Care Home: The Minstrels Nursing Home

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What the care home does well The people living in the home live in clean, comfortable, well maintained and safe accommodation. They are well cared for by a well managed, educated, committed and competent care team. Those people who were spoken with expressed satisfaction with the care and service provided by the home. All people are assessed before entering the home and there is a recreational and activity programme provided which provides stimulation. There is a thorough assessment and review of care with wherever possible the involvement of each person and or their relative/family. There is a comprehensive programme of education provided which ensures that staff know how to care and support the people living in the home. What has improved since the last inspection? They have improved the range of activities provided in the home as a result of discussions with the people living in the home. They have increased the levels of equipment provided which has made it easier and safer to care and support people who are confined to bed. They have increased the amount of training provided to meet the diverse needs of the people living in the home and further developed the skills of the staff. As a result of this 80% of care staff have obtained a nationally recognised qualification. What the care home could do better: There were no requirements as a result of this inspection. The management team acknowledge that the home is going through a period of change. They intend to review and train staff about introducing a more person centred approach to care. In line with this new care records will be introduced. In addition training will be provided about the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. We have recommended that they address this issue and choice in care plans. They carry out regular quality assurance monitoring audits and surveys. They continue to be proactive and keen to introduce new methods and approaches to care and support. Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Minstrels Nursing Home 90 Sleaford Road Boston Lincs PE21 8EY     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: Tobias Payne     Date: 2 1 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for 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 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: The Minstrels Nursing Home 90 Sleaford Road Boston Lincs PE21 8EY 01205369235 01205358515 sandra.copeland@the-minstrels.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Minstrels Healthcare Ltd care home 48 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The category PD applies to one service user aged 60 who is named in the notice of proposal to register dated 18th May 2005 The home is registered to provide personal care for service users of both sexes whose primary needs falls within the following categories: - Old age, not falling within any other category (OP) (48) Physical Disability (1) The maximum number of service users to be accomodated is 48 Date of last inspection Brief description of the care home The Minstrels Nursing Home is registered to nursing and personal care for 48 people. On the day of the inspection there were 21 people receiving nursing and 16 personal care. The home is on a main road in a residential area of Boston, approximately one mile from the town centre. It is on a bus route and parking is available in the grounds of the home. The building is modern in design and laid out over two levels, served by a shaft lift. On the same site is a separately registered care home providing personal care for 47 older people and 28 independent living apartments. Each service overlooks Care Homes for Older People Page 4 of 28 Over 65 48 0 0 1 Brief description of the care home a large, landscaped central lawn with mature trees and shrubs with walkways. The Minstrels is owned by Retirement Villages Ltd. The philosphy of the home is we believe in the promotional maintenance of the care values base which includes the rights, responsiblities, equality, diversity and confidentiality of all residents residing here. There are 5 double, 38 single bedrooms of which 29 are en-suite. There are a variety of sitting areas, 2 lounges and one large dining room. The fees at our inspection visit on the 22/1/2009 ranged from £351 to £499 a week for people with a contract for care funded by Lincolnshire County Council. For those people who were self funding fees ranged from £358 to £444 each week. Extras were for hairdressing which ranged from £4 to £25, chiropody £5, manicure £5, aromatherapy £6.50p, toiletries and personal newspapers and magazines. Information about the home including a copy of the last inspection report, the statement of purpose and service users guide can be obtained from the management of the home. Care Homes for Older People Page 5 of 28 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: This key inspection was unannounced and started at 8.10 am. It was carried out using a review of all the information available to us about The Minstrels Nursing Home. This inspection took place over 6 hours. We spoke with 10 people living in the home, 3 visitors, 5 staff, the site/manager and the area manager of the company who was visiting the site during the inspection. On the day of our inspection visit the manager for the home was not available but we were assisted by a senior member of staff in charge of the home. The main method of inspection was called case tracking. This involved selecting 2 people and tracking the care they received through the checking of records, discussion with them, the care staff and observation of their care. Care Homes for Older People Page 6 of 28 We also examined the annual quality assurance assessment (AQAA) that was sent to us by the manager before this key inspection. