Inspection on 21/09/06 for Alexander Heights

This inspection was carried out on 21st September 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

Alexander Heights 30/06/09

Alexander Heights 19/08/08

Alexander Heights 05/09/07

Alexander Heights 06/12/05

Alexander Heights 11/07/05

Alexander Heights 17/02/05

Alexander Heights 21/10/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Alexander Heights Alexander Heights Winsley Hill Limpley Stoke Bath BA2 7FF Lead Inspector Alison Duffy Unannounced Inspection 09:40 21 September 2006 st 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 Alexander Heights DS0000028312.V290931.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. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alexander Heights Address Alexander Heights Winsley Hill Limpley Stoke Bath BA2 7FF 01225 722888 01225 723017 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) Avonpark Care Centre Limited Jean Chapman Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: Alexander Heights is a residential care home registered to care for 28 older people. The home is not registered for Nursing Care. Intermediate Care is not provided. The home is located within a Care Village in Limpley Stoke near Bath. The accommodation is on the first floor of a purpose built unit. Access is gained via a passenger lift or stairs. There is a terraced area, adjoining the airconditioned conservatory style lounge. Residents have access, if they are independent or have support, to well-maintained gardens at ground level. There is a small shop, library and a GPs surgery within the complex. Residents have their own room with an en-suite facility. Communal areas consist of the conservatory, a separate dining room, a games room and two lounges. There is a central kitchen and all laundry is undertaken within facilities also used by other units on site. Staffing levels are maintained at three members of care staff on duty throughout the waking day. There are also domestic staff and an activities organiser. The complex provides central catering, laundry and maintenance staff. At night there are two waking night staff and an on call management system. Mrs Jean Chapman is the registered manager. Mrs Chapman has been in post since May 2006. Mrs Chapman has experience of working with older people within a supervisory role. The fees for the home are dependent on the size of the room occupied and the individual needs of the resident. This ranges, on a weekly basis from £580.00, up to £900.00, for a suite, which includes a sitting room. Additional charges for chiropody, hairdressing and personal items apply. Residents are able to pay extra, for additional support, such as individual staff time and specific activity including a walk around the garden. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place initially on the 21st September 2006 between the hours of 9.45am and 5.30pm. The inspection was concluded on the 17th October 2006 between 9am and 5pm. Mrs Jean Chapman, the Registered Manager was available throughout and feedback was given at the end of both days. At the start of the inspection, discussion took place with Mrs Chapman regarding current care provision and the developments made since Mrs Chapman began her new role. The inspector then viewed care planning information, daily records, the complaints log, health and safety information, the fire log book and staffing rosters. A tour of the accommodation was made and the medication systems were examined. On the second day of the inspection, discussion took place with residents and a number of relatives, in the privacy of bedrooms. Staffing information including recruitment and training was also viewed. The management of residents’ personal monies was examined and the inspector observed the serving of lunch. As part of the inspection process, surveys were given to all residents. Comments cards were also sent to each resident’s primary relative, their GP and various interested health care professionals. Many comment cards were returned and a number of relatives contacted CSCI by telephone to discuss various aspects of service provision. While there were many aspects of a positive nature, a number of comments contained negativity. In general terms, these included fees and additional extras, staffing, activity and the condition of the environment. On a positive note, there were many comments made regarding the improvements the new manager has made. One relative confirmed ‘as far as I can tell XX always seems comfortable and well cared for. I have always found the staff I have met to be pleasant and caring. XX seems very relaxed with them. During illness, I was impressed by how caring the attention was that XX received.’ A resident stated ‘I receive all the care I need. The staff are very good and pleasant. The food is good and I have a lovely bedroom.’ Other comments are highlighted within the main text of this report. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 6 Residents are enabled to follow their preferred routines. For example, they are able to get up when they wish, spend time in their rooms and have visitors as they wish. A varied menu is available and clearly displayed. A separate menu is in place for specialised diets. All meals consist of three courses and there is a choice of each meal. GP’s and District Nurses visit the home on a structured basis and as required. Residents therefore gain regular input and their health is closely monitored. What has improved since the last inspection? What they could do better: The current standard of the accommodation is in need of some refurbishment. This includes replacing some carpets and redecoration. Many curtains within residents’ bedrooms require replacing. Some areas of the home, such as residents’ bedrooms, en-suite facilities and the servery, need greater attention to cleanliness. Staffing levels require review, as having three members of care staff, with current dependency levels is minimal. Some relatives choose to fund additional support or individual time with staff. The home has an activities organiser yet due to the amount of hours worked, provision to address residents’ individual needs is limited. Consideration should be given to how external trips out, can be further developed. There are a number of residents within the home at present who have high dependency needs. Some residents choose to receive additional support, to meet their needs at key times. This gives an additional cost to the resident. Further consideration needs to be given however, to ensure the practice of enabling residents with deteriorating health needs, to remain at the home and within Avonpark Centre, does not breach the home’s registration. Care planning information does not fully reflect how residents’ needs are to be met. The documents contain a high level of assessments, which do not give staff information about how required care provision should be delivered. Mrs Chapman is currently addressing this shortfall with an additional care planning format. