Care Home: The Sycamores Nursing Home

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What the care home does well The home has good pre-admission procedures. People`s needs are assessed before they move in and they are given the opportunity to visit the home to see if it is the right place for them. It was clear during the inspection that the staff know and understand the needs of each person and do everything they can to support people`s needs. People`s right to make individual choices is respected and supported. We observed interaction between people who live at the home and the staff, as friendly without being overly friendly. The home keeps us informed of any significant occurrences affecting the health and well-being of the people who live at the sycamores. People`s views are taken into consideration with regards to any decisions that are made. What has improved since the last inspection? Since the last key inspection written records are in place to show that fire safety checks are carried out weekly. This mean that people and staff are safe. The home has improved their recruitment and selection systems with detailed information that is enough to justify how decisions have been reached for the protection of people and in the interests of equal opportunity for prospective employee. There is rolling programme for redecoration and replacement in place for the premises. What the care home could do better: People`s information must be stored properly so that it is only accessible to staff on a need to know basis. Although all staff receive and have the opportunity to receive training in line with the regulations, some consideration should be given to providing nurses employed at the home with training that meets with the requirement of the NMC (Nurses and Midwifery Council). Which mean that they update their nursing knowledge for them to continue to practice and carry out their duties as a nurse. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: The Sycamores Nursing Home 131-133 Harehills Lane Leeds Yorkshire LS8 4HZ     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: Valerie Francis     Date: 0 7 0 4 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 Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 27 Information about the care home Name of care home: Address: The Sycamores Nursing Home 131-133 Harehills Lane Leeds Yorkshire LS8 4HZ 01132406446 01132407997 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: European Care Lifestyles (B) Ltd care home 18 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home The Sycamores Nursing Home is in two adjoining Victorian houses which have been converted to provide accommodation for 18 people with a mental illness. It is situated in the Harehills area of Leeds close to the busy junction of Harehills Lane with Roundhay Road and a range of local amenities. There is a small garden and courtyard parking area to the rear of the building. The facilities are spread over four floors and there is no lift, therefore the home is only suitable for people who are mobile. Three bedrooms are shared and 9 of the single rooms are less than 12 sq mtrs in size. None have en suites facilities. 18 Over 65 1 Care Homes for Adults (18-65 years) Page 4 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced visit by one inspector who was at the home from 10:00 am until 5:30 pm. During the inspection all of the key standards were looked at to assess the standard of care that people receive. The inspection process included looking at the information we have received about the home since the last key inspection. The purpose of the key inspection is to make sure the home is operating and being managed for the benefit and well being of the people who live there. During the visit we spoke to people living in the home, staff, management team and any visitors. We looked at the running of the home, care plans, risk assessments, healthcare records, meeting minutes, staff recruitment, training records and the premises were looked at. An annual quality assurance assessment (AQAA) was completed by the home and this information was used as part of the inspection. Surveys were sent to people and staff. Care Homes for Adults (18-65 years) Page 5 of 27 The current fees for care are between five hundred and twenty seven pounds and eighty five pence to nine hundred and fifty eight pounds and ninety five pence per week. Personal toiletries and clothing, chiropody, hairdressing and transport for social outings are not included in the fees. Feedback of the findings of the inspection was given to the manager and deputy. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? What they could do better: 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 Adults (18-65 years) Page 7 of 27 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home carry out a thorough pre-admission assessment before a placement is offered. There is also an introduction procedure, to make sure the home is able to meet their needs. Evidence: We were told that the referring agency is given a copy of the homes statement of purpose which is then passed on to the person. They then have the opportunity to make a decision if they want to move into the Sycamores. We were told that the information can be made available in other languages. Where possible the home encourages people to visit the home before reaching a decision. We looked at the information received from the referring agency for the last person who moved into the home and found that the home is given up to date and comprehensive information about the person. This means that the home can make a decision about the person moving in. People told us It was a good move because they gave me a choice. We saw information that made us come to the conclusion that the home looks Care Homes for Adults (18-65 years) Page 9 of 27 Evidence: carefully at the health, care and support needs of people, staff training and the needs of the people in the home. The manager said before they invite people to visit, the home is given background information or any previous assessment information from the referring agency. The manager or deputy manager will visit people to carry out an assessment and make sure the home can meet their needs before offering a place. Further assessment is made when people visit the home for a meal or for an over night stay. Care Homes for Adults (18-65 years) Page 10 of 27 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To maintain their autonomy and independence, staff support people to make choices and decisions about all aspects of their daily lives. People are involved in the planning of their care and they get the level of care and support they need in a way they prefer. Evidence: Three individual care and support plans were looked at. They show that people are involved in developing and reviewing their plans. The plans reflect the individuals preferences and needs and clearly show the persons involvement in making all the decisions that affect them. The plans reflect peoples individuality and contain sufficient details to assist staff and help them to understand each person. Care Homes for Adults (18-65 