 39 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 39 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 who may use this service and their representatives are provided with information they need to help them choose if this service will meet their needs. Evidence: Copies of the statement of purpose and Residents Brochure were provided at the inspection. These contain detailed information about the services provided, the facilities and also includes the complaints procedure. Information about the home is provided in a user friendly format, including large print, Braille and on audio tape. The home is using innovative method to provide information about the service. There are plans to develop the website with a short film about the day in the life at St Josephs. Additionally, they are in the process of developing a DVD to send to all prospective enquirers to the home. The filming and still photography has been completed and work is in progress to apply the script. The AQAA reflects all the filming was undertaken with specific permission from residents, staff and families and visitors. Care Homes for Older People Page 11 of 39 Evidence: People spoken with confirmed they or their relative had had been provided with information and the opportunity to visit the home, before deciding if was the right place for them. This was also confirmed in Residents Have Your Say surveys, 12 out of 13 surveys returned, said they received enough information to help them decide if this was the right home for them. They surveys also reflected all 13 people confirmed they had been issued with a copy of their contract. Relatives who had helped residents complete their surveys commented, my first impressions of the home are very good, I was recommended St Josephs by friends and am very pleased, all staff are friendly and approachable. My relative has settled in really well and this makes me feel very confident that their short stay will become a permanent one and the staff look after my relative really well, they are nicely settled and they have made acquaintances within the home. The records and care pathways of three people living in the home were tracked to ascertain how well the home is meeting their individual needs. All three people tracked had a detailed pre admission assessment completed, which covered all areas of the individuals health, personal and social care needs. Information provided in the AQAA and verified at the inspection confirmed all pre admission assessments, where practicable, are conducted in the residents own home or in hospital, prior to admission to St Josephs. Additionally, where people had been referred through social services, a copy of the social workers assessment had been obtained, held on file and used to complete the individuals care support plan. From the information obtained in the pre admission assessment an holistic care plan is developed, which is person centered, and takes into consideration the individuals life history and current needs and choices. To ensure the home are able to meet peoples specific needs, they are supported to access extra services through the National Health System (NHS) or Social Services including, access to equipment supplies, physiotherapy and audiology appointments for hearing aids. Care plans reflected there has been input from health care professionals, such as the speech and language therapists, dietitians, and the district nurses. Additionally, staff are provided with training to ensure they have the knowledge and skills to provide care and support appropriate to the needs of the individual(s). Trial visits to the home are encouraged, to ensure that people considering moving to the home are fully informed and involved in the decision making process. The AQAA reflects people that live some distance away or are physically unable to visit, are encouraged to discuss the service over the telephone, additionally a senior can arrange to visit them and provide information using photographs to help them to visualise the home. Care Homes for Older People Page 12 of 39 Evidence: The AQAA and statement of purpose clearly reflect that the service offers emergency admission placements, however an initial assessment including obtaining information from the clients General Practitioner (GP) is still undertaken to ensure the home can meet the individuals needs. The home does not provide intermediate care. All people moving into the service and their representatives are provided with a contract, setting out their fees, the roles and responsibilities of the provider and their rights and obligations whilst living in the home. Care Homes for Older People Page 13 of 39 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 who use this service receive health and personal care, based on their individual needs, and can be assured that at the time of their death and dying they will be supported by a staff team who will have the skills to ensure the comfort and dignity of the individual who is dying. Evidence: The AQAA states there has been improvements made to the care plan and information gathering process, which has been subject to significant changes since St Josephs opened in August 2005. Three peoples care pathways and care plans were tracked as part of the inspection. Care plans had photographs in place of individual residents to identify and personalise the care plan document. The plans are built around the individual needs of residents, which have been discussed and written in conjunction with them and their family and includes their preferences, choices and daily routines. Evidence was seen that these are being reviewed monthly. Care Homes for Older People Page 14 of 39 Evidence: The plans are divided into sections, which include the individuals personal details, including next of kin, General Practitioner (GP), medical history, medical and professional interventions, reviews, support plans and risk assessment. These collectively set out the actions required by care staff to ensure that peoples health, personal and social care needs are met. Plans are written in a person centered way, all about me, and include a comprehensive life history. These provided