Inspection on 24/08/05 for Aldergrove Manor Nursing Home

This inspection was carried out on 24th August 2005.

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

Aldergrove Manor Nursing Home 07/04/10

Aldergrove Manor Nursing Home 14/01/10

Aldergrove Manor Nursing Home 18/08/09

Aldergrove Manor Nursing Home 18/09/07

Aldergrove Manor Nursing Home 25/07/06

Aldergrove Manor Nursing Home 14/03/06

Aldergrove Manor Nursing Home 18/01/05

Aldergrove Manor Nursing Home 18/08/04

Aldergrove Manor Nursing Home 15/03/04

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Inspirations

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Aldergrove Manor 280a Penn Road Penn Wolverhampton WV4 4AD Lead Inspector Rosalind Dennis Unannounced 24 August 2005 11.00 th 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. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Aldergrove Manor Address 280a Penn Road, Penn, Wolverhampton, WV4 4AD 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) 01902 621840 01902 621841 Southern Cross Healthcare Mrs Debbie Rowley Older People 70 Category(ies) of Dementia (19) registration, with number Old Age (27) of places Physical Disability (17) Terminally Ill (7) Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) The home may accomodate up to 34 elderly persons requiring nursing care of which up to 7 persons may require palliative care. 2) Ground floor nursing / palliative care unit (34 beds). Date of last inspection 18.01.05 Brief Description of the Service: Aldergrove Manor is owned and managed by Southern Cross Healthcare Ltd. The manager is Mrs Debbie Rowley and the Operational Manager is Ms Julie Preston. It is a purpose built, two storey building, standing in it’s own grounds and is situated on the outskirts of the city of Wolverhampton. The home is set back off the main road on one of the main routes into Wolverhampton. It is on a main bus route, close to the cities railway system and within easy access to local shops and community facilities. All 71 bedrooms are single with en-suite, some of which have interconnecting doors for couples. Since the last inspection in January 2005 the structure within the home has changed and the home now consists of a 19 bedded unit for older people with dementia, a 17 bedded unit for younger adults that have physical disabilities and a 34 bedded nursing unit which includes allocation of 7 beds for palliative care. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 24th August 2005 and lasted for a period of six and a half hours. The inspection included a tour of the three units within the home, observing activity, looking at care records and observation of documents. During the inspection the inspector spoke with five residents, four relatives and staff that work at the home. The manager was not on duty on the day of inspection, however the deputy manager and other staff on duty offered their fullest co-operation throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that wound care records are kept under review and amended as necessary to ensure that staff are fully aware of individual resident’s needs. To ensure that the home has a robust recruitment procedure the registered person must audit all staff files to ensure that all necessary pre-employment checks are undertaken and records of these kept within each staff file. During the inspection two residents and three relatives raised concerns that since the development of the units within the home, staffing levels and Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 6 competence of staff on the nursing unit has changed. Although staffing levels were found to meet the home’s registration requirements, further discussion and review by CSCI will be undertaken. 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. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 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, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 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. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) 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. (YA NMS 4) 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) 3 The home has a satisfactory admissions procedure that provides for an effective needs assessment for each resident. EVIDENCE: A random selection of care files from each unit within the home demonstrates that residents’ care needs are appropriately assessed prior to and on admission to the home. In addition to the initial assessment, risk assessments are also conducted and these were present on all files seen for example; nutrition, pressure sore risk, falls risk, moving and handling and risk management plans for residents that are assessed as needing bed rails. Individual files were also observed to contain a life story/social profile of the resident to encourage staff to deliver care in a personalised way. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 9 One resident recently admitted to the Young Physically Disabled Unit (YPD Unit) had signed in his care file to confirm his involvement in the assessment process. This confirmation could not be found in other files seen, however the home has recently changed all care documentation and observation of files showed that staff have had to rewrite and transfer information into new care files. Therefore resident involvement in the assessment process will be assessed again at another inspection. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 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 and 11 Residents have risk assessments and care plans in place that identify their needs and the safe ways to meet them, however by not amending wound care records in a timely way staff may not be provided with all the information they need to fully meet the residents needs. EVIDENCE: A range of care plans and risk assessments were examined from a random selection of files from each of the three units. Care documentation on the nursing floor was examined in detail and a good range of care plans and risk assessments were in place on all files seen that Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 11 had been reviewed on a regular basis. Visits by other healthcare professionals such as speech and occupational therapists were recorded in some resident’s files indicating that specialist advice is sought appropriately. Information regarding the care given on a daily basis is contained within files that are kept in residents’ rooms. Three relatives spoke positively regarding this system stating it was nice to be able to look in the file when they visit to confirm the care that had been given. One resident also stated she regularly looks at her own file. The home is planning to implement routine 6 monthly reviews with residents and their relatives to enhance communication. Files on the YPD Unit and Dementia Care Unit also contained a range of care plans appropriate for the resident. One file examined on the Dementia Care Unit detailed that the resident had a leg ulcer however a record of the last wound dressing change could not be found within this residents care file. This could cause confusion to a member of staff not familiar with the resident and therefore could result in the residents needs not being met. A discussion with a member of care staff also indicated that senior care staff have attended wound care courses and perform some wound dressings. Both issues were brought to the attention of the deputy manager for clarification and action. During the inspection a healthcare professional visited to talk with staff on current developments with palliative care and she spoke positively regarding the home’s involvement and enthusiasm in ensuring that staff are up to date with these developments in order to enhance the care of individuals requiring palliative care. Sufficient staff working within the home have a recognised palliative care qualification and additional specialist support and guidance is provided by community hospice staff as required. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 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. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 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) 13 The home’s policy on visiting encourages and enables residents to maintain contact with their families and their friends. EVIDENCE: Three residents confirmed that they regularly had visitors and felt that their visitors could visit at any reasonable time of the day. Observation of documents regarding a recent incident that occurred at the home demonstrates that the manager seeks appropriate advice prior to imposing restrictions on visiting. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) 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 The home does have a complaints procedure although further consideration is needed regarding the location of the procedure to ensure it is visible to all. EVIDENCE: A recent anonymous caller to CSCI had discussed that she was unaware of the homes complaints procedure. A relative visiting the home on the day of inspection and a recent anonymous caller to CSCI stated that they were unaware of the homes complaints procedure. Observation during the inspections identified that the complaints procedure in the main reception area had been removed whilst this area was decorated and although a copy of the procedure was available on another notice board it was not clearly visible to visitors to the home. The manager is advised to reconsider the positioning of the complaints procedure to ensure it is visible to all. Residents reported that they would notify the manager or deputy manager if they were unhappy with any aspect of their care. Two residents and one relative reported to the inspector their dissatisfaction with the laundry service in that items of clothing regularly go missing and this was brought to the attention of the deputy manager for investigation and action. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 14 During the inspection two residents and three relatives expressed their concern regarding recent changes within the structure of the home and this is covered in a later section of this report titled “Staffing”. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 15 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 live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) 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 and 26. The standard of the environment in this home is good providing residents with an attractive, clean and homely place to live. EVIDENCE: A full tour of the home was not undertaken, however a random selection of individual and communal rooms were observed to be clean and decorated to a satisfactory standard. Two residents on the nursing floor and two residents on the YPD unit spoke of their satisfaction with their bed –rooms and with the level of cleanliness throughout the home. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 16 The home communicates effectively with CSCI and the local infection control team during outbreaks of infectious illness and the deputy manager also attends regular meetings with the local infection control team to keep up to date with current developments regarding infection control. Observations made during the inspection confirmed that systems are in place to control the spread of infection and staff were observed utilising appropriate protective clothing when necessary. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. 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) 27 and 29. Although staffing levels within the home meet requirements of registration further review of the staffing structure within the home is needed to ensure that all residents needs are met. The procedures for the recruitment of staff are not robust which could potentially result in the employment of inappropriate staff. EVIDENCE: The minimum required staffing levels for the nursing unit and dementia care unit are documented on the homes CSCI registration certificate in the reception area. The staffing levels for the YPD Unit are not documented but were confirmed as: 4 care staff morning and evening and 2 care staff at night. During the inspection one relative visiting the Dementia Unit commented favourably regarding the new structure of the home. Two residents on the YPD Unit reported that the level and competence of staff on the unit was sufficient to meet their needs. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 18 A recent anonymous caller to CSCI had expressed concern regarding the levels and competence of staff on the nursing unit, two residents and three relatives also spoke of similar concerns during the inspection and were very specific in their view that these changes occurred when the units within the home were created. The two residents commented that although the care was generally good they felt that staff appeared rushed in their work and had less time to spend with them, relatives commented that senior care staff had been moved to staff the new units. Observations made during the inspection and discussion with senior staff identified that 7 older residents requiring nursing care are still located on the YPD unit and nursing staff from the nursing unit are overseeing their care. Although observation of the duty rotas and discussion with the deputy manager demonstrates that the home has attempted to compensate for this by exceeding the minimum required level of care staff by one, comments made both before and during the inspection have prompted further review by CSCI regarding the staffing structure of the new units. In view that some staff are now caring for a different age range of residents it is recommended that staff have access to and are made aware of the specific National Minimum Standards relevant to their work area. A sample of three staff files identified deficits in the homes recruitment practice as two files contained only one written reference per employee. All other required pre-employment checks including obtaining a CRB disclosure prior to commencement of employment had been completed. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 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. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 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) X EVIDENCE: Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 20 The above standards were not inspected during this inspection, however the environment was observed during the inspection to be safe and secure. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 21 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 x 2 x 3 3 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 3 x x x x x x 3 Score Standard No 7 8 9 10 11 Score 3 2 x x 3 Standard No 27 28 29 30 3 x 2 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x x MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x 37 x 38 x Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 22 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. 2. Standard OP 8 OP 29 Regulation 17 Requirement Timescale for action 1/10/05 Wound care must be recorded in the residents plan of care and reviewed on an ongoing basis. Regulation The registered person must audit 1/10/05 19, all staff files to ensure that all elelements as required by Schedule 2. Schedule 2 of the Care Homes Regulations 2001 are obtained prior to employment and contained within each file. (Previous timscale of 26/02/05 not met). 3. 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 16 27 Good Practice Recommendations The manager is advised to reconsider the postioning of the complaints procedure to ensure it is visible to all. It is recommended that staff working within the home have acces to and are made aware of the specific National Minimum Standards relevant to their work area. Aldergrove Manor E56 000017175 Aldergrove Manor v246695 UI 240805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 2nd Floor, St Davids Court Union Street Wolverhampton WV1 3JE 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. Extracts may not be used or reproduced without the express permission of CSCI. 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