years) Page 11 of 27 Evidence: Everyone is supported and encouraged to make their own choices about how they lead their lives. The care plans reflect this and show that people are supported to achieve their goals. Those who commented confirmed that they get support to live the way they choose and agreed that the service meets their different needs. There is on going review of plans, to make sure they always reflect any changes in their health and support needs. An assessment is made of any activity that is seen to be a potential risk; plans are in place to manage and minimise the risk. This means that people are supported to have their rights, independence and choice. These assessments are reviewed and kept up to date. There is ongoing monthly review of peoples care plan, to make sure that any changes in their care are reflected in their plan. From discussions with people, staff and the evidence seen, it was clear that staff support people to maintain their independence and improve the quality of their lives. During our discussions and observation of staff interaction with people, it appeared that staff know and understand the needs of each person who lives at the Sycamores. We observed that staff do all they can to promote peoples independence and autonomy and everyone is treated as an individual. From conversation with people and information in the surveys it was clear that peoples personal choices are respected and supported. People told us it is good they give you the opportunity to do what you want, the nurses and staff are always good to me. People are supported to meet their individual cultural and spiritual needs. Confidential information about people is only shared with those staff who need to know. We spoke to staff about sharing information, it was quite clear that they understood confidentiality and data protection, and their role in the home. People were confident that their information is handled sensitively. However, peoples information was stored on shelves in the office, it is acknowledged that office has a lockable door and most of the time it is locked. This room is also accessible to people and visitors, which could mean data protection and confidentiality could be breached. Care Homes for Adults (18-65 years) Page 12 of 27 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to follow activities of their choice and are offered a good choice of food to make sure their dietary needs and preferences are met. Evidence: Peoples care plans include information about their choice of recreational and leisure activities and their goals. We found that the activities people follow was what they want to do. People have the opportunity to attend further education classes or take up paid or voluntary employment,if they wish. Some people attend a day centre. There are regular meetings with people to make sure that they are involved in making decisions about the way their home is run. The manager and staff make sure peoples Care Homes for Adults (18-65 years) Page 13 of 27 Evidence: views are taken into consideration with regards to any decisions that are made. During our discussion with people they told us that they are supported to lead their lives in the way they choose. The staff are aware of peoples preferences and the home is run in the best interests of the people who live there. Individual choices about spiritual and cultural matters are reflected in the plans and the staff all know and understand each persons needs and choices. People are encouraged to help with the household tasks and look after their own rooms. One person told us that they like gardening. People also enjoy choosing the meals they would like and everyone makes their own drink. We were told that the home do not carry out nutritional risk assessments for everybody. These are only carried out if there was a concern about the person. However, most people have their weight check monthly. Some consideration should be given to carry out nutritional risk assessment for all people who use the service to make sure that they are not at risk and any risk is identified quickly. Care Homes for Adults (18-65 years) Page 14 of 27 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples personal and health care needs are met, and are protected by the homes medication systems. Evidence: Peoples care plan reflects their choices for all aspects of their life, for example the way people prefer their care and support to be provided is clearly detailed. People told us that staff are very good, they treat us well. We saw records of appointments with health care professionals. We were told that people are supported and encouraged to keep appointments. The home also encourage each person to have their annual health check. Staff work closely with health care professionals to make sure people receive the care and treatment they need. The plans cover each area of the individuals care needs. They all contain enough information to assist staff how to care and support the individual. Care Homes for Adults (18-65 years) Page 15 of 27 Evidence: People said that they always receive the medical and health care support that they need. The home seeks advice about peoples health from health care professionals, and the care plans show that the staff act upon the advice they are given and understand the routines people like to follow. People are supported to be as independent as possible in their daily lives and there are risk assessments in place with plans on how each risk is managed. On the day of the inspection, one person visited their psychiatrist with prompts from staff to attend the meeting, we saw so that staff had some up to date information this person was encouraged if they wanted, to share information about their visit. During the visit, all the staff were seen to treat people with respect and maintain their dignity. People said that they receive the care and support they need, they are supported to maintain their independence and their wishes are respected. The medicines are kept safe and secure and the Medicine Administration Record (MAR) charts are securely stored. Most of the medicines are supplied by the pharmacy in a monitored dosage system, but some are kept in the original packaging. The MAR charts, clearly show the quantities of medicines received and in stock for each person. The medicines supplied in the monitored dosage system appeared to be administered and recorded accurately. There were signatures to confirm that staff had administered the medicine. There is an agreement with people that their medication would be administered by staff. Care Homes for Adults (18-65 years) Page 16 of 27 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at the home know that their concerns would be taken seriously and acted upon. Staff have received suitable training and understand the safeguarding adult policies and procedures, which makes sure that people are safe. Evidence: People indicated in surveys and during discussions at the inspection, that they are satisfied with the service they get at the home. The complaint procedures is available to people, visitors and staff. At the time of the inspection no complaint had been