Inspection on 03/07/06 for Ardgowan House

This inspection was carried out on 3rd July 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ardgowan House 15/09/08

Ardgowan House 09/10/07

Ardgowan House 12/01/07

Ardgowan House 16/01/06

Ardgowan House 22/07/05

Ardgowan House 28/02/05

Ardgowan House 02/09/04

Ardgowan House 27/02/04

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

CARE HOME ADULTS 18-65 Ardgowan House 4 Middle Street Newsham Blyth Northumberland NE24 4AB Lead Inspector Karena M Reed Key Unannounced Inspection 3rd July 2006 10:00 Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 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 Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 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 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. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ardgowan House Address 4 Middle Street Newsham Blyth Northumberland NE24 4AB 01670-367072 01670 367072 deborah.jobson1@btinternet.com 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) Mrs A Jobson Mrs A Jobson Care Home 13 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (7), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (5) Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Ardgowan House is a home registered to provide personal care to thirteen adults, categories of registration include eleven places for adults with mental health problems, five of these places are for people over sixty-five years of age and one place is for an adult with learning disabilities. The home is situated in a residential area on the outskirts of Blyth. It is close to local shops and pubs. The town centre and coast are also nearby. The home does not provide nursing care. The home consists of a large detached house with a small front and very large rear garden. All bedrooms are for single occupancy. There is a dining room/combined lounge, separate lounge, conservatory and a quiet room. A passenger lift is not available but some bedrooms are located on the ground floor of the property. There are two bathrooms, two shower rooms and sufficient lavatories for the needs of residents. A bathroom and shower room are fitted with equipment to assist physically dependent people. Fees payable for living at the home at the time of inspection in July 2006 vary between £359 and £370.45. Additional charges are payable for hairdressing, private chiropody, holidays, personal toiletries and newspapers. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over four hours. A partial tour of the premises took place and a sample of records were inspected which included: 4 care plans, the fire log, accident book, admission /discharge book, complaints record, staff communication book, staff meeting minutes and four staff files. The proprietor, one support worker and three residents were interviewed at the time of inspection. Questionnaires were received from six residents. What the service does well: What has improved since the last inspection? What they could do better: This was a very disappointing inspection although efforts are being made to physically improve the environment attention must be paid to creating a staff team and ensuring the necessary records are retained to ensure the well being of residents. Requirements and recommendations from previous inspections must be carried out in a more timely way. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 6 An office must be created to ensure a more homely environment for residents. A suitable medication cabinet must be obtained and secured in an appropriate safe place. Care plans must be updated at least three monthly to show the amount of care and support being provided to residents. Reviews of residents care needs must take place at least annually to ensure their daily and future living requirements are being met. Risk assessments must be carried out to ensure a safe environment for residents at the same time as allowing them to lead as fulfilled a life as possible. A nurse call system must be provided in all bedrooms to allow residents to call for assistance from staff if required. The carpets to the identified areas must be replaced or cleaned to maintain satisfactory hygiene levels within the home. Staffing levels must be reviewed to ensure sufficient staff are available on duty at peak times of the day to meet the needs of residents. Staff supervision must take place at least six times a year to assist staff development. The management style should be more open to ensure the smooth running of the home for the benefit of staff and residents. Staff photographs and proof of identity must be placed on staff files to assist in the protection of residents. The CSCI must be informed of any accidents or events that affect the well being of residents. A record must be kept of any theft or burglary that takes place within the home and CSCI notified. Records must be available as required for inspection as required by The Care Homes Regulations 2001. The fly screen at the kitchen window must be replaced in the interests of health and safety. 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. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users’ individual aspirations and needs are assessed. The home collects enough information about the needs of residents before they move in to help ensure staff are aware of the amount of care and support needs of the resident as they settle in. EVIDENCE: The records for a resident recently admitted to the home showed that an assessment of their care needs had been carried out before their admission. The resident and their family were involved in the initial assessment. This information and the care manager’s assessment of the resident’s care needs were used to ensure all the needs of the resident could be met by staff. The records contained a range of information , some of the information was old and no longer relevant having been collected when a resident moved into the home some years ago. Records should be sorted to ensure the most accurate, up to date information is available for staff to read to ensure they are aware of all the care needs of the residents. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are adequate arrangements in place to ensure that residents’ health and social care needs are met. There is no system of reviewing the changing care needs of residents. Residents are supported by staff but care plans do not reflect the amount of care and support that staff are providing to residents. Residents are encouraged to be involved in decision- making and to communicate and make their views known. Staff support residents to take risks as part of independent living. EVIDENCE: The home has adapted the environment to make sure it can provide care and support to residents who have become older and more physically dependent, however care records looked at did not record the amount of care and support provided by staff . Residents care plans were not updated three monthly or as their needs changed to show the amount of care and support provided by staff. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 10 This information about the amount of care and support provided by staff was to be found in the daily records. There was no system established by the home to review the care needs of residents when they did not attend a day service. Meetings are held with service users about the running of the home. Service users spoken to stated that they were involved and consulted about decisions involving themselves. Although the home supports residents to remain independent and take risks in order to live a more fulfilled lifestyle up to date risk assessments were not present in residents care records. Risk assessments should be put in place for the two men as discussed at the time of inspection. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in age, peer and culturally appropriate activities. Residents are part of the local community. Residents enjoy appropriate leisure activities. Residents are encouraged to have appropriate personal, family and sexual relationships. Residents’ rights and responsibilities are recognised in their daily lives. Residents are offered a healthy diet. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents spoken to confirmed that they are involved in the running of the home and involved in making decisions about their lives. Residents’ records and residents meeting minutes provided evidence that all residents are consulted and asked their opinion and encouraged to make decisions. Conversation with residents showed staff support residents to acquire skills and become more self sufficient in aspects of every day living. Residents all pursue their own individual hobbies and interests. They have enjoyed trips to the Sage music centre, St Mary’s lighthouse, York, Alnwick and Blackpool. They also enjoy meals out at a local pub and visiting the theatre. Within the home residents enjoy quizzes, beetle drives, video nights and playing bingo. Some residents attend drop in centres and day centres during the week. Residents care plans and case records detail any family involvement. Conversation with residents also provided evidence that they are encouraged to maintain contact with family and friends, staff providing the necessary levels of support for them to do so. Residents are asked individually daily what they wish to eat. A light snack is available at lunch times and a cooked meal is served in the evening. On the day of inspection tuna fish sandwiches and sausage rolls and peas were being prepared for lunch. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do receive support in the way they prefer and require. There are arrangements in place to ensure that service users’ health care needs are met. Systems are in place for residents to retain and administer their own medication where appropriate. EVIDENCE: Four care plans and case records were inspected. The daily records detailed the care and support required for some complex needs. They reflected the changing needs of service users due to incapacity and old age. The care plans however did not accurately record these needs and the care and support provided by staff. The home also respects the wishes of the individual when dealing with incapacity, and is preparing for the ageing of service users. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 14 Records showed when residents had seen health professionals eg doctors, community nurses, etc. Records also showed when residents had seen opticians and dentists. Staff receive training before they administer medication to residents. A system is in place to oversee the medication of residents who retain and administer their own medication. Discussion took place again with the proprietor about the current location of the medication cupboard. It is currently in the residents’ smoking lounge, thought should be given to relocating the medication out of such an environment and obtaining an appropriate medication cabinet. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure. There have been two complaints received by the CSCI about the home since the last inspection. The complaints were substantiated. It was evident from records that complaints were viewed negatively by the staff and management team. A procedure for responding to allegations of abuse is available. All staff have received training about Protection of Vulnerable Adults. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The building is becoming better maintained with better quality furnishings and décor in the communal areas, which creates a pleasant environment for those living there. A more homely environment will be created when the office is finished. Systems are almost in place to provide a safe environment for service users and staff. Specialist equipment is being provided. There is a quite good standard of hygiene around the home. EVIDENCE: There is an ongoing programme of decoration and refurbishment around the home. A conservatory has been built in order to provide an extra living room for the use of residents. An office is being created and this should prevent office equipment and notices being placed in service users living areas: Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 17 medication cupboard in the smoking room, filing cabinet and official records being kept in the lounge/dining room and staff notices on the kitchen door. A bathroom and shower room have been adapted for more physically dependent residents as they become older or incapacitated. The proprietor was advised a nurse call system should be installed as soon as possible as advised at the previous inspection in order to provide a safe environment for an older more physically dependent resident who may need to summon staff for assistance. This is appropriate for other residents too. A risk assessment should be carried out for the person and the person should also be informed night staff needed to carry out checks during the night to check the safety of the person. The bedroom of more physically dependent people should also be equipped to ensure their safety. The proprietor was advised of equipment that should be placed near the person’s bed at night to reduce the risk of falling as they walked. There was a good standard of hygiene in communal areas apart from the fly screen in the kitchen was broken. The carpet in the rear hallway was soiled , the carpet in bedroom 5 required cleaning . Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff. Residents are not supported by an effective staff team at all times of the day and night. Residents are supported and protected by the home’s recruitment policy and practices. Residents’ needs are met by appropriately trained staff. Staff are not supervised. EVIDENCE: Examination of staff rotas and discussion with the person in charge and members of the staff team showed that the numbers of staff are as follows: 8.00am- 12.00pm 12.00 pm –4.00pm Ardgowan House 2 staff 2 staff DS0000000521.V289190.R01.S.doc Version 5.2 Page 19 4.00 pm- 10.00pm 10.00pm- 7. 00 am 2 staff I sleep in and 1 waking staff The proprietor lives on the premises four days of the week. These numbers include the management team of manager and one assistant manager. Discussion took place about reviewing this arrangement. There is a senior staff member on each shift. Staff members carry out food preparation. Discussion took place with the proprietor about the deployment of staff and their responsibilities during the day especially as some residents were becoming more physically dependent and requiring more assistance and support. It was agree that two staff members would be on duty from 7.00am in order to provide assistance and support to residents that chose to get up at this time and at the same time provide some supervision and breakfast to other residents. Thought should be given to the deployment of staff at peak hours of the day in order to ensure there are enough care hours for the needs of residents. It was good to see increased training opportunities for staff. All staff have enrolled for National Vocational Qualifications at levels 2 and 3. Staff are receiving training about “person centred planning”, moving and handling training. Two staff have enrolled for an assessor’s award. Future training includes about falls. The necessary checks are being carried out prior to the workers being appointed. Two written references were available on the staff files examined from the most recent employers. An application form had been completed for each staff member. CRB checks are carried out before a person is appointed. A regular system of supervision was not operating to ensure that staff had the opportunity to discuss any training needs and to discuss any areas of concern with the manager. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents benefit from quite a well run home. Residents and staff do not benefit from the ethos ,leadership and management approach of the home. There is no system for reviewing the quality of care provided by the home. The residents’ rights and best interests are not safe guarded by the home’s record keeping policies and procedures. The health, safety and welfare of residents are promoted and protected for the most part. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 21 EVIDENCE: There is a system in place to ensure that the staff are given training in moving and handling skills, fire safety, first aid and food hygiene. No nurse call system is available yet for service users yet to summon staff assistance if ill or incapacitated. The fire logbook indicated that fire safety checks are carried out routinely. The Accident Book recorded falls and accidents to residents. The manager has not notified CSCI of any events that affects the well- being of residents. No photographs were available on individual staff files. There was no proof of identity on individual staff files. Staff meeting minutes recorded the disquiet and unrest felt by staff to one staff member that was not conducive to the smooth running of the home. The minutes also recorded the theft of a large amount of money from the home but there was no record of any investigation by the police or the home owner. The residents’ personal allowance records and keys to the safe were not available at the time of inspection. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 1 3 x 1 1 x Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2)(g) Requirement An office must be created and remove all notices and storage equipment from service users’ living areas. To provide a nurse call system To provide certificate for gas supply. To update care plans at least 3 monthly or as care needs change. Timescale for action 01/09/06 2. 3. 4. YA42 YA42 YA6 13(4) 13(4)c 15(2)(b) 01/09/06 01/09/06 31/08/06 5 6 7 YA9 YA30 YA41 13(4)(b)(c) 8 YA33 To carry out risk assessments as required. 23(2)(d) To clean the carpets as identified. 37(1)(a)(b)(c)(d)(e)(f)(g) To notify the Commission of any events that affects the well being of residents 18(1)(a) To ensure staff are in sufficient numbers to DS0000000521.V289190.R01.S.doc 15/08/06 15/08/06 05/08/06 31/08/06 Ardgowan House Version 5.2 Page 24 9 10 11 YA36 YA38 YA41 18(2) 12(1)(a)12(5)(a) 17(3)(b) 12 13 14 YA41 YA41 YA42 Schedule 2 7(9)(19)(1)(2) 12(f) 13(4)© meet the needs of residents. To carry out regular staff supervision. To ensure a more open style of management. To ensure residents financial records required for inspection are available. To ensure staff records are complete. To keep a record of any theft or burglary and notify CSCI A suitable medication cabinet to be obtained and placed in amore appropriate site. 01/09/06 05/07/06 15/08/06 31/08/06 05/08/06 01/09/06 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 YA33 Good Practice Recommendations To review the current sleeping in arrangements. Ardgowan House DS0000000521.V289190.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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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