information of the individuals past, focusing on significant and important events in their life, what matters to them and why. This information provides vital links to the persons past, which has formed their identity, and forms the basis of communication and provides staff with an understanding of the individual. Additionally, the care plans contained a good description of how peoples dementia had progressed and the effect it was having on their life. These clearly set out a description of the individual and how to recognise their well being, which included, they are generally a happy person, with a good sense of humour, they enjoy the feel of different fabrics and will happily spend hours looking at magazines and observing others. The care plans are set out in a way that could easily be used by people unfamiliar with the individual, to deliver a personalised and consistent service. Comprehensive risk assessments are in place, identifying the risks for activities of daily living, such as mobility and personal hygiene and the action required by staff, to minimise these, whilst enabling the individual to retain some independence and choice. The home uses a traffic light system, no or minimal assistance (green), requires some assistance (amber)and requires hoisting and transfer aid (red). The assessments took in all activities that a resident may undertake during the day, for example transferring from bed to chair. It gave staff clear guidance on how many staff were required, and were applicable, which mobility aids to use. The assessment also gave information on any history of falls, condition of skin and any communication and behavioural needs the resident may have. Other assessments include pressure area management and nutrition The manager and a senior have become falls champions, and attend regular meetings with the Primary Care Trust (PCT), piloting different ideas to reduce the level of falls for people living in the home. The manager completes a monthly analysis of falls, to find out why they have occurred. A sample of the assessments seen reflected where individuals are at a high level of risk, action has been taken to minimise these. One individual who had had 7 falls within a month, had been provided with appropriate aids and equipment to promote independence, minimise the risk of further falls and had had their medication reviewed by their GP, which had reduced the number of falls. The monthly analysis is put onto a graph and provided to seniors to monitor and to review each person at the end of each month to assess if the level of falls has reduced. Care Homes for Older People Page 15 of 39 Evidence: Daily records are well written and provide a good overview of how each individual has spent their day, they also document the care provided and give an indication of the individuals health and well being. These reflect people in the home are able to access health care services, when required. The home has a positive relationship with the local GP and district nurses, who make regular visits to the home. Dates and details and outcomes of appointments had been clearly recorded in peoples care plans. Additionally, the AQAA reflects the home has contact with outside agencies including chiropody, continence advisors, dental, optical, audiology, pharmaceutical and mobility suppliers, which ensure people using the service, can maintain choice when receiving these services. One of the people tracked during the inspection, due to deterioration in the health has been assessed as requiring permanent bed rest. A new assessment has been completed reflecting the equipment provided to aid their comfort and wellbeing, it also reflect staff are to pop in at frequent intervals to chat and ensure radio or TV is tuned into appropriate programmes for background sounds. Staff were observed in their room chatting with them. The required health charts are being kept and monitored, such as fluid intake output, turning and nutrition charts, to reflect they are receiving a good intake of fluid and a balanced diet. The AQAA reflects staff are trained in the delivery of person centered care, providing choices, and treating people with dignity and respect at all times. The staff actively encourage residents to maintain a level of independence, encouraging them to complete even the smallest of tasks for themselves. This is particularly the case within the dementia care unit, residents are encouraged to assist where they can as this improves their well being. This was confirmed in discussions with residents and staff. Staff were able to give a verbal account of the needs and preferences of individual residents. People living in the home confirmed that staff treat them with dignity and respect. The interactions between residents and staff were observed to be friendly and appropriate. A relative who had helped a resident, to complete their Have Your Say survey, commented, as a relative I would like to praise the staff for their support and care, it is not an easy task, but the staff are always cheerful and willing. Another person spoken with commented, the resident in the room next to me is enough to drive me round the bend, however staff are so kind and patient with them. Time was spent with the senior observing them administer the lunch time medication. They had a good knowledge of medication and about ensuring people receive their medication at correct times and complications that may arise from missed medication. The home uses the Monitored Dosage System (MDS). Photographs of residents had been attached to the Medication Administration Records (MAR) charts folder to avoid Care Homes for Older People Page 16 of 39 Evidence: mistakes with the persons identity. The practice of administering medication is being generally well managed. The MAR charts inspected were found to be completed correctly, staff had made good use of the codes to reflect if medication had not been administered and the reason why not. The medication room is well equipped, and contains a controlled drugs cupboard which meets regulations and a small fridge for medicines. The temperature of the fridge and medication room is being monitored daily to ensure they are at the correct safe temperatures for storing medicines. 