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 7 Medication requires a greater overview to monitor safe practice. There were some gaps in the medication administration record and an error was noted. Protocols for ‘as required’ medication need to be documented. Discussion should also be held with the pharmacy to ensure that all medications are satisfactorily labelled. Another member of staff should countersign all written medication instructions. 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. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 8 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 Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 9 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): 1, 3, Standard 6 is not applicable Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Sufficient information is given before admission in order to enable residents to make an informed choice. Additional support, which is provided through the relatives’ request, is not fully evidenced. While enabling residents with high dependency needs to remain within the home, careful consideration is needed, to ensure categories of registration are not breached. Further clarity and detail within the assessment process will enable residents’ needs to be met more efficiently. EVIDENCE: As stated earlier in this report, Alexander Heights forms part of a care village. A number of residents commented upon the benefits of this, especially with limiting anxiety. They became familiar with staff so that the transition period of moving to Alexander Heights was easier. Some continue to have a spouse living in another unit. This enables regular visiting. Some residents commented that they were aware of the home and its provision before moving in. Some had previously visited friends. One resident also confirmed that they had Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 10 respite. This was helpful to find out what it would be like to live at Alexander Heights. Another resident confirmed they received a very informative guided tour before their admission. Within comment cards, nine residents confirmed they had sufficient information about the home before moving in. Six residents acknowledged that they had received a contract although three said they hadn’t. One relative confirmed, ‘prior to and on XX’s arrival, Mrs Chapman and staff were extremely friendly and welcoming.’ Other comments about admission included ‘the staff and managers at Alexander Heights and Avon Park have been very helpful. It is positive that differing needs can be met on the same site,’ ‘the staff explained that they would help XX with personal care according to wishes and not impose a routine’ and ‘XX was given a summary of support/activities resources and general facilities available.’ Before admission, all residents require an assessment letter from their GP. Mrs Chapman undertakes an assessment and relevant information is gained from previous placements, as applicable. One discharge summary was viewed and a number of recommendations were in place. These included weekly weight monitoring and a nursing plan for ulcers. Risks were identified in relation to pressure sores and falling. These aspects however were not clearly identified within the home’s assessment. Terms such as ‘TLC’ were stated. The issue of falling out of bed was addressed within daily records when the resident expressed concern. In the interim, a chair was used to reduce this risk. This is inappropriate. The risk of falling out of bed, despite being within assessment documentation, was not identified within the care plan. Mrs Chapman reported that the resident did not mention this concern during discussions that were held during the assessment process. Mrs Chapman also reported that two risk assessments were in place, yet these were not seen. There was a conflict of information whereby the home’s assessment highlighted that night sedation was not required. In the discharge summary this was not so. In such instances, further clarity identifying the apparent reasons for any discrepancy should be stated. Control measures to minimise any risk must also be addressed before admission. Within the inspection it was noted that there were a number of residents who required a high level of assistance with all daily living tasks. This included two residents being in bed at all times. Another resident required full assistance with all personal care and aspects such as feeding. While acknowledged that some residents are waiting for nursing home places within the village, the level of high dependency needs has an impact on service provision. Consideration must be given to ensure that the home’s registration is not breached, as the home is not registered for nursing or dementia care. Mrs Chapman reported that some relatives had asked for the opportunity to purchase additional support for their relative. This was so that their relative could gain benefit from additional, individual staff time. Three relatives have Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 11 now purchased domiciliary support through Avonpark Care Centre Limited. It was reported that any resident may choose to purchase this support from external agencies. Further clarity, regarding this service, is required in the Statement of Purpose. Within comments cards, there was some concern about the perceived high dependency levels within the home. Specific details will be forwarded to Mrs Chapman, so that these can be investigated and addressed as required. Alexander Heights does not provide intermediate care and therefore Standard 6 is not applicable to this service. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 12 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, 9 and 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Care plans contain a high level of information, yet due to the formats, locating key aspects is difficult. This gives the potential for individual needs not to be addressed. Residents have access to regular health care professionals who are based on site. Current systems do not encourage residents to maintain an adequate level of fluid intake. Medication practices need greater monitoring to ensure a safer system. EVIDENCE: The care-planning format recently introduced, contained a number of assessments and rating scales. It did not give attention to how the residents’ care was to be provided. The home could not evidence individual needs and how these were being met. Preferred daily routines were not stated. Some key themes such as post-operative care had not been addressed. It was stated that one resident’s reason for admission was that they were nearly blind. There was no evidence, however of any identified need in relation to their sensory loss. How staff were supporting and managing their needs was also not evident. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 13 Some instructions were apparent, yet there was no explanation for the reason of the required task. It was also not clear, if the task was occurring in practice or how it was being monitored. This included instructions such as ‘encourage hourly fluids’ and ‘needs checking in the night.’ The assessments sometimes highlighted risks such as pressure damage yet control measures were not clear. Some daily records evidenced practice that was not highlighted within the plan. This included ‘turned regularly.’ Mrs Chapman reported that she would adapt the plans accordingly. This would involve adding an additional framework to summarise key needs. Within the second day of the inspection, Mrs Chapman confirmed that staff had worked hard to address a number of issues within the new framework. Following this work, each care plan contained a summary of need, for easier reference. One resident spoke of the difficulty of doing up buttons and the comments from staff about the need of trying to be independent. It was also expressed that only some staff recognise the need for assistance with cutting up food or pouring drinks from a teapot. There was no evidence of this within plans of care. Some terms within written documentation would benefit from greater clarity. For example, there were many times when ‘needs assistance’ was recorded. Subjective terms such as ‘can be aggressive at times’ were also used. Staff are therefore advised to use factual accounts and give clarity within guidelines of required intervention. All plans highlighted a recent date of review. Despite this, in some instances, the documentation did not reflect the resident’s condition. For example, in one instance, a risk of wandering into other residents’ rooms was recorded. In practise however, the resident was immobile. Mrs Chapman was therefore advised to review the reviewing system of care planning documentation. As stated earlier in this report, a number of residents purchase additional support. These arrangements are not documented within care plans. Clear documentation regarding the personal care provided to these residents is available within the resident’s room. This included the amount of fluid taken and the management of position in relation to pressure care management. Residents have regular access to their GP and to a District Nurse. Both visit regularly on a planned basis and can also be seen as required. Due to the set up of the village, residents are unable to routinely choose their own GP. If however there were a particular difficulty, attempts would be made to address individual wishes. Residents are able to access other services as required. These include chiropody, the opticians and dentist. Referrals can be made to specialised services such as a dietician. Within surveys, comments included, ‘medically the response is very good’ and ‘I am kept informed of events.’ Another relative said they were quite happy with the overall care of XX although the home is not very forthcoming with medical changes. They have to find out by talking to the GP. Mrs Chapman confirmed that staff are generally very good at informing the resident’s next of kin, although notifying additional Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 14 members of a family, is not generally undertaken. A GP confirmed satisfaction with the home. Within comment cards, in relation to the question: “do you receive the medical support you need?” Six residents said yes and five said usually. One confirmed they receive excellent care, while another said ‘it’s slow.’ To limit unnecessary admissions to hospital, residents have been asked about resuscitation. A form has been developed to record their views and residents or their family members have signed the document. The content of the form details whether they wish to be admitted to hospital. Do not resuscitate is also highlighted on some. Mrs Chapman confirmed that the matter had been instigated by the GP. While this is acknowledged, the format does not reflect this practice. It was noted that hot drinks are not routinely served to residents unless after a meal. A number of thermos flasks are located in the lounge so that residents can help themselves. One resident reported that they don’t go down for drinks and another stated they couldn’t manage the thermoses. Further comments included ‘the drinks don’t taste very good so I don’t bother.’ This system is restricting the amount of fluid intake for some. Within feedback, Mrs Chapman reported that she would reinstate the drinks trolley. Residents have jugs of water in their room although one resident did not have a glass. Another resident said that the staff do not change the water on a daily basis. Mrs Chapman did not believe this to be so, although was advised to monitor the situation. Two relatives, within comment cards, raised concerns about insufficient fluid intake. A number of residents have bedrails. Documentation was available to demonstrate some specialised assessments. However, in one instance, there were no bumpers attached to the rails. It was also reported that one resident tried to climb over the rails yet there was no evidence of review or how this risk would be managed. Within another assessment, a weekly review was recommended. This had been undertaken on a monthly basis. Mrs Chapman is therefore required to review the use of all rails and gain specialised assessments for all. Within comment cards, one relative reported ‘as far as I can tell XX always seems comfortable and well cared for. During illness, I was impressed by how caring the attention was that she received. Three staff arrived almost immediately. I always receive prompt reports when I telephone the home.’ Other comments included ‘absolutely wonderful’, ‘the care is fantastic’ and ‘generally pleased with XX’s care.’ Also, ‘XX would like a bath once a week if possible on a set day. Needs help with getting dressed and getting undressed and would like confirmation that this can always take place.’ Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 15 In general, one relative reported ‘I have no complaints what so ever about XX’s care. The staff are delightful and they accommodate XX very well. XX has some challenging behaviour, which they treat very well. They know XX’s likes and dislikes. XX is looked after very well. There is never any aroma in the home and the food is good.’ Another relative stated ‘I’ve not got a bad word to say about the home and have never found any negative things.’ Five residents confirmed that they always receive the care and support they require. Three said usually, one said sometimes and one said not always. Additional comments included ‘staff do their best’ and ‘I am impressed by the care and consideration given to me by the staff. I am grateful for their efforts.’ Also, ‘the staff are prompt in coming to help me when I pulled the ‘bell’ cord’ and ‘the quality of care I receive is usually good, yet varied according to the experience of the member of staff.’ An additional comment included ‘I don’t believe there’s a better place in the UK.’ Medication was discussed with the senior carer responsible for the medication systems. A restricted number of staff administer medication. This follows medication training and competency testing. The home uses a monitored dosage system and therefore stock is kept to a minimum. All is kept in locked cupboards within the ‘treatment room.’ Some bulk ordering of medication is undertaken. This is signed by the GP and has been agreed with a CSCI Pharmacy Inspector. There were a number of gaps within the medication administration sheets. Staff had also not signed for topical creams. There were a number of handwritten instructions that had not been countersigned. Within one record an error was noted. These matters were raised with Mrs Chapman and the senior carer, who is responsible for the medication systems. The instruction was to give 5mls of the medication although a staff member had recorded 10mls. Mrs Chapman is required to investigate this error. There were two medications without residents’ names and a number of boxes gave ‘as directed’ instructions. Documentation demonstrated that one resident was without their inhaler for nine days. Dates of opening eye and eardrops were recorded. Variable dosages of a medication and the times of ‘as required’ medication are not always stipulated. Protocols for ‘as required’ medication are also required. Within discussions, two residents voluntary raised the issue of personal care being provided by a male carer. While one reported that they have now ‘got used to it’, another reported that they would rather not have a male carer assisting them to dress. Mrs Chapman reported that this rarely happens although would ensure preferences are revisited. This must be documented in detail within care planning information. The organisation is also required to extend the information within its policy in order to address the issues of gender working. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 16 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): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an activity organiser, yet further consideration should be given to how residents’ individual social needs, both within the home and the wider community are to be met. Visitors are encouraged at any time and residents are able to entertain in the privacy of their room. An extensive menu is available giving choice and a varied selection of food. EVIDENCE: The home has an activities organiser who undertakes 16 hours a week. On the day of the inspection a number of residents had had their fingernails painted. A quiz was also taking place in the lounge. Other activities advertised on the board, included snakes and ladders, a coffee morning, bingo and scrabble. Due to the nature of the activities, not all residents would be able to actively join in. For example, those with poor hearing may find certain aspects, within the group setting, difficult. Through discussion it was apparent that some residents enjoyed music, reminiscing and walking. These interests were not reflected however in their daily lives. Some residents reported that there was little to do. Others spoke favourably of following their solitary interests. This included reading the newspaper and watching television. One resident stated ‘I’m fortunate, as I can go downstairs and meet with my friends from the flats.’ It Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 17 was reported that staff did not have time for individual work with residents. This included time for discussion or a walk around the garden. On the notice board outside the office, weekly events detail minibus trips. Although regular, residents need to be able to manage the service independently. This restricts the opportunity for many. The Service User’s Guide, states that Alexander Heights has weekly outings and extra outings are arranged on the activities programme. This needs clarification, as in practice such events do not appear to be occurring. Mrs Chapman confirmed that there are often activities, such as parties taking place. This included an introductory party for residents and relatives when she commenced employment. Residents’ birthdays are also celebrated. Within comment cards there were many comments about activities. These included ‘XX generally enjoys it but does mention quite often that he gets bored and there are not enough ‘outings’ and ‘entertainment’ especially at weekends,’ ‘XX never goes outside and therefore never gets any sunlight’ and ‘due to poor sight, joining in with activities is difficult. Music is a passion which would benefit from being developed.’ One relative stated ‘the level of internal and external activities would appear to be adequate and is arranged by a charming and caring young woman.’ Four residents confirmed there are always sufficient activities in the home, which they can join in with. Two residents said ‘usually’ and three, said ‘sometimes.’ Residents confirmed they were able to get up and go to bed when they wanted. They could also spend time in their room as they wished. Family visits were reported to be invaluable. Visitors are able to visit at any time and use the resident’s room. One visitor reported that they are always welcomed and receive a tray of tea to share with their relative. Another however, reported that refreshments are not offered and the welcoming is not always warm. Many residents regularly go out with their relatives. One resident reported that this was the highlight of their world. The menu is displayed within the lounge. It demonstrates a choice for each meal. All meals consist of three courses. A diabetic and vegetarian menu is also available. All food is cooked within the care village’s main kitchen and then transported up to the kitchenette. The food is plated according to individual wishes. Many residents confirmed that the food is always very good. Others were less positive. One said it very much depended on who was cooking. Another said the ‘food’s not so good.’ This particular resident had toast for lunch, as she didn’t like the main meals on offer. Staff deliver breakfast on a tray to individual rooms. Some residents confirmed that you could have your meals in your room. Others felt there was an expectation to have lunch in the dining room unless you were ill. One relative expressed concern that XX was eating less due to the probability of not wanting to attend Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 18 the dining room. At the last inspection, some residents expressed that meal times are lengthy. This was again confirmed within a comment card from a relative. Mrs Chapman reported that lunch generally takes place between 12.45 and 1.30pm. Observations during the site visit found residents being assisted to the table at 12.40pm yet the lunchtime meal had not been served at 1.05pm. Within comment cards, in response to the question, do you like the meals at the home, two residents confirmed ‘always.’ Six said ‘usually’ and one said ‘sometimes.’ Additional comments included ‘I enjoy vegetables and would like as many as possible,’ ‘the soups are very enjoyable’, ‘I would like more curries’ and ‘I wish they would serve garden peas more often – its always carrots and brussel sprouts.’ Further comments included ‘the food varies according to the chef’ and ‘needs a wider variety, the meals are sometimes cold but this has been mentioned to management.’ One resident confirmed ‘the meals are excellent with a varied menu and good quality cooking.’ Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 19 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): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents and their representatives are clear about the ways in which to give their comments and raise any concerns. Training regarding local procedures and clarity with policies would ensure residents further protection from abuse. EVIDENCE: There is a copy of the home’s complaint procedure next to the visitor’s book in the corridor. Residents confirmed that they would speak to a member of staff if they were unhappy. One resident also said that ‘Jean is very good and will listen.’ Through discussion however it was evident that some residents did not want to grumble. Mrs Chapman reported that she is encouraging residents to give their views and believes complaints can develop the service. A relative also highlighted this by stating ‘by highlighting concerns, I hope Alexander Heights will continue to improve further.’ A record of complaints is maintained. Since the last inspection, two anonymous complaints have been received. One included alleged restraint, yet it referred in general, to Avonpark. Due to being anonymous it may not have been specifically related to Alexander Heights. It may have been related to another service within the organisation. The organisation investigated both complaints and found no evidence to uphold the complaints. Mrs Chapman was advised however to further monitor both situations. As part of the inspection process, a large number of comment cards were returned from residents and relatives. While there was positive feedback, some negativity was also raised. Such Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 20 comments will be forwarded to Mrs Chapman to investigate as required. The comments highlight that greater consideration is needed with gaining and acting upon individual views. The comment cards highlighted that eight residents knew who to speak to if they were unhappy. Of these, one said ‘I would speak to the manager’ and another said ‘I would speak to Jean, the boss, she’s very helpful.’ One resident said they ‘usually’ knew who to speak to and two said they ‘sometimes’ knew. One relative confirmed that the resident ‘worries about being a nuisance but is not sure to whom to talk to with any problem. Maybe a particular carer could be identified for this purpose?’ Another relative stated ‘since the new manager took up post there has been much improvement and several of the issues have been addressed. Generally I feel that the care XX receives is good and she is more settled.’ Nine residents confirmed they knew how to make a complaint. One relative stated that they would make a complaint on behalf of their parent. They stated ‘I find the staff almost always approachable and receptive.’ One resident confirmed that they would ‘find the right people.’ Another said they didn’t know how to make a complaint and acknowledged ‘this is not my strong point – I’m not in the habit of making complaints.’ The home has varying information available regarding abuse. One policy is need of updating as it refers to in house investigations. It also identifies ‘the matron needing to inform the operations manager.’ A summarised version of the Wiltshire and Swindon Vulnerable Adults procedure is available. Some staff have signed to demonstrate receipt of their individual copy of the ‘No Secrets.’ The document was not readily available within the home. Mrs Chapman was advised to display a copy and review all other documentation accordingly. A number of staff have received abuse training. It was recommended however to enable all staff to receive training on local reporting policies. An external facilitator from the Vulnerable Adults Unit could undertake this. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 21 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, 20, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. While areas of the home are satisfactory, some aspects would benefit from refurbishment. The heating continues to require attention to ensure residents are comfortable with the temperature of the environment. All bedrooms are personalised and individual in style. Some aspects of cleanliness require attention to ensure a satisfactory standard throughout the home. EVIDENCE: Alexander Heights is located on the first floor and is therefore accessed via a passenger lift or stairs. One resident confirmed ‘it’s nice position with surrounding countryside.’ All rooms provide singe occupancy and include an en-suite facility. This may be a toilet or a toilet and shower. Rooms vary in size and there is also a suite. The suite consists of a bedroom, sitting room and bathroom. There are additional communal bathrooms with assisted baths. Communal areas consist of a dining room and two communal lounges. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 22 At the last inspection, a requirement was made to ensure that residents are able to regulate the temperature of their room. Two relatives and a resident commented upon this within comment cards. Mrs Chapman confirmed that the work is in the process of being finalised. Air conditioning units and additional fans have been placed in the corridor. Mrs Chapman reported that all units have been risk assessed. On a tour of the accommodation it was noted that there were areas, which would benefit from refurbishment. For example, the wallpaper in the main corridor is discoloured and in some areas has been marked and is coming away from the wall. The carpet is also worn, discoloured and is showing its age. While some residents’ rooms are satisfactory, others are in need of redecoration and re-carpeting. Some walls are marked, the paint on some windows is flaking and some carpets are worn or discoloured. In one room, it was noted that the carpet is beginning to ‘ripple’ causing a potential trip hazard. It has since been reported that this work has been completed. There are marks on some of the ceilings and in one area of the corridor ceiling tiles have been removed leaving open areas. Mrs Chapman confirmed that this was due to workmen. The flooring in a toilet was also very marked. One en-suite facility did not have a lampshade and in many rooms, the curtains were coming away from the track or the hem had come down. One resident confirmed their room had never been decorated, although when they moved in, they were told it would be done. Mrs Chapman confirmed that some carpets have been replaced. She has also identified the need for further replacement including the hallway. Mrs Chapman reported that line management has scheduled refurbishment for next year but a date has not been identified. Some rooms have kettles so that residents can make their own refreshments. Mrs Chapman reported that all have lockable storage space. Within comment cards, there were varying comments about the environment. These included the quality of the furniture and fittings and the standard of the corridor lighting. Individual comments will be forwarded to Mrs Chapman to investigate as required. Within the accommodation, it was noted that some areas would benefit from greater cleaning. For example, a number of floors had not been vacuumed and a hand washbasin was dirty with brown deposits. Dust was evident within windowsills and the meal server was dirty with splashes and particles of food. One resident said, ‘they hoover one day and clean the sink the next’ Another said ‘it depends whose on as to how well it’s done.’ A relative’s comment identified a limited attention to detail and another felt the toilets could do with a better clean. A further relative felt that selective areas of the premises suffer badly from bodily smells. Further comments from relatives about cleanliness included ‘we are impressed with the overall hygiene of the home and the care Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 23 given to XX’s laundry and personal looks’ and ‘cleanliness/hygiene is good – bathrooms are cleaned on a daily basis.’ Within comment cards returned from residents, six said the environment was ‘always’ fresh and clean, three said ‘usually’ and one said ‘sometimes.’ Accompanying comments included ‘the home is spotless - they clean the shower and toilet every day,’ ‘it’s quite a good standard,’ ‘the bathroom is now cleaner and fresher than before’ and ‘it needs some decoration and updating.’ On the first day of the inspection, the fire door from the kitchen to the dining room had been propped open. Mrs Chapman was informed if the door needed to be propped open, she needed to install a mechanical device, which was linked to the fire alarm system. On the second day of the inspection, Mrs Chapman reported that the device had been fitted. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 24 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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing levels although maintained in line with the previous Registration Authority should be reviewed to enable the individuality of residents to be promoted. While over 50 of staff have an NVQ qualification, developing training in relation to older age would be of benefit. Negative feedback regarding staff needs to be investigated so that residents are assured satisfaction with their care. EVIDENCE: Within the care team there is a head of care, a senior care assistant, four care assistants and four night care assistants. There is also a housekeeper, two domestic assistants, a laundry assistant and an activities co-ordinator. Staffing levels are maintained at three carers throughout the waking day. Within the inspection, it was noted that some residents have high dependency needs, which in relation to personal care, require the assistance of two staff. This leaves one member of staff to support the remaining residents. It is a requirement that staffing levels are reviewed. At night two staff provide waking night cover. There are also two domestic staff and a housekeeper on duty during the week. This reduces to one at weekends. The activities co-ordinator works 16 hours between Monday and Friday. Catering and maintenance staff are deployed centrally. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 25 A number of residents said that the staff are very busy. Another said ‘some are better than others, some are lovely, some are abrupt.’ One reported that they would ‘love to chat but the staff don’t get time.’ A member of staff also confirmed that they are rushing between residents and don’t get any real time to spend with them. An additional resident said ‘there are a lot of people here who need a lot of medical attention, so the staff are busy with them.’ Investigation regarding these views is required. Within comments cards there were many comments about staff. On a positive note these included ‘I have always found the staff I have met to be pleasant and caring,’ ‘staff try their best and some are very good,’ ‘staff are good and are friendly’ and ‘the staff/carers are overall very caring.’ More negatively, there were comments, from residents and relatives, about staffing levels, some attitudes and language barriers. Such comments will be forwarded to Mrs Chapman to investigate as required. In relation to attitude there were two negative comments about night staff. These were discussed with Mrs Chapman who confirmed the member of staff no longer works at the home. Within further comment cards received from residents, eight confirmed that staff always listen and act on what you say. Three said ‘usually’ and one said ‘not always.’ In relation to the question ‘Are staff available when you want them?’ Five residents responded ‘always’ and six said ‘usually.’ Additional comments included ‘I receive all the care I need. The staff are very good and pleasant. The food is good and I have a lovely bedroom’ and ‘I appreciate any attention/chats staff have time to give.’ Mrs Chapman is currently undertaking a review of training provision. There is a training matrix showing courses all staff have undertaken yet this needs updating to ensure an accurate reflection. At present there are four members of staff who have NVQ level 2. A senior care assistant also has NVQ level 3 and the head of care is undertaking NVQ level 4 in care. Two domestic assistants have NVQ level 2 in Cleaning and Support Services. Four staff undertook infection control training in August and two undertook elder abuse. Manual handling training is planned for all staff. Discussion took place with Mrs Chapman regarding the need to extend training provision to address specific conditions or issues of older age. Such topics include sensory loss, diabetes, tissue viability and death and dying. Since the last inspection two members of staff have commenced employment. Both members had completed application forms. One form however was dated 14.06.06 and the contract was dated 20.06.06. The member of staff commenced employment on the 28.6.06. The home could not evidence, within documentation, that they had undertaken an interview, a POVA First check or how the member of staff was to be supervised until their CRB disclosure was received on the 18.08.06. The other form contained no details of referees yet references with ‘to whom it may concern’ were located on the file. Information regarding a work permit was also unavailable. Later within the inspection Mrs Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 26 Chapman contacted the member of staff. A copy of the work permit was then supplied. All staff receive a probationary period of three months. There was no evidence of the assessment undertaken at the end of the probationary period. It was reported that all documentation is maintained within the organisation’s main office. It was agreed that a copy of such, would be kept in the home. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 27 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, 35 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The new manager is focused, motivated and has identified shortfalls which she is aiming to address. However, intervention from an organisational level regarding refurbishment and a quality auditing system is required to ensure the improvement of identified areas. Health and safety is given priority yet greater focus on staff’s knowledge of fire procedures would ensure further protection. EVIDENCE: Mrs Chapman began employment at the home in May 2006. She has recently completed the registration process to become the Registered Manager. Mrs Chapman has experience of working with older people in residential, day care and domiciliary care settings. Mrs Chapman is up to date with all mandatory training and has also successfully completed the Registered Manager’s Award. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 28 Since being at the home, Mrs Chapman has undertaken a Fire Marshall’s course. Before Mrs Chapman’s appointment, the home had a manager who was only in post for a short time. Before this, there was an established manager who had worked at the home for many years. In only a short period of time, residents and staff have therefore undergone many changes, which have been unsettling. Mrs Chapman has acknowledged this and reported that she has tried to build on existing practices and develop the team approach. One member of staff confirmed that the changes have been hard although the home is now beginning to settle. This member of staff believed Mrs Chapman’s management style was positive. She felt Mrs Chapman was approachable, motivating and had given the team confidence. Regular staff meetings are now held and the key worker system has been developed. Mrs Chapman reported that she is now encouraging staff to interact more with health care professionals such as GPs. In general, Mrs Chapman confirmed that she wishes to empower staff and have them more involved with making decisions. Within comment cards there were many positive comments about Mrs Chapman and the developments being made. These included ‘the manager has proved to be extremely helpful and is anxious to ensure XX’s comfort in responding to her needs,’ ‘the new manager is making a difference and things are starting to improve’ and ‘things are much better now that Mrs Chapman has arrived. Staff are now working as a team and things have improved greatly and are coming together.’ Additional comments included ‘since Jean Chapman has arrived, improvements are starting to be made and things are getting better’ and ‘the appointment of a new manager appears to be improving levels of communication, administration and health and safety for both residents and staff.’ Mrs Chapman reported that she has recently sent questionnaires out to residents, in order to gain their opinions of the service. This information has been collated and requests are being investigated. The home does not have a formal quality assurance system and therefore there are no quality audits that take place. This is an area that needs further attention. Mrs Chapman confirmed that residents are encouraged to manage their financial affairs. Some have transferred the responsibility to their family or representative. Fees are generally paid by standing order although some residents choose to write a cheque. Mrs Chapman reported that she is not involved within this process, as specific members of the organisation deal with the financial side. A number of residents keep small amounts of money in the homes’ safe. The records of all transactions were viewed and three cash amounts were checked. One error was noted. Mrs Chapman was required to investigate this. Residents or their relatives receive a monthly expenditure sheet, which details all transactions. Mrs Chapman reported that health and safety audits take place on a regular basis. Staff undertake monthly assessments and an external consultant Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 29 completes a yearly audit. Health and Safety training is part of the home’s mandatory training plan, yet refreshers need to be arranged. Risk assessments have been reviewed and each room has an individual assessment. Records demonstrated that the maintenance person regularly monitors hot water temperatures. The fire log book demonstrated satisfactory testing of the fire systems although there was no evidence of staff fire instruction. Documentation to demonstrate external contractor visits, were also not available on file. Mrs Chapman confirmed that these are kept centrally although in the future, would be copied and stored within the fire log book. