Inspection on 24/01/06 for Albert House

This inspection was carried out on 24th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Albert House 28/06/07

Albert House 06/06/06

Albert House 25/07/05

Albert House 09/03/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Albert House 22 Albert Road Colne Lancashire BB8 0AA Lead Inspector Mrs Keren Nicholls Unannounced Inspection 24th January 2006 10:25 X10015.doc Version 1.40 Page 1 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 Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 2 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. 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. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Albert House Address 22 Albert Road Colne Lancashire BB8 0AA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01282 862053 Albert House Residential Home Ltd Mr Peter Alan Perris Care Home 17 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (15) of places Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Within the overall total of 17, a maximum 15 service users may be accommodated requiring personal care who fall into the category of OP (either sex) Within the overall total of 17, a maximum of 2 (named) service users may be accommodated requiring personal care who falls into the category of DE(E) 21st October 2005 Date of last inspection Brief Description of the Service: Albert House is a residential care home providing 24-hour accommodation and personal care to 15 older persons and two (named) older persons who have a dementia. The registered provider Mr Perris, is also the manager. The home is an extended detached house located on the main road in Colne town centre, within easy reach of shops, library, market and other amenities. There is limited on-street parking at the side of the home and across the main road. A public car park is a short walk away. The home has limited parking in the garden courtyard at the rear of the home. There are steps (with handrails) and a ramp to the main front door. There are steps (with handrails) to the back door (accessed through the enclosed courtyard. Outside are lawned front gardens and a private garden at the rear of the home. The home has two ground floor lounges (one with adjoining dining room accessed by two steps) and a separate dining room (adjoining the kitchen), which is the designated smoking area. There is one double bedroom with ensuite and 15 single bedrooms on the ground and first floors. There is a passenger lift to access upstairs and mobility adaptations such as handrails and disabled toilet facilities. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced visit to Albert House in the inspection year April 2005 to April 2006. A total of 9.15 hours were spent on the premises over one and half days. During this time the inspector spoke with 12 of the 17 people who live at the home and looked at written information, including records. The inspector talked to the owner/manager of the home and the staff, looked at communal rooms and with the permission of residents, some bedrooms. Since the last inspection, there had been two additional visits to Albert House in response to complaints raised with the Commission for Social Care Inspection. The manager had complied with the several requirements and recommendations made following these visits. The Social Services Directorate are following up elements of one complaint. What the service does well: What has improved since the last inspection? A ramp has been constructed to the front door, so residents with disabilities no longer needed to use the steps. To help to protect residents from risk of harm, the staff had carried out nutritional screening; risk assessments for prevention of falls and pressure sores; and had made sure that footrests were used with wheelchairs. An issue regarding restraint had been satisfactorily resolved. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 6 The medication practices had improved, with secure medication storage. The manager had continued his NVQ level 4 training, to ensure he had the management and care skills necessary to improve quality of care at the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. 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. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Not everyone had an agreed contract (terms and conditions of residence), to enable them to know what their rights and responsibilities are. Care plans need to improve, to reflect the initial and on going needs assessments and ensure that all needs are adequately met. EVIDENCE: Contracts (terms and conditions of residence) that adequately described the rights and responsibilities of all parties were available. These were reviewed annually as fees change but not everyone had an up to date contract. Although there were good systems for assessing needs prior to people moving into the home, the plans of care for daily living were lacking in the detail necessary for staff to understand how to meet needs in the longer term (see also Standard 7). Some residents’ plans did not contain the initial needs assessments and social histories from the Social Services Directorate. Therefore, new staff particularly did not have full knowledge of some people’s needs. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 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. 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. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Care planning had improved, by ensuring that risks to residents were identified and minimised. However, not everyone’s needs were fully met as some people’s plans did not sufficiently detail how needs were to be met and by whom. Medication practices could improve to ensure safety. EVIDENCE: Inspection of a selection of care plans and discussion with those residents showed that risk of harm had been minimised in respect of nutrition; monitoring of weight; risk of falls; risk of pressure sores and using footrests on wheelchairs. Daily diary records had also improved and described the care and attention that had been given. Residents spoken with thought that staff adequately met their general care and personal needs. Some plans did not identify how some special needs, especially mental health, emotional and sensory needs were to be met. Several residents thought staff had insufficient time and some did not have the expertise to meet these needs. Providing medicines protocols for variable dose and ‘when required’ medicines should reduce the risk of under or over medication, especially of those who buy their own ‘homely remedies’. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. 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. Service users maintain contact with family/ friends/ representatives and the local community as they wish. 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. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The home enabled residents to choose preferred lifestyles and to take charge of personal affairs. EVIDENCE: There was an expectation that everyone would handle their own financial and personal affairs, as far as they were able. Residents said that they had help from families with personal finances and were given copies of fees and payments records. Residents and their representatives had information about accessing independent advocates (in the service user’s guide). People had control over their lives and made choices about staying in their rooms, going out and joining in with activities. One person said “I get up and go to bed when I like and I prefer to watch TV in my room”. Two people made their own arrangements about going out to clubs and getting taxis. Everyone had brought some possessions to personalise their private rooms. Several had TVs and favourite furniture. One element of a complaint involved issues of choice and mental capacity to make informed choices about consent in intimate relationships. Several residents commented they did not think everyone’s choices and feelings were taken into account, especially at mealtimes and in communal areas. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 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. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The procedure to protect vulnerable adults from harm was appropriate, but staff needed training in order for them to understand how to follow the procedure and how to respond effectively to suspicion or allegations of abuse. EVIDENCE: Residents were protected by good financial practices and there was a procedure based on ‘No Secrets’ guidance, which if followed, should help to protect residents from harms. However, not all the staff had read the procedure and staff felt that training would help them to better understand protection issues. The procedure referred to ‘whistle blowing’, but a whistle blowing procedure was not available in the policies file and staff spoken with did not have a clear understanding of what this meant. Poor recruitment practices did not ensure that residents were properly protected (see Standard 29) and staff had a limited understanding of how the Protection of Vulnerable Adults (POVA) register worked. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 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. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 25 The home had an excellent standard of cleanliness and was nicely decorated and furnished. The building and grounds were maintained in good order, providing a comfortable and ‘homely’ environment, appropriate for current residents. Wheelchair storage was hazardous to residents. EVIDENCE: The premises had been improved with a ramp to the front door (making easier access for wheelchair users), new lounge carpets and a new dining table. Residents were happy with the standards and several people said the home was always very clean and they liked their private bedrooms. Albert House does not accommodate wheelchair users (as defined in the National Minimum Standards), but four people needed wheelchairs to move around the home. Wheelchair storage by the dining room door was hazardous as during the inspection three residents knocked against wheelchair handles. To enable privacy, one person requested a bedroom door key. For safety and comfort, hot water and ambient room temperatures should be monitored. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. 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. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 The recruitment and selection process was not robust in all cases and in order to safeguard the welfare of the residents must be improved. The induction and foundation programme for new staff must be followed, in order to meet the health, welfare and safety needs of residents. EVIDENCE: Following sickness, maternity leave and three staff leaving, there had been three new care workers, a cook and cleaner in the last six months. The staff files of three new staff members indicated that the home had not undertaken all the necessary recruitment checks to ensure protection of residents prior to employment. Criminal Records Bureau and Protection of Vulnerable Adults (POVA) checks were requested after staff had started work. Two written references had not been obtained prior to employment. Late checks have been an on-going concern at Albert House. The manager sent for references at the time of inspection and delayed employment pending receipt. Residents generally agreed that staff were “alright”, although some had “odd days”. Three people pointed out that it was sometimes hard for the residents to get to know a staff member and for them to get to know their needs before they left. Induction programmes were available in staff files, but had not been completed. This had the potential to place residents safety at risk and for staff not to meet needs: For example, new staff had not participated in fire drills, were unclear about the fire procedure, had not read all the policies and had insufficient information about some residents’ social histories and care needs. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. 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 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. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 and 38 Limited progress had been made in supervision of staff and quality assurance processes. This resulted in some practices that did not promote the health, safety and welfare of the people using the service. Good financial systems and records safeguarded residents. EVIDENCE: The registered manager had made little progress in meeting recommendations from previous inspections to ensure residents will receive consistent and improving good quality care. For example, systems for consulting residents individually or collectively were not put into action with the result that residents felt that there were significant delays in responses to their comments and requests and more ‘minor’ concerns were “forgotten”. Several residents were concerned and disappointed that the owner-manager’s commitments frequently took him away from daily care and he had insufficient time to concentrate consistently on their day-to-day life at the home. “He’s Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 15 always so busy – its hard to catch him and when you do he has five minutes, then he’s rushing off somewhere”. Several residents commented that they wanted the manager to be at the home to oversee staff care practices. The manager recognised that time was a problem, especially lately, and had plans to alleviate this situation. Staff were informally and sporadically supervised, so residents were not confident that every staff member was competent and promoted the home’s aims and objectives. Although staff training in health and safety issues had been arranged (such as moving and handling), it had not happened and had the potential to place residents and staff at risk. The home had sound policies and procedures regarding service users money and other financial arrangements. The certificate of liability insurance was displayed and there was up to date insurance cover in respect of loss or damage to the assets of the business. The manager submitted a business and financial plan, including a training plan and budget. Current residents did not use the secure facilities that were provided for the safe storage of valuables and monies. ‘Case tracking’ showed that written records of financial transactions and fee payments were kept. Residents spoken with about finances said that they or their families managed their own monies, kept their own personal allowances and paid fees. The manager helped residents to access their bank accounts if they so desired but policy otherwise was for residents to manage their own personal finances. Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 16 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. 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 2 2 2 Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 Requirement Every service user must have a care plan, which sets out in detail how physical and mental health; personal; psychological; emotional and social care needs are to be met. Each service user must be consulted about his or her plan and plans must be regularly reviewed and revised with each person. All staff must be made aware of the protection from abuse procedure and must have sufficient training in order that they may properly protect service users. Safe storage for service user’s wheelchairs must be provided. The registered persons must ensure that thorough recruitment procedures are followed prior to employment, to establish the fitness of persons working at the care home, which include obtaining and checking the authenticity of references, obtaining criminal records bureau checks (CRB) at an DS0000061635.V280263.R01.S.doc Timescale for action 31/03/06 2 OP18 13(6) 31/03/06 3 4 OP19 OP29 23(2)(l) m13(4a) (c) 19(1-7) Sch2 28/02/06 28/02/06 Albert House Version 5.1 Page 18 5 OP30 18(1)(c) 6 OP33 24(1)(3) 7 OP33 24(2) 8 9 OP36 OP37 18(2) 17(1-3) 10 OP38 18(1)(c) 11 OP38 23(4)(e) appropriate level and POVA checks. (Timescales of 31/4/05 and 25/7/05 not met) The manager must ensure that all staff receive training appropriate to their role. For example, this may include care of older people; dementia care; the principles of care; assessed special care needs of individuals (such as sensory impairment and emotional care). The registered persons must establish and maintain a system, (which provides for consultation with service users and their representatives) for