7 people are currently prescribed controlled drugs. A random inspection of three peoples controlled drugs was checked against the controlled drugs register and found to be accurate, which reflects, people are receiving medication as prescribed, by their GP. The home has comprehensive range of policies relating to self medicating and ordering, storing, administration, monitoring and returning of unused medication. Improvements have been made to ensure the change over of monthly medication is booked in more efficiently and returns are sent back to the pharmacy more promptly, so that medication that is not required, is not stored unnecessarily. Carefores Home Director of care services undertakes regular spot checks and audits of the medication, to monitor and encourage good working practice. The most recent medication audit, carried on 6th June 09, sampled 4 boxes of medication, these were found to be correct, and blister packs checked, were found to be consistent with the MAR charts. The AQAA reflects staff at St Josephs treat all residents who are dying with compassion, dignity and understanding. This is extended to their families and friends who need a tremendous amount of support during this difficult time. The staff are honest and open with everyone to ensure that the individual receives the very best care including pain relief, access to spiritual needs and the comfort from their families and loved ones. Staff respect the individuals need for quiet and they go about their work in an unobtrusive way whilst ensuring that everyones needs are met without delay. This was confirmed in a discussion with staff who commented, this is a home for life, we look after residents regardless of how long they are here, and it is a big comfort to residents to know that they can stay here. A residents, Have Your Say survey also commented, during recent months several residents have been unwell and there have been several deaths. I have been very aware from my own experience and observation of others, how extremely good the care staff have been with much patience, people have gradually got better. Where death has occurred there has been great sensitivity in dealing with situations. To me personally this extremely good care and kindness of staff has been greatly appreciated and is very reassuring. Care Homes for Older People Page 17 of 39 Care Homes for Older People Page 18 of 39 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 using this service are supported to make choices about how they spend their time and to live ordinary and meaningful lives. Evidence: Discussion with residents and visitors and information provided in the AQAA confirmed St Josephs goes the extra mile for the residents to ensure their experience is the very best. During our visit we spoke with six people living in the home who shared their experiences of what it is like for them, living at St Josephs. They told us, they are able to spend their time as they wish and that they were happy living there. Comments included, I like being here, they look after me well and staff spend time taking me out and I spend my time watching soaps, I go out shopping with my family, and I pursue my hobby of flower arranging, nothing could be better and I have no criticism of the home, it is excellent. One person began the conversation with negative feelings about the home, however further discussion reflected they were in the process, of making a difficult decision to sell their home and move into residential care on a permanent basis. They commented, the care provided to others in the home is second to none and that staff are all very nice and helpful. Other residents told us, I love living here, I get good care. I can do what I want, go out for the day with friends, Care Homes for Older People Page 19 of 39 Evidence: spend time in the garden. I have a call pendent, so that I have access to staff when I need it, and I have regular visitors and activities are available, but not really anything I want to join in with, however I do attend functions such as BBQ and quiz nights. We also spoke to two people visiting the home, who told us, I visit regularly, it is a terrific home I can not complain, if I did have concerns would go to the manager and my relative can be a bit aggressive, however the staff communicate in a very nice way, I normally visit, twice a week around lunchtime, the food is good, and I am always offered a meal and the home is like a 5 star hotel, our family feel comfortable with our relative living here, they are well looked after, they are good staff, staff get a smile from them. There are always plenty of staff around, particularly in the dementia unit. One of the visitors told us, my friend has been here nearly two years, it is like living in a hotel with carers around you. I am very happy with the service they are receiving, the care staff are very friendly and helpful, whenever my friend asks for something, they respond very quickly. Information provided in the AQAA and verified at the inspection confirmed staff support residents in both parts of the home to participate in activities, within the home or outside. Staff and management work hard to raise funds to ensure that activities are available. Many of the fund raising exercises include social gatherings such as Christmas party, summer BBQ providing an opportunity for residents, families and staff to get together and really build the family feel of the home. The introduction of a quiz night once a month has been a huge success and was well supported by families and friends, a few of the residents joined staff teams to add support. However, one person spoken with commented there were not enough activities in the elderly frail unit and more frustratingly that people dont want or are unable to take part. Discussion with the manager and confirmed in the AQAA reflected that activities are widely publicised for the residents who reside in the frail elderly part of the home, however it can often be difficult when external activities tailored to accommodate their requests, are planned and then they do not wish