Inspection on 13/04/05 for 5 Fallings Heath Close

This inspection was carried out on 13th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

5 Fallings Heath Close 22/05/07

5 Fallings Heath Close 26/08/04

Similar services:

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Westbourne MHC Westbourne House 5 Fallings Heath Close Darlaston, Walsall WS10 8BT Lead Inspector Rachel Higgins Unannounced 13/04/05 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 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Westbourne Mental Nursing Home Address Westbourne House,. 5 Fallings Heath Close, Darlaston Westmidlands WS10 8BT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 568 8188 0121 568 8188 Accord Housing Association Ltd Vacant Care Home with Nursing 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28/02/05 Brief Description of the Service: Westbourne House is part of a small housing development provided by Accord Housing Association. The building has the appearance of a large detached house and is fully in keeping with the other houses in the close. Situated on the outskirts of Darlaston, it is close to the shops and has good public transport access close by. The home offers nursing care for up to eight adults and older persons with enduring mental health problems. All accomodation is in single rooms on both floors, with communal dining ,lounge, toilet and bathroom facilities.There is a small quiet /smoking lounge on the first floor. A lift is also available. Ancillary support services of catering,domestic and laundry are provided in the home, maintenance is provided centrally by the Association. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on the 13h April 2005. The inspection focused on 12 standards and took approximately seven and a half hours to complete. The deputy manager Mary Grannell was present throughout the inspection. Information was collated from care documentation, case tracking, staff and service user files and a tour of the building. One resident and one staff member were spoken during the inspection. What the service does well: The home has a clear and accessible complaints procedure and has received one complaint, which was responded to within the timescale. There are appropriate policies in place to safeguard residents. Staff receive induction and foundation training. Five out of seven care staff have completed their National Vocational Qualification in care level 2. The home is cheerful, airy and clean with no offensive odours. Furniture and fittings are of domestic style and in good order. Visitors are welcome at any time, residents are able to see them in a variety of areas in the home. Staff help residents fit into the community by encouraging them to visit community services such as cinema, shops, leisure centres and pubs. Residents are encouraged to take part in housekeeping tasks. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6-10 and 18–21) (Standards 11–17) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37–43) Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) not assessed EVIDENCE: Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6-10 and 18 –21 (Adults 18-65) are: 7. 8. 9. 10. 11. • • • • • • The service user’s health, personal and social care needs are set out in an individual plan of care. Including their physical and emotional health needs. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. Service users receive personal support in the way they prefer and require. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 7, 9, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7,8 (older people) and 6,19 (younger adults) Care records and documentation need improving to ensure that the healthcare needs of service users are identified and met. EVIDENCE: Files contained review and outcome monitoring tracking sheets, which cover a number of topics such as independent living, education, training and health. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 10 These are scored and from this assessment care plans are written and implemented. These were not reviewed on a regular basis. Files contained health care plans, but these did not cover all of the identified healthcare needs. In the notes of one service user it was identified that staff were to observe for signs of Congestive Cardiac Failure, shortness of breath; there was no care plan in place or what action should be taken. One care plan stated that blood pressure should be kept within a certain range but there was nothing documented to state what action should be taken if it went above/below this range. In another file there was a profile on the service user, which identified other healthcare needs but this had not been transferred to the care plan. The care plans in the files had been updated on a monthly basis. The care plan for one resident identified that weekly blood pressure should be taken; this has not been done since 25/02/05.There were no care plans in place for social needs. No life profiles. Files contained no social worker reviews. Support plans had not been updated. Residents are allocated a key worker and the resident had signed some care plans. One file contained oral hygiene care plans. Files contained individual and specific risk assessments such as fire, smoking and unsafe in wider community, which had been updated monthly. However there was no nutritional, falls or tissue viability risk assessments even though both service users wish is to lose weight. The home is advised to contact the dietician for advice. One resident has incontinence and the risk assessment had not been updated since 4/07/02.The home needs to gain further advice from the continence specialist nurse. One manual handling assessment also needs to be updated. The home has a multi disciplinary form, which is completed when the resident is seen by a healthcare professional. The home must ensure that this is completed for each visit. The form showed that residents are able to access healthcare professionals. One resident has not seen the dentist or optician, according to the deputy manager this is because she does not wish to. The home must ensure that this is documented in the residents file. One resident has regular blood tests, not every visit or result of the test had been documented. Daily records did not always show continuation of care. The home must ensure that all documentation is securely stored. On the 25/3/05 Diazepam had been handwritten on the Medical Adminstration Record (MAR) sheet. There was no prescription available to check that the dose and timings of these were correct. On the 11/4/05 the time of administration of the medication had been changed by hand from 2200hrs to 1800 hrs. Again there was no prescription available and there was no evidence or documentation in the care notes to suggest that the General Practitioner had been consulted. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 11 – 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Including opportunities for personal development. Service users engage in appropriate leisure activities. Service users maintain contact with family/ friends/ representatives and the local community as they wish. And have appropriate personal, family and sexual relationships. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15, 16 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14,12,13,(older people) and 12,13,15 ,16, (younger adults) Improvements in documentation are required to evidence that resident’s social needs are identified and met. EVIDENCE: Resident’s choice in relation to social interests, leisure, routines of daily living and cultural interests are not documented and there are no social care plans in place. Information regarding activities is not circulated within the home. The home has activity sheets but these are not always completed and do not state what activities were offered or participated in. There was also no evaluation of the activity. Residents are asked if they would like to participate in choosing the menu. One resident spoken to stated that activities were offered and that she chooses what time to go at bed at night. Activities are offered but not daily. Activities included reading, bingo, painting and outings. She had also been on holiday/day trips to Torquay, Weston Supermare and Yarmouth One resident has a job, which he goes to once a week, but there is no plan to improve his employment skills or financial understanding. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 12 Visitors are welcome at any time. Residents can see their relatives/visitors in the dining room, lounge or their bedroom. Relatives and service users are given written information about the homes policy on maintaining relatives involvement. There is no opportunity for relative’s involvement in daily activities or opportunity to meet people or make friends who do not have their illness. Staff help residents to integrate in to the community by encouraging them to visit the cinema, shops, leisure centres and pubs. Staff handle residents pocket money and residents are offered a key to their room. Mail is not opened without resident’s agreement. The resident spoken to stated that not all staff knocks before entering their bedrooms. Residents are able to chose when they wish to be alone or in company. Residents are encouraged to participate in housekeeping tasks but these are not documented. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. Including neglect and selfharm. The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Complaints are handled appropriately and investigated within the timescales. Residents are protected from abuse EVIDENCE: The home has an appropriate complaints procedure; this is displayed on the notice board. A record is kept of all complaints made and the details of the investigation. There has only been one complaint and this was from a resident. This was investigated within the timescales. The staff member spoken to was aware of the complaints procedure but the resident spoken to was not aware of who they would make a complaint to. The home has the appropriate policies in place to safeguard residents. Seven staff has received protection of vulnerable adult training. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. Service users have sufficient and suitable lavatories and washing facilities. Provide sufficient privacy and meet their individual needs. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. And lifestyles. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26, Residents live in a clean and comfortable well maintained property. EVIDENCE: The home is situated at the end of a close and is in keeping with the surrounding properties. It is clean, comfortable and airy. There is a passenger lift and nurse call systems. Furniture and fittings are in relatively good order and are of domestic style. The deputy manager stated that all requirements from the fire and environmental health departments had been actioned. The home is carpeted throughout. The home needs to address the carpet that is lifting at the top of the stairs and the marked lino and bathmat in the bathroom. The home was clean, hygienic and free from malodours. Hand washing facilities, gloves, aprons, liquid soap, paper hand towels were readily available. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 15 Hand washing posters were sited. Mops were not inverted but stored in fluid. There were no alginate bags available for infected linen. No staff had received infection control training. The staff member spoken to was aware of infection control practice. The laundry had paint peeling off the walls; the home must address this to ensure that the walls are impermeable. The laundry is very small and there is no segregated area for clean and dirty washing. There was no cleaning schedule in place and there was no written schedule for the replacement of mop heads. The home has been advised to contact the infection control nurse for further advice. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 36 (Adults 18-65) are: 27. 28. 29. 30. • • • Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. Service users benefit from clarity of staff roles and responsibilities. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28,29,30, Some areas in the procedures for the recruitment of staff need improvement to ensure that residents are safeguarded. Further progress in respect of staff training is required. EVIDENCE: Two files were inspected. No files contained photographs. Both files contained a copy of the passport. The home does not keep copies of the Criminal records or Protection Of Vulnerable Adult check so it was not possible to evidence that staff had commenced employment after receipt of these. The home must ensure that the references written on the application form are those that are obtained and if this is not possible the reasons why are documented. There were gaps in employment history on both application forms. Staff files are audited by head office. There was no evidence that staff had read the General Social Care Code of Conduct. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 17 The deputy manager stated that staff receives induction within 6 weeks of commencement of employment and there are currently 2 staff completing their foundation training. Staff receive equal opportunity training which the deputy manager states includes disability/equality and anti racism training. Staff receive 5 paid training days a year. Training and development assessments are completed at staff appraisals and reviewed 6 monthly. The home has a training matrix. Only two staff have not completed their National Vocational Qualification in Care level 2. Current levels of mandatory training are as follows – only 2 staff have up to date manual handling training. No staff have received infection control training. 4 staff have received medication training. All staff have received food hygiene training. 11 staff are to receive First aid training on the 21st April. Staff receive external fire training every three years and in house training once a year. It was not possible to evidence which staff have received fire drills as there was no evidence of which staff had attended. The home must gain advice from the fire department regarding the number of fire training and drill sessions required per year and ensure that the course content of the fire training is clearly documented. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home and from competent and accountable management of the service. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. Service users are confident their views underpin all self-monitoring, review and development by the home. 32. 33. 34. 35. 36. 37. 38. • The Commission considers standards 33, 35 and 38 (Older People) and Standards 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed at this inspection EVIDENCE: Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 3 x 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 2 x x x x x x 2 Score Standard No 7 8 9 10 11 Score 2 2 x x x Standard No 27 28 29 30 x 3 2 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 x COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x 37 x 38 x Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 schedule 3(3,m) 17 Requirement Timescale for action 15/04/05 2. 8 13(4,c) 12(1a) 13(b 17(3a) The registered persons must ensure that: 1.careplans are implemented for all health and social needs 2. Six monthly reviews with the service user (involving significant others) is undertaken and copies of these are available in the service users file. 3. All files are kept secure 15/04/05 The registered persons must ensure that: 1.Files contain falls,nutritional,tissue viability,manual handling and continence risk assessments 2.Risk assessments are updtaed on a regular monthly basis. 3.Advice is sought from the continence nurse for IT 4.Advice is sought form the dietician for IT and PW 5.All visits/refusals by service users to see healthcare professionals are documented 6.Daily notes show continuation of care 7.If service users do not wish to see healthcare professionals this is documented Version 1.20 Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Page 21 3. 9 13(2) sch 3(i) 4. 12 16 n 12 The registered persons must ensure that 1.Copies of prescriptions are kept 2.Changes to the timings of medication administration is only done in conjuction with the prescribing professional and this is documented. 3.there is a list of up to date medication The registered persons must ensure that 1.Choice and preference is documented for all all routines of daily living 2.An activities programme is implemented 3.All activities participated in are documented and evaluated. 4.Plans are implemented to improve residents financial and employment skills. The registered persons must ensure that 1.support given by staff to service users to maintain family links and friendships are documented The registered persons must address the 1.marked lino and bathmat in the bathroom 2. The carpet which is lifting at the top of the stairs on the landing The registered persons must 1.Purchase aliginate bags 2.Address the peeling paint on the laundry wall 3.Implement a laundry cleaning schedule 4.Gain advice from the Infection Control Nurse As a Care home with Nursing a 13/04/05 30/04/05 5. 13 16m 30/04/05 6. 19 23 30/04/05 7. 26 13(3) 30/04/05 8. 26 23(2)(k) 30/05/05 Page 22 Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 9. 29 sch 2 10. 31 8(1)(a) 11. 38 18a,c,13, 4 23(4) sluicing disinfector must be provided. Previous outstanding requirement The registered person must ensure that: 1.Gaps in employment history are explored 2.photograph is available 3.Copies are kept of CRB and POVA checks 4.References received are those named on the application form and if this is not possible the reasons why are documented. The responsible person must provide details of actions taken to recruit to the vacant registered manager position This is an outsatnding previous requirement The registered persons must ensure that 1.The couse content of delivered fire awareness sessions are documented 2.All staff receive infection control training 3.All staff receive mandatory training 4.Advice is sought from the Fire department with regards to the appropriate number of fire training and drills required The registered persons must ensure that all staff receive protection of vulnerable adult training 13/04/05 30/05/05 30/04/05 12. 18 13(6) 30/05/05 13. 14. Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 26 29 14 Good Practice Recommendations Mop heads are appropriately stored Staff receive individual copies of the General Social Care Code of Conduct Housekeeping tasks undertaken by residents are documented in the individual plan Westbourne MHC E55 S20797 Unannounced Westbourne V220611 130405 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Mucklow Office Park West Point Mucklow Hill Halesowen B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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