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the home. It was very clear, accurate and detailed. Before making our visit we asked the people who live there to send us comments about the support they receive. We received comment cards from 6 of the people living in the home. All comments in the main were positive. We also received positive comments from 3 staff. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 28 Care Homes for Older People Page 9 of 28 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 28 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 living at this home receive clear information to suit their needs to enable them or their relatives/advocates to make an informed choice as to whether or not they wish to live in this home. Where a person is referred to the home they receive a comprehensive assessment to ensure that their needs can be met. Evidence: The home had a statement of purpose and service users guide. This was available in two separate folders. Information was clear and detailed and described all the services provided by the home with profiles of all the staff. There was a detailed admission procedure, which described the needs of the people coming into the home. We could see that where a person asked to move into the home the management team would assess them and written confirmation would be sent to show that the home was able to meet their needs. Care Homes for Older People Page 11 of 28 Evidence: Each person had terms and conditions of being admitted to the home. This was clearly outlined in the statement of purpose and service users guide. The home did not provide intermediate care. Care Homes for Older People Page 12 of 28 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. There is clear and detailed care planning system in this home. This and the homes internal audit system ensures that the health and welfare needs of people living in the home are fully met. People are encouraged to make decisions for themselves and be independent with the support and guidance of staff. Medication is safely given by nurses and senior care staff who know what they are doing and are safe in their practise. Evidence: Each person had a detailed care plan outlining their care and support. The care plan had been produced wherever possible with the involvement of the person, their family/advocate and other relevant people. They also had a key worker who was responsible for ensuring their needs were being met and provided a more personal service. The management team told us that they were in the process of introducing a more simple but individual method of recording care and support. The aim being to make Care Homes for Older People Page 13 of 28 Evidence: care more person centred. To enable this to happen staff would receive training before it was introduced. We saw records for 2 people. Each person had a separate file with an admission checklist, admission information, moving and handling assessment, pain chart, body map, risk assessment, family and social background, consent to bed rails, care plans, progress reports, weight, nutrition (using a nationally recognised malnutrition universal screening tool), dietary, oral health and other assessments as required to meet the needs of the person. The care plans were preprinted with space for the name of the person to be hand written. These care plans had goals and needs, desired outcomes and ways of achieving this for normal issues. However where the person had specific care and support needs they could be handwritten and made more individual. Examples we saw concerned how the manage a persons breathlessness or Eczema. We saw that care plans were reviewed each month and that every 4 months there would be a brief report of the persons care following a meeting with the person. Records were signed and dated. We did not see a great deal of information in the care records about choice and decision making. However we could see that this was taking place by way staff in their day to day made contact with the people living in the home and their response. The people told us they had choice concerning their interests activities and lifestyle. Where required, people living in the home were referred to GPs, Community Nurse, Community Psychiatric Nurse, Tissue Viability Nurse, Continence Nurse, Physiotherapist, Opticians, Dentist and Chiropodist. We spoke to a visiting nurse case co-ordinator who told us I have been very satisfied with the approach and knowledge of the staff who have been accompanying me when I saw on the people living here. They asked me if I needed any assistance and waited in a discreet manner. Where possible people were supported to take their own medication independently and at the time of our inspection all the people living in the home needed some level of support to make sure they took their medicines in the way prescribed. Nurses and senior care assistants gave out medication. There was a policy and procedure for medication and there had been a visit by a pharmacist on the 26/11/2008 with no concerns. The report stated the home continues to provide high standards. A full audit was carried out which is satisfactory. The management assessed each person before they were considered safe to administer medication. Records we saw were clear, and well maintained. We also noted that they had introduced a very clear audit trail to show the reasons why prescribed medication had not been given. People we spoke with were satisfied with the way staff cared for them and had confidence in the staff. We saw throughout our inspection staff attended to the people in a warm, friendly manner, knocking on doors before entering their bedrooms and Care Homes for Older People Page 14 of 28 Evidence: asking whether they needed any help. We also noted there was a