to attend. Activities provided for all people living in the home include, group physiotherapy sessions, chair exercise class, entertainment, board games, art and crafts, film shows at The Bridge Project, day trips including trips to the shops, beach, garden centres, treasure hunt, quiz evening and flower arranging. Time was spent sitting with people in the dementia unit observing what was going on and the general interaction between staff and residents. People were observed walking about the home and in the garden, some had chosen to stay in their room. There is a relaxed go with the flow approach in the unit, staff and residents started playing with a balloon, and other residents joined in. Staff were seen sitting and just being with Care Homes for Older People Page 20 of 39 Evidence: people and there was a lot of feeling based communication, hugs and touching to offer love and reassurance to people. One resident was observed sitting and playing and cuddling a fluffy owl, which they were clearly fond of and invited the inspector to feel how soft it was. Staff are aware of peoples past interests, one resident used to play a lot of golf, a pitch and put has been purchased for the garden and some garden shears for another resident who likes to do some gardening. The manager advised there are spare handbags, general bric a brac, dressing up clothes and fluffy cushions situated around in the dementia unit, although not seen, the manager commented these had most likely been removed by residents. A tog wheel on a board has been mounted on the wall outside the lounge, providing a tactile object for people to use. Three residents were observed baking fruit buns. Another resident was seen entering and spending some time in the relaxation room, which has a range of sensory objects, such as fibre optics, a projector, bubble tube and music. Staff use this room to provide residents with soothing and relaxing hand massages, using therapy oils. People confirmed, they are encouraged to undertake domestic tasks, one resident has a daily routine of folding napkins and laying the tables at meal times. Memory boxes have been put together for all residents living in the dementia care unit. A sample box was seen during the inspection. Boxes have the persons name printed on them, residents are encouraged to help personalise the boxes on the outside and place memorable items inside. These boxes are kept in peoples rooms to be used at any time of day. The AQAA reflects the home does not have set visiting times, families or friends are encouraged to visit at anytime, and many stay for lunch or supper. This was confirmed in discussion with residents and visitors and observation of people receiving visitors throughout the day. There was a lot of activity with people going out with staff and relatives. The resident group is predominately white European however the AQAA states there are two people of different nationalities living in the home. Both have lived in the United Kingdom, for over thirty years and both speak excellent English. The home is a multi cultural employer, which recognises the importance of maintaining cultural links for people living in the home. This is of benefit to one of the residents as two staff from the same country are able to converse with the resident, in their native language. The other resident receives visits from a relative each week and they also converse in their native language. The menu displayed by the dining room reflects the home offers a wide and varied choice of meals. Hot and cold drinks and snacks were seen being offered throughout the day. The AQAA reflects only fresh ingredients, including seasonal vegetables and Care Homes for Older People Page 21 of 39 Evidence: local suppliers particularly for meat and vegetables and fruit. Pictorial menu cards have been a resounding success for residents living dementia encouraging them to take an interest in what they eat. Residents Have Your Say surveys told us, the food is excellent, yet to hear anyone complain about the food, and the food is home cooked and the meals are healthy and we are helped and encouraged to eat more that we would ourselves. One person commented, a bottle of beer now and then would be welcomed. Care Homes for Older People Page 22 of 39 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 who use this service have access to a robust and effective complaints procedure and are protected from abuse. Evidence: The policies and procedures for dealing with complaints, whistle blowing and safeguarding the people living in the home were examined. The complaints procedure is also displayed in large print for those with poor eyesight, it can also be read to individuals if this is identified as a need. People using the service, relatives and staff confirmed they are aware of the complaints procedure and are encouraged to raise any concerns or complaints they may have. They were clear they would talk to the manager about any concerns and were confident that these would be dealt with. Residents and staff told us, the manager is very approachable and I feel able to discuss any concerns openly with them. They also told us, they are extremely satisfied with the service and that they feel safe and well supported and the staff provide an all round service of excellent care, coping with patience and compassion with all demanding situations which can arise, time is always found to deal sympathetically, with enquiries. Of the 13 residents Have Your Say surveys returned, in response to the question, did they know who to speak to if they were unhappy, 12 people had ticked the always Care Homes for Older People Page 23 of 39 Evidence: box, with one person making no comment. The complaints log was seen, which reflected 9 complaints have been made about this service, in the last twelve months. Information in the log book confirmed the 9 complaints, numbered 14 to 22, had been investigated and feedback with written response to complainant within timescales, who were satisfied with the outcome. The homes Safeguarding Vulnerable Adults (SOVA) policy was reviewed in April 2009. It clearly defines what is meant by a vulnerable adult, types