reviewing and improving the quality of care at Albert House. The manager must supply a copy of the report of the quality improvement review to the Commission and make a copy available to service users. The manager must ensure that all the staff are appropriately supervised. The registered persons must ensure that all records that are specified in Schedule 2 of the Care Homes Regulations 2001 (information and documents in respect of persons working at a care home) are maintained and kept up to date. (Timescales of 31/4/05 and 31/8/05 not met) The manager must ensure that everyone receives training in safe working practices appropriate to his or her work. This may include; first aid; infection control; health and safety; basic food hygiene; moving and handling and fire safety. Fire drills and practices must be DS0000061635.V280263.R01.S.doc 30/04/06 31/03/06 30/04/06 31/03/06 28/02/06 31/03/06 05/02/06 Page 19 Albert House Version 5.1 held at suitable intervals and that staff and (as far as practicable service users) are aware of the procedure to be followed in the event of a fire, including the procedure for saving life. 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 Refer to Standard OP2 OP3 Good Practice Recommendations The manager should ensure that every resident has agreed a contract (statement of terms and conditions of residence) (2.1). Recommendation carried forward from inspections on 23/4/04, 9/3/05 and 25/7/05: That the needs assessments and the care plans are fully completed with all service users (3.4). Recommendation carried forward from inspections on 23/4/04, 9/3/05 and 25/7/05: That service users care plans should set out in detail the action that needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met (7.2). Plans should be agreed and signed by service users whenever capable and/or their representative (if appropriate and with the agreement of the service user) and recorded in a style accessible to the service user (7.6). Recommendation carried forward from inspections on 23/4/04, 9/3/05 and 25/7/05: The registered provider/manager should ensure staff are knowledgeable about entitlements to NHS services, including the standards for older people in the NHS National Service Framework, (to ensure that service users have information about entitlements and access to advice). (8.13) The criteria for ‘when necessary’ and variable dose medicines should be clearly defined and recorded for all service users using such items (9.3) The manager should continue to review the instructions to DS0000061635.V280263.R01.S.doc Version 5.1 Page 20 3 OP7 4 OP8 5 6 OP9 OP14 Albert House 7 8 9 OP24 OP25 OP30 10 OP31 11 OP32 12 OP33 13 OP36 14 OP38 staff in respect of care support and risk management of those who lack mental capacity in making informed consent choices in intimate relationships. This should be balanced with the rights and choices of other residents. (14.1) Service users should be given their own key to his or her bedroom door (unless risk assessment identifies otherwise) (24.6) The ambient temperatures in bedrooms should be monitored, to ensure they meet the needs and wishes of individual service users (25.1) Recommendation carried forward from the last inspection on 25/7/05: That induction training specific to role is carried out within the first 6 weeks of employment (30.1) Recommendation has been brought forward from previous inspections: That the registered provider/manager completes his NVQ level 4 course in care and management (31.2) Recommendation carried forward from last three inspections: That the registered provider/manager evidences how management planning and practice encourages innovation, creativity and development (32.5). Recommendation brought forward from several previous inspections: That the arrangements for reviewing the quality of care at the home are maintained, by for example, publishing the results of the service users questionnaires (33.4); using feedback from service users to inform planning decisions (this may be from formal and informal meetings) (33.6); seeking the views of staff, family, friends and other stakeholders about how the home is achieving goals for service users (33.7); and progressing action to implement the requirements and recommendations identified in inspection reports (33.10) Recommendation carried forward from the last two inspections: That the registered persons implement a programme of staff supervision sessions, at least 6 times a year, which covers all aspects of practice, the philosophy of care at Albert House and career development needs (36.2 and 36.3). Recommendations carried forward from previous inspections: a) All care staff should receive accredited moving and handling training, fire safety training, first aid and training in infection control. In addition, all persons who handle food should have at least basic food DS0000061635.V280263.R01.S.doc Version 5.1 Page 21 Albert House hygiene training (38.2). There should be a qualified first aider on every shift. The cleaner should have training in infection control. b) That regular recorded tests are undertaken to ensure pre-set valves to regulate hot water are working correctly (38.3) c) Carry out COSHH risk assessments (38.4) d) Ensure that all staff receive induction and foundation training and updates to meet TOPSS specification on all safe working practices (38.9) Albert House DS0000061635.V280263.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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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