lot of laughter between staff and the people living in the home. The people told us everyone here is so kind and polite and I find staff so kind and patient. Care Homes for Older People Page 15 of 28 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. Social activities are varied, well managed, creative and provide stimulation and interest for people living in the home. Visitors are made to feel welcome and supported. People enjoy varied and nutritious meals. Evidence: When admitted to the home details were obtained of each persons interests. There was a written programme of activities, which was displayed on the notice boards throughout the home and there was also a monthly newsletter giving details of activities available. Social activities were provided by an Activities Co-ordinator. Activities for the week of our visit included one to one contact, hairdressing (which was taking place on the day of our visit), music and singing, outings to town and Bingo. Each person had a record of activities provided. There was a residents committee which met every 12 weeks. Records were kept of each meeting. We spoke with 2 visitors who told us they could visit whenever they wished and always received a warm and friendly welcome. People in the home also told us that the staff were able to take the people out in wheelchairs to local shops and supermarkets. The home also had a mini-bus for larger groups or longer excursions. Care Homes for Older People Page 16 of 28 Evidence: The people living in the home were offered 3 main meals a day, plus snacks. Menus were on a four-week rota and the people were involved in meal planning. Fresh fruit, vegetables and meat were bought from local suppliers and catering staff were able to change suppliers if they were dissatisfied. Boston Borough Council awarded the home 2 stars (good) in August 2008 following an inspection, in recognition of the catering service provided. The report stated good standard throughout. Catering staff were aware of the dietary needs of the people living in the home and provided soft, liquidised, low fat and diabetic options. Meals were served in the dining room with tables with clean table cloths or in their bedrooms on a tray. We saw staff were assisting those people who needed assistance in a dignified and sensitive manner. All the people we spoke with were complimentary about the food. The menu was displayed on the wall of the dining room. Comments we received included, the food is very enjoyable and I like the food and find it well cooked and staff go out of their way to find something to suit me. Care Homes for Older People Page 17 of 28 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 know how to make a complaint and feel that staff will listen to their views. The care team know how to respond to a complaint and how to act in order to protect the people from abuse. They are protected from abuse by correct and safe recruitment procedures. Evidence: Each person received a copy of the complaints procedure in the service users guide. The information was also on the notice board and in the statement of purpose. These included our new Cambridge Regional office address and phone number. No complaints had been received by the home or the Commission since the last inspection. We and the home had received no safe guarding issues. None of the people living in the home or staff had any complaints about the home and felt they could discuss any concerns with staff or the management. Staff we spoke with knew what to do if they received a complaint from a person living in the home. All staff were correctly recruited including a check by the criminal records bureau (CRB). During their induction each member of staff received information about abuse. We asked 3 staff what abuse was and they all knew what their role was and what to do if abuse was Care Homes for Older People Page 18 of 28 Evidence: suspected. Staff also received regular refresher training to ensure their knowledge was up to date. Care Homes for Older People Page 19 of 28 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 clean, comfortable and safe accommodation. Evidence: The home employed a maintenance worker and had an ongoing maintenance programme. Redecoration had been carried out since the last inspection. The manager inspected all parts of the building every 6 weeks. All faults or deficiencies were reported and acted on at once. During our visit we walked around the home and found all areas of the home we saw were clean, tidy, well maintained. People told us my rooms is lovely, they look after my clothes well and the home is clean and tidy. The home provided an assisted specialist bath, an over bath hoist, grab rails, raised toilet seats and shower seats. All bathrooms, toilets and en-suite facilities were wheelchair accessible. There were a variety of hoists, alternating pressure mattresses and a number of profiling beds for those people confined to bed. We noticed that there were daily records kept of the pressure in the alternating pressure mattresses in order to ensure they were working correctly. People we spoke with told us they were satisfied with the decoration and cleanliness of the home. They also spoke of how they liked their bedrooms. They were encouraged to bring into the home small items of furniture, television, pictures and personal items. Care Homes for Older People Page 20 of 28 Evidence: There was a separate laundry with commercial washing equipment. Care Homes for Older People Page 21 of 28 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. There is a safely recruited, well-trained, supported staff team available who have the skills to meet the varying needs of the people living in the home. A wide range of inhouse training and National Vocational Qualification training is provided. Separate staff are provided for