of abuse, prevention of abuse, and what staff should do if they suspect abuse. The AQAA reflects the home take the protection of vulnerable adults very seriously and that this is emphasised during training. Training is open and interactive, and staff are encouraged to talk about their experiences and what they would do in certain circumstances. Staff are monitored through supervision on their understanding of SOVA issues and verbally tested through the supervision and training route. Additionally, external training in safe guarding is now becoming the normal process of the company, utilising free training that is available in both Essex and Suffolk. Staff also have access to e learning (computer based training) offering staff more flexibility in the way on which they learn. Staff spoken with were clear about their role and their duty of care to raise any concerns they may have about other members of staff conduct and in reporting of incidents of poor practice and suspected situations of abuse, however they were less clear about reporting incidents to the local authority safeguarding team via Social Services, Customer First service. The home has an open culture where individuals told us they feel safe and supported to share any concerns in relation to their protection and or safety. The manager continues to let us know about things that have happened in the home and they have shown that they have managed issues well. Two safeguarding referrals have been made about this service by the adult and community services based at West Suffolk Hospital regarding two admissions from the home to the hospital. The home worked well with social services and us, to ensure both incidents were fully investigated, with satisfactory outcomes for both individuals, who remain at the service. Discussions with staff confirmed they had received training to support people whose behaviour could develop into physical and verbal aggression. They were able to give clear descriptions of how they would support people to manage this aspect of their care. One person commented, I have not really experienced a situation, of aggressive behaviour, however residents have every right not to like you and sometimes they just dont. In these situations, I would find another member of staff to support them. Support plans and Antisocial Behaviour Charts (ABC) charts are in place, which reflect Care Homes for Older People Page 24 of 39 Evidence: the types of behaviour the individual may exhibit, things that may trigger behaviour to occur and staffs approach to deal with the situation. These are person centered, in that they focus on what is important to the individual, the antecedents, and consequences rather than the behaviour itself and recognise that behaviours are determined by feelings and emotions and to prevent behaviour from escalating, these need to be understood. Staff files and discussion with staff confirmed all staff are subject to Criminal Records Bureau (CRB) checks prior to commencing employment. This was confirmed in discussion with staff and comments received in staff have Your Say surveys, which included, I had to wait at least a month before I could start work waiting for my CRB and recruitment checks to come through and I was recruited fairly and had all documents in place prior to employment. Care Homes for Older People Page 25 of 39 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. The physical design and layout of the home provides the people who live there with a safe, well maintained, comfortable and a homely environment, which encourages independence and wellbeing. Evidence: On entering the home there is a nice atmosphere. The AQAA states the home provides a quality homely environment, which has often been described by our residents as more like a hotel. St. Josephs is homely, it is not simply a care home but it is the residents home and also a home to their families. This was confirmed by our visit to the home and in discussions with people living there and visitors and in 13 residents Have your Say surveys, which told us, I consider the home to be a warm and happy environment, the rooms and public areas are always spotless and the bedrooms are kept clean, as well as all the living areas and St Josephs is fortunate in its setting, which provides a very pleasant environment inside and out. Home is exactly what it feels like, with beautifully kept gardens, building and interiors and the home is comfortable and clean, with nice gardens, and nice staff, which makes me feel safe. The home is bright and welcoming, with spacious communal areas, which are nicely decorated using colours, which are pleasing to the eye and create a calm and homely atmosphere. Furnishings are domestic in style, as are the lighting, carpets and Care Homes for Older People Page 26 of 39 Evidence: curtains. Soft furnishings throughout the home are designed for the specific use of older people, without being clinical. The lay out and design of the home enables the people who live there to be as independent as possible. Corridors and door ways are suitable for electric and self propelled wheelchairs and there are numerous disabled access doorways to the outside, to ensure ease of movement throughout the building. St Josephs is divided into two units, one for elderly care and a specialist dementia care unit, known as Gainsborough. The elderly unit consists of 33 single rooms, on two floors, each with toilet and hand wash basin en suite facilities. 