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 30 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X X X 2 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 31 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 OP3 Regulation 12(1)(a) Requirement The Registered Person must ensure that aspects identified within the assessment process are addressed within the individual care plan. Control measures, in relation to identified risk must be addressed before the resident’s admission. The Registered Person must ensure that the home’s assessment is an accurate reflection of need. This must give clarity and sufficient detail to assess whether the home can meet the residents’ needs. The Registered Provider must ensure that external qualified health care personnel review all residents to ensure all are within the home’s category of registration. The Registered Person must ensure that all care plans show how the required care is to be provided. Any assessment such as pressure care must identify intervention and monitoring required. The Registered Person must DS0000028312.V290931.R01.S.doc Timescale for action 17/10/06 2 OP3 12(1)(a) 17/10/06 3 OP3 12(1)(a) 31/01/07 4 OP7 15 28/02/07 5 OP7 15 28/02/07 Page 32 Alexander Heights Version 5.1 6 OP8 12(1)(a) 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) 10 OP12 16(2)(n) 11 OP19 23(2)(d) 12 OP25 23(2)(p) ensure that residents and/or their representatives are consulted with when developing care plans. Important aspects identifying individual needs must be addressed. The Registered Person must ensure that the systems of providing drinks to residents are reviewed to able each resident to have an adequate fluid intake. The Registered Person must ensure that staff sign to demonstrate that medication and topical creams have been administered. The Registered Person must investigate the identified medication error and inform CSCI of any further action to be taken. The Registered Person must ensure that protocols are available for ‘as required’ medication. The time when ‘as required’ medication is administered must also be recorded. The Registered Person must ensure that a review of all activity provision is made. A programme taking into account residents’ individual wishes and the opportunities for external activity must be developed. The Registered Provider must ensure that a programme of refurbishment, to address the shortfalls in the accommodation is forwarded to CSCI. The Registered Provider must ensure that residents are able to maintain the temperature of their room at a standard acceptable to them. This was identified at the last and subsequent inspection and is 17/10/06 17/10/06 31/12/06 31/12/06 31/01/07 31/12/06 31/01/07 Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 33 13 OP26 23(2)(d) 14 OP27 18(1)(a) 15 OP33 24 16 OP38 13(4)(c) due to be completed shortly. The Registered Person must review cleaning schedules and staff deployment to ensure all areas of the home are cleaned to a satisfactory standard. The Registered Provider must ensure that proposals to address staffing levels in order to meet residents’ individual needs are forwarded to the CSCI. The Registered Provider must ensure that a formal quality assurance system is implemented, which complements the recent allocation of resident surveys. The Registered Person must ensure that all staff receive fire instruction on a regular basis in line with the home’s fire risk assessment. 31/12/06 31/12/06 28/02/07 17/10/06 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 Refer to Standard OP1 Good Practice Recommendations The Registered Provider should ensure that the opportunity of purchasing additional support from a domiciliary care agency is identified within the Statement of Purpose. The Registered Person should ensure that terms such as ‘needs assistance’ and ‘TLC’ are clarified within care planning documentation. The Registered Person should ensure that the current reviewing system of care plans is monitored so that all information is an accurate reflection of need and provision. The Registered Provider should ensure that any documentation regarding resuscitation is clearly identified, as that of the GP. The Registered Person should ensure that another member DS0000028312.V290931.R01.S.doc Version 5.1 Page 34 2 3 4 4 OP7 OP7 OP8 OP9 Alexander Heights 5 6 7 OP9 OP9 OP10 8 9 OP12 OP14 10 11 OP14 OP15 12 13 14 15 OP16 OP18 OP29 OP30 16 OP38 of staff countersigns any hand written addition to the medication administration sheet. The Registered Person should ensure that all medications are clearly labelled with specific instructions. The GP should be asked not to state ‘as directed.’ The Registered Person should ensure that in the event of a variable dose of medication, staff record the specific number of tablets administered. The Registered Person should ensure that residents’ preferences of a male or female carer are addressed within care planning information. The Registered Provider should ensure that the gender working policy is further developed. The Registered Person should ensure that a review of the number of hours available for activity provision is undertaken. The Registered Person should ensure that residents’ wishes of their preferred routines are revisited and recorded within plans of care. This should include when they wish to have a bath. The Registered Person should ensure that the notice board is specifically related to the needs of residents within the home rather than the complex. The Registered Person should give consideration to how mealtimes can meet the needs of all residents. Matters such as the length of time the meal takes to serve should be taken into account. This was identified at the last inspection but has not been addressed. The Registered Person should give consideration to enabling those residents who find it difficult to express their views, opportunities to do so. The Registered Person should ensure that staff receive training about local reporting procedures from a member of the Vulnerable Adults Unit. The Registered Person should ensure that documentation reflects a robust recruitment procedure. The Registered Person should ensure that training provision includes topics associated with older age such as tissue viability, continence, sensory loss and death and dying. The Registered Person should ensure that documentation demonstrating the servicing of the fire safety systems is maintained in the fire log book. This was identified at the last inspection but has not been addressed. Alexander Heights DS0000028312.V290931.R01.S.doc Version 5.1 Page 35 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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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