nursing/care, housekeeping, administration, catering, laundry, maintenance and activities. Evidence: People we spoke with felt the home was adequately staffed with people who were experienced and competent to care for older people. People we spoke with did not express any worries about the level or availability of staff. During our inspection visit we saw staff attended to the needs of the people promptly and in a calm and friendly manner. People living in the home told us, although they may be busy they always have time to have a chat, If I need help I can call on them and they will come to find out what the problem is and I am quite satisfied. The management told us they monitored the dependency and varying needs of the people. We examined the files for 2 new members of staff. Records were clear, detailed and showed that staff were safely recruited in accordance with the regulations. This Care Homes for Older People Page 22 of 28 Evidence: included a check by the Criminal Records Bureau (CRB). Each person received an induction programme then a more comprehensive nationally recognised induction. There was a wide range of training provided. This included formal training in care to National Vocational Qualification standards (80 of the staff had achieved NVQ level 2 and a further 3 had achieved NVQ level 3). in addition 2 of the catering staff had obtained NVQ in support services. Training over the last year had included, moving and handling which is provided every year with all new staff receiving training within 3 months of being employed, fire prevention, food hygiene, dementia awareness, safe handling of medicines, nutrition including swallowing, positioning and equipment. In addition, there are mandatory yearly training for health and safety, abuse prevention and first aid. There were 2 staff who were moving and handling trainers. Staff told us they received regular supervision and an annual appraisal. We spoke with 5 members of staff who told us when I started here I received a supported induction which prepared me for my job, I shadowed a member of staff before I started working which eased me into my job, I have since then started NVQ level 2, the work is very hectic at times but we work well as a team and I love working here. Care Homes for Older People Page 23 of 28 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 and staff benefit from the positive leadership of the management team. Management record systems show that peoples health, welfare and safety are promoted. The management team ensures that the people living in the home have the opportunity to voice their views and opinions. The management uses feedback from questionnaires from a number of sources and quality assurance systems to make improvements. Evidence: The manager was a registered nurse with many years of experience in nursing practise and management. She had been the manager of the home for many years. She also had a management qualification. There were detailed policies and procedures, which enabled staff to deliver care and support the people in the home. The company had a policy on equality and diversity. Regular staff and residents meetings were held. We saw staff attending to the people in a confident, knowledgeable, and sensitive Care Homes for Older People Page 24 of 28 Evidence: manner. There was a relaxed atmosphere throughout our inspection visit. People told us, I am very happy here, It is very comfortable and I like being here. Two visitors told us we have been very satisfied with the care and approach of the staff. They have been very kind and supportive. Staff told us I receive regular support, supervision and we have a good team and manager. We looked at the records of three peoples personal allowances and found clear records with receipts and signatures. The company had comprehensive quality assurance procedures. These included 40 completed surveys from the people living in the home in October 2008 which resulted in positive responses. They also carry out an internal quality audit and there was an annual plan for quality assurance. The management carried out internal audits of medication and care plans. They also made monthly unannounced monitoring visits as they were required to do. The company had received the Investors in People award in recognition of its commitment to staff development. The home had a range of policies and procedures and these were regularly reviewed and updated. We found the records very clear and detailed. The company had comprehensive health and safety policies, which also included detailed and up to date risk assessments. There were regular tests of the fire system as well as regular fire drills and monthly monitoring of hot water temperatures. There were also infection control policies and staff made use of alcohol hand rub bottles throughout the home to further prevent infection. Records showed that equipment was regularly checked and serviced and there were systems to monitor any maintenance issues. We found records throughout our visit were available, well maintained and up to date. Care Homes for Older People Page 25 of 28 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 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 3 The manager should ensure that each person has an assessment of their mental capacity in line with the Mental Capacity Act 2005. This will ensure that all the needs of the people coming into the home can be met. In addition staff should receive training in order to ensure they are aware of the implications when providing care and support. The manager should, in the future review of the care record system, ensure that choices of the people living in the home are fully reflected in the individual care plans. 2 7 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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