23 of these have additional en suite showers installed. A further 8 en suite bedrooms are provided in the convent area of the home. Gainsborough unit has 17 rooms on the ground floor and a further 9 single rooms on the 1st floor, these all have toilet and hand wash basin en suite facilities, 2 of the rooms on the 1st floor also have en-suite shower facilities. The elderly unit has two lounges, one large with a conservatory leading out into the garden and a smaller lounge over looking the front entrance, used as a private meeting area for residents and their guests. Other communal areas consisted of a dining room and 3 small kitchenettes for residents and relatives to make their own hot drinks and snacks. The home has its own hairdressing salon, a regular hairdresser visits twice a week, people also have own hairdressers visit. The room is also used for Chiropodist visits. The convent has its own lounge, residents kitchen and bathing facilities. Gainsborough unit is self contained and has the added security of a keypad entry system on entrance doors and a safe fenced garden. Bedroom doors have monitors fitted to them linked to the nurse call system, alerting staff if residents leave their room at night. The unit has been specifically designed with wide corridors, which flow into communal seating areas and out into the gardens, to allow people freedom of movement. There is a sensory room and a small kitchenette for residents who have supervised access for cooking. Communal areas are provided with a range of comfortable seating, including sofas and armchairs. The enclosed garden over looks the river and a school, we were advised people enjoy watching and hearing the children at playtime. The home has two gardens both have views over the river and water meadows. These are well maintained, with a range of plants, flowers, hanging baskets and seating for people to enjoy in the nicer weather. The garden area for Gainsborough unit is safe, well planted, bright and interesting for the residents. The AQAA reflects one of the residents has developed and designed the garden area on the annexe who describes this as their contribution to the beauty of St Josephs, they tend to the garden with the assistance of the regular gardener. Care Homes for Older People Page 27 of 39 Evidence: People living in the home are encouraged to personalise their rooms, and to add finishing touches of their own to make their living space more homely. Bedroom doors in the dementia unit had pictures of the individual or of animals attached to help people recognise their room. Bedrooms are nicely decorated with peoples personal effects to reflect their individual personalities, hobbies and interests. Information provided in AQAA and verified at the inspection confirmed the home is maintained to a high standard of decoration. An operations manager has been appointed to oversee the management of the environment. There is an ongoing programme of maintenance to ensure the home retains its current high standard of decor. The main dining room, lounge, hallways, and several bedrooms have recently been redecorated, with further plans to replace some of the carpets in bedrooms on Gainsborough unit, as these have become tired and worn. Additionally, the AQQA states there are plans to re decorate areas of the dementia unit, as it appears rather plain and lacks depth of colour. This is to be discussed at the September residents and relatives meeting, to look at ideas of how improvements can be made. The home has sufficient bathrooms and toilets available to meet the needs of the people living there. The elderly unit has 3 separate bathrooms, with Jacuzzi style air baths, with providing optional hydro massage facility, these are fitted with an electric hoist. 1 bathroom also has a disabled access shower cubicle. The dementia unit has 2 large bathrooms 1 with disabled access shower, both with fixed hoists; these too are fitted with the optional hydro massage facility. The home is generally equipped with aids and equipment to promote mobility and maximise peoples independence, including grab rails and other aids, which are available in corridors, bathrooms, and toilets and where required, and in residents own rooms. The home has a range of hoists. Risk assessments seen in peoples care plans confirmed, each person is assessed to ensure the correct equipment is being used. Call systems are provided throughout the home in all individual and communal rooms, people also have access to pendants which link into the call system and ensures that people using the service have access to staff at all times. The laundry facilities are clean and tidy with appropriate equipment to launder soiled linen, clothing and bedding. Systems are in place to minimise risk of infection via the use of dissolvable red bags for any soiled laundry soiled. Additionally the home has an OTEX laundry system, which controls the risk of infection. The system works by lifting the fibres in the clothing, the injection of ozone into the water ensures disinfection of the clothing, without the potential risk of damage to the clothing. Appropriate Care Homes for Older People Page 28 of 39 Evidence: protective equipment, such as aprons and gloves and hand washing facilities of liquid soap and paper towels are provided in all en suite and toilet facilities, where staff may be required to provide assistance with personal care. The AQAA reflects staff training in the control of infection is ongoing with regularly inspections by senior managers and ongoing monitoring by senior staff, to ensure that at all times the control of infection does not go unchecked. Of the 13 residents Have Your Say surveys returned, in response to the question is the home fresh and clean, 10 people had ticked the always box, with three people ticking the usually box. Discussion with people and their relatives during the inspection also told us, the home is always clean and tidy, the cleaners are always in and out, and there always toilet rolls available. Care Homes for Older People Page 29 of 39 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 using this service are supported by a staff team that are available in sufficient numbers and who are trained, skilled and competent to do their jobs. Evidence: Information provided in the AQAA and verified at the inspection confirmed, St Josephs has a very dedicated team of staff, many of who have been employed at the home since it opened. The duty roster reflects the home is staffed twenty fours a day, seven days a week. The normal staffing ratio is 12 staff between the hours of 8am and 2pm, and 10 staff between the hours of 2 to 10pm. These figures include a senior care officer and senior care assistant on each shift. Staff are split between the two units, normally 5 staff to each unit, however staff confirmed this depends on the needs of residents, and staff