brought to the attention of the CQC. However, a referral had been made to the safeguarding adult unit at Leeds social services and the issue investigated. The home has adult protection policies and procedures with a whistle blowing policy in place which is accessible to staff. The manager had a clear understanding of the procedures and responsibilities for reporting allegations of abuse. Staff were also aware of the procedures, on how to safeguard adults from abuse. The manager has attended protection of vulnerable adults trainer course and most staff have had adult protection training. We saw that, although most staff have access to the organisations policy on violence and aggression and training, it has been some years since they attended the course. All staff are only employed following a satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) first check. Staff have access to the organisations procedure on handling peoples money. A record is kept of all transaction of peoples money carried out by staff. Care Homes for Adults (18-65 years) Page 17 of 27 Evidence: Care Homes for Adults (18-65 years) Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a safe, clean environment. Evidence: We found that the home was clean to a reasonable standard and free from any unpleasant odours. We were told that there is an ongoing programme of refurbishment of the premises. Bedrooms had been personalized by the occupant and reflected the persons interest and taste . On the day of the inspection one person had a new bed delivered that was specially made for him. We found that although the large sitting room had been refurbished and had comfortable chairs; this room still lacks a domestic and homely atmosphere. The smoke room gave an institutionalised atmosphere; we saw people sitting in rows on hard chairs in a room which had no atmosphere. The manager said this is to encourage people to have their cigarette and leave the room quickly. Protective gloves and aprons are available for staff to use when necessary as part of the homes infection control measures. There are sufficient, accessible toilets and bathrooms on both floors of the house. One of the toilets on the first floor needed redecorating and the wood panels around the toilet needed replacing. Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: Care Homes for Adults (18-65 years) Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are trained and competent to meet the needs of the people who use their service. People are protected by the homes recruitment procedures. Evidence: The home provides care to 18 younger adults with mental health issues, who are mainly independent but still requires care and support from staff. The home currently employ 10 care staff and 5 nurses. Staffing levels at the home appeared to be enough to meet the current group of people living in the home. All staff receive induction training, and other training such as moving and handling, health and safety and adult protection. We were given a copy of the homes training matrix which highlighted other training that is offered at the home, such as mental health and violence and aggression. We saw that some staff have had this training sometime ago. We noted that there was no training given on any of the peoples diagnosis, to make sure staff have the skills and knowledge they require to meet peoples care needs. People are protected by thorough recruitment procedures, which ensure that staff are suitable to work with people who live at the home. Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: There are three staff on duty during the day, two in the afternoon Mondays to Friday, two staff Saturdays and Sundays during the day and two waking night staff. We looked at three staff records, all staff had completed an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks were carried out. We were told that no new staff begin work until a satisfactory result is obtained. This means that applicants are safe to work with vulnerable people. The manager and other nurses employed at the home have ongoing updated training but it was not clear how these nurses keep up with the training requirement of the NMC ( Nurses and Midwifery Council). Some of the staff have achieved an NVQ (National Vocational Qualification) level 2 and four have level 3. During discussions with staff they commented that there is on going training, which is discussed at a supervision meeting with their supervisor, and at their annual appraisal. Staff said they had no concerns about their employment at the home. Care Homes for Adults (18-65 years) Page 22 of 27 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed in the interest of the people who use the service who are seen as important and are safeguarded. Evidence: The manager and the deputy manager are both qualified nurses, who have the experience of working with the service user group and have the skills to run the home in the best interests of the people who live there. Peoples information is stored on shelves in the office which is accessible to people and visitors. we acknowledged that this room has a lockable door, but to make sure confidentiality is maintained and data protection is not breached, peoples information must be stored securely. The home helps people to keep their money safe and accurate records are kept of all transactions. All monies are securely stored. The comments made by people and staff support our observations that the home is Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: well managed and run in the best interests of the people who live there. Observations during the inspection visit and comments from visiting professionals confirm that peoples views are valued and taken into account. Peoples views are sought through meetings and informal discussions with the people who live at the home and any health and social care professionals who are involved in peoples care. Quality assurance questionnaires are sent out at ad hoc times, the outcome is displayed on the residents notice board. We were told the information is used to help improve the service provided at the home. The policies and procedures are kept up to date to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. Staff have basic health and safety training. All these measures make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. Care Homes for Adults (18-65 years) Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 25 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 10 So that confidentiality and data protection is not breach, some consideration should be given to have peoples information stored in a lockable cupboard. Some consideration should be given to carry out nutritional risk assessment for all people who use the service to make sure that they are not at risk and any risk is identified quickly. Peoples information must be stored properly so that it is only accessible to staff on a need to know basis. this means the data protection and confidentiality is not breached. 2 17 3 41 Care Homes for Adults (18-65 years) Page 26 of 27 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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