will swap, they are not restricted to set numbers. Nights are covered by 4 awake staff between the hours of 10pm and 8am. There was evidence from the staff rota, discussion with residents and staff that staffing levels are well maintained. We received 6 staff Have Your Say surveys, which told us 5 staff thought there are enough staff to meet the needs of the people using the service, one person did not make a comment. Care Homes for Older People Page 30 of 39 Evidence: The AQAA states staff are very keen to improve their levels of training and understanding of their roles. All 6 staff surveys told us, they received good training and support to ensure they have the skills and knowledge to do their jobs and to meet the different needs of the people living in the home. Training courses are held internally and externally, privately and college based. Some of the training is mentored in house, through written and verbal questioning, and externally assessed and formally accredited. Staff also attend conferences and care shows, and have access to e learning (computer based training). Subjects available to meet the specific needs of the residents include stoma care, falls, Parkinsons, continence, epilepsy, non violet intervention and neurological disorders. Records, discussion with staff and information provided in the AQAA reflects the most recent training has included moving and handling, dementia care, food hygiene, first aid, safeguarding adults, mental capacity, deprivation of liberty, health and safety, risk assessments, control of substances hazardous to health, medication, infection control, customer services, principles of care, falls and prevention and food safety management. St Josephs has 44 permanent care staff, 29 staff have completed an NVQ 2 or above. These figures reflect the home has 65 per cent of staff who hold a recognised qualification, which is above the National Minimum Standard (NMS) 50 per cent. The AQAA reflects more staff have been enrolled to take higher level awards, which has become normal practice with several staff gaining level 3 and now working towards level 4. Discussion with the director of care services and the manager confirmed training is given priority. Seniors are to attend training in September, run by dementia care matters, which will provide an holistic approach to dementia care. A traffic light system is used on the computer, which indicates amber when training is due. The organisation has a rolling programme of mandatory training and has access to distance learning through local colleges. Comments received in residents surveys confirmed the staff are always very friendly, helpful and very caring. Discussions with staff and observation of their actions with residents during the inspection confirmed this. One member of staff commented, it can be difficult to communicate with people with dementia, they described how peoples moods could change, happy and bouncy, and then sad. They demonstrated a real feelings based approach to support the individual by, sitting with them, offering them cups of tea, reassurance and comfort, and trying to encourage happy memories. The AQAA reflects the home has a robust recruitment processes in place, to select the right candidate and to protect the people living in the home. All 6 staff surveys, records seen and discussions with staff confirmed they had been recruited fairly and all relevant documents and recruitment checks, required by regulations, to determine the fitness of the worker had been obtained prior to them commencing employment. Care Homes for Older People Page 31 of 39 Evidence: Carefore Homes Ltd has their own induction processes for care staff, which meet the Skills for Care, Common Induction Standards (CIS). Records seen and staff spoken with confirmed they had received a very good induction, which included an orientation tour of the home, introduction to care home procedures, health and safety issues, personal care, and moving and handling. 3 staff ticked the box always and 3 ticked the box usually in response the question, if their induction covered everything they needed to know to their job. Additionally staff spoken with confirmed they had received a good induction, one person told us, I feel my induction and training is ongoing, we are on a constant learning curve. Discussion with staff during the inspection told us, they enjoy working in the home, comments included, I enjoy coming to work the residents are lovely, and I have worked in 3 different care homes and this is the best and I can not think of anything to improve, we have a very good staff team, we never use agency, all of the staff are flexible and will cover for each other. Other comments included, I have worked here since the home opened, we had days and days of training, and got to know building before people moved in and we get a lot of training and staff are happy here, we are a contented workforce who work to a high standard, I cannot think of anything that could be done better. Another person commented, I have worked in many residential homes, working at St Josephs is the best. I would like my grandparents to come here, I would recommend St Josephs. Care Homes for Older People Page 32 of 39 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect and is run in the best interests of the people living there by a competent and qualified manager. Evidence: Lorraine Hodges is the registered manager of the service. They have a range of qualifications to support their position as manager, which include the Registered Managers Award (RMA), National Vocational Qualifications (NVQ), levels 2, 3 and 4 in care, NVQ assessors award and a 1 year diploma award An emotional Journey, accredited by Surrey university. The director of care services provided information in the AQQA about the management of the home. They commented that the manager has worked tremendously hard to achieve their own personal goals as well as those of the organisation. They also comment that the manager has a strong sense of loyalty and duty to the residents, staff and the company, and is constantly looking at ways to Care Homes for Older People Page 33 of 39 Evidence: improve the service. Information received in the Have Your Say surveys and discussion with residents also provided positive feedback about the manager, comments included, the manager is first class, no one could wish for better, they are very patient and the manager has an open door policy, I can approach them or the seniors if I have any concerns. Staff told us, St Josephs has a very good manager, they are supportive and understanding, they spend a lot of time with the residents and their families and us, and we have support from the manager I find them very understanding and they always put the residents first, they undertake activities with residents, including in their own time, which I admire. The AQAA reflects there have been changes to the management structure, within Carefore Ltd, with additional posts created. The creation of the Operations Manager and designated administrative support has meant that the roles and responsibilities have been re defined, reducing some of the pressures on managers of the services. Monthly managers meetings have given managers the opportunity to meet, with the director of care services and to share ideas. The manager completed and sent us their AQAA when we asked for it, it contained excellent information about the service, which supported evidence found during our inspection. The AQAA reflects a high level of understanding about the importance of equality and diversity and evidence to show they listen to people living in the home and consult with relatives. The AQQA clearly demonstrates where the home has improved and what further improvements they intend to make to further enhance the the service, they are currently providing. The Director of care services makes regular visits to the home as part of these organisations commitment to monitoring quality and performance and to ensure that people living in the home receive the very best in service and care. They meet with residents, families, staff and other residents representatives during these visits, taking into account all of their views including noting what the home does well and also areas that could still be improved. Additionally, surveys are sent annually to obtain residents and relatives perspective of the service. These are currently provided in tick box format and the manager confirmed they are looking to develop these to make them more user friendly. People using the service are provided with opportunity at regular residents meetings to have their say about how the service is being run and managed. The minutes of the meetings are then made available to residents. Staff join these meetings to ensure that people are provided with the opportunity to have their say and express their Care Homes for Older People Page 34 of 39 Evidence: opinions, particularly those with communication difficulties. The AQAA reflects yearly relatives and residents meetings are also held, these again are formal meetings with a specific agenda and minutes produced. Relatives, friends, residents and residents representatives are encouraged to submit details of what they would like placed on the agenda. This ensures that every individual is given the opportunity to share their views and concerns on what we do well and also what areas they would like to see improvements in. Handling of peoples individual finances were not inspected on this occasion, however the AQAA provided detailed information of the processes in place to ensure residents financial interests are safeguarded. As part of the new management and support structure the AQAA reflects personal finances are now handled centrally at Blackbrook House, another Carefore run home. Cheques are cashed through the residents personal finance cheque account operated by the administration department. A small amount of cash does remain on the premises of St Josephs and invoices for hairdressing, chiropody, manicures, newspapers etc are sent to Blackbrook House and paid from the residents cheque account. Accounts and statements are sent out on a monthly basis to the person who manages the resident personal finances. The accuracy of the residents money confirms that this was the most efficient and secure way of managing this aspect of the service. Records seen, discussion with staff and feedback in staff Have Your Say surveys told us that staff feel supported to do their jobs. 5 staff ticked the box always and 1 ticked the box usually in response the question, do you get enough support from the manager and meet to discuss how you are working. Staff commented, I get good support from the manager and director of care services, who is often at the home and I receive regular supervision and supervise care staff, we are will supported. A certificate was seen in the entrance hall, reflecting Babergh District Council, yearly visit to the service, to inspect food safety and management. They have a scoring system referred to as scores on the doors, which reflected that St Josephs had received a positive 4 star rating, out of a possible 5. The home takes steps to safeguard the health, safety and welfare of people living and working in the home. Risk assessments are carried out for all safe working practices with significant findings recorded and the action taken to minimise risks occurring. The most recent gas, electrical safety certificates, including Portable Appliance Testing (PAT) were seen and records showed that all equipment is regularly checked and serviced. Certificates confirmed the passenger lifts and moving an handling equipment is being regularly serviced as per the manufacturers recommendations in line with the Lifting Operations and Lifting Equipment Regulations (LOLER). The fire logbook showed Care Homes for Older People Page 35 of 39 Evidence: that the fire alarm, emergency lighting and fire fighting equipment is regularly serviced. Emergency lighting and the fire alarm system are tested weekly. Care Homes for Older People Page 36 of 39 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 37 of 39 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 38 of 39 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 39 of 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!