Inspection on 01/12/06 for Avon Manor Care Home

This inspection was carried out on 1st December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Avon Manor Care Home 25/05/07

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

CARE HOMES FOR OLDER PEOPLE Avon Manor Care Home 50 Manor Road Worthing West Sussex BN11 4SH Lead Inspector Mrs D Peel Unannounced Inspection 1st December 2006 09:30 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 Avon Manor Care Home DS0000067679.V319902.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 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. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avon Manor Care Home Address 50 Manor Road Worthing West Sussex BN11 4SH 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) 01903 230049 Cobham Care Ltd Mrs Lisa Moulding Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First visit since registration with current providers Brief Description of the Service: Avon Manor is a Care Home, which provides care and support to elderly people who have dementia and other related mental disorders. It is currently registered to accommodate up to twenty-four residents. The home is a detached property situated in a residential area of Worthing with local shops and other amenities within walking distance. The seafront and beach are nearby. Communal facilities include a lounge, dining area and a smaller dining area, which leads out onto a conservatory. There are twenty-four single bedrooms, which meet or exceed the national minimum standards for individual accommodation in care homes for older people. Six bedrooms are located on a mezzanine floor accessed by steps. There are limited outdoor facilities, which at the moment include a safe decking area, but there are plans to extend the outside area at the front of the house for use by residents. The current scale of fees being charged at the home is from £389 to £585 per week. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to Avon Manor was carried out by Mrs Diane Peel, a Regulatory Inspector and Mrs Jeanette Dattoo, a pharmacy inspector on the 1st December 2006. This was the first visit to Avon Manor since a change of registered provider on the 16th June 2006. As a new registration the home was required to be inspected within the first six months. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. In addition the intended outcomes for thirty-three standards were assessed; these included the key standards for care homes providing a service to older people. During this visit the lead inspector visited all communal areas and twelve residents’ bedrooms, sampled at random on each of the floors. A case tracking exercise for five residents was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met by the home and other outside professionals. The pharmacist inspector viewed medication storage and records of medication receipt and administration, spoke to staff about medication procedures and observed administration practice. Where possible residents were spoken with to gain some information about what it is like to live at the home but the majority of residents were unable to provide feedback about the quality of information provided about the home and, the terms and conditions of living at the home and the complaints process. The records of four staff were inspected and staff were spoken with informally during the visit to find out what it is like to work at the home. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 6 Samples of other records required to be kept by the home were viewed during the visit to ensure that the provider is meeting their obligations with regard to the administration of the home. What the service does well: What has improved since the last inspection? This was the first visit to the home since a change of provider in June 2006 and it was observed that improvements to the environment had already been made. Other work is currently going on to improve the laundry and food storage facilities and there are plans to improve the outdoor facilities for residents to use. Bedrooms are gradually being redecorated and bedroom furniture and carpets being replaced. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 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 Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good standard of information about the home is included in The Statement of Purpose and Service User Guide but it is not routinely provided to all prospective residents relatives or their representative so that they have information about the home, which they can refer to. Residents have a contract /statement of terms and conditions which outlines the terms of residency within the home and what is included in the fee. All prospective residents and their representatives have the chance to visit the home to see what the home has to offer and an assessment of need is carried out to ensure that the home can meet individual peoples needs. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 10 EVIDENCE: Avon Manor has a comprehensive Statement of Purpose and Service User Guide, which is on display in the entrance to the home. The manager told the inspector that it is not routine practice to give a copy to all prospective residents or their representatives. This matter should be considered to improve the quality of information received by residents and relatives. The Statement of Purpose and Service User Guide sets out the criteria and procedure for admission to the home and states that “on receiving a referral, whenever possible the relative and whenever possible the service user and his/her relative should be encourage to visit the home as a first step in the assessment process”. Records kept by the home and sampled by the inspector showed that resident’s needs are assessed before they move into the home. When residents are receiving funding for their stay at the home they have a separate Statement of need and individual placement agreement. Five residents surveys were returned to the inspector during the visit. All surveys reported having had a contract and they were either with solicitors, next of kin or the contract was between the home and West Sussex Social and Care Services. Out of the five returned two reported that the resident had visited the home prior to moving in and one said that their family had visited to view the home. One assessment of need observed identified that English was a second language and that this person would need access to an interpreter. Care records seen recorded visits by an interpreter. Intermediate care is not offered at Avon Manor but the home is able to offer periods of respite care. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of information in some care plans may result in residents not receiving the help and assistance, which they require. Other daily records are in place to monitor the health care needs of residents and record intervention from medical professionals. Some improvements to medication practices were needed to ensure the security and administration of medicines. EVIDENCE: Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 12 All residents had a daily monitoring records and records of physical care, which had been carried out. But for two out of the five care records viewed there was no care plan to assist staff to meet the assessed needs of those residents. There was a lack of documented actions required to meet the identified needs of the residents. For one resident who had become aggressive on a number of occasions there was no information for staff on how to avoid causing this behaviour or how to respond to it. A requirement has been made that all residents have a comprehensive care plans which staff can follow to meet the assessed needs of residents. Information provided by the manager prior to this visit to the home has demonstrated that the home seeks professional advice when there are difficulties in meeting the particular needs of individual residents and care other records show that residents have access to Doctors, District Nurses, and Chiropodist. Medication policies and procedures were available for staff. Medicines were stored in a locked cupboard and a locked trolley chained to wall. It was noticed that medication keys were not kept securely and immediate action was taken. Medicines needing cool storage were stored in a section of a fridge. Eye drops were replaced after being opened for four weeks. Receipt of medicines was recorded but receipt of a controlled drug was not entered in the separate register. Two records had items marked for self-administration, which the manager agreed to review. Where a variable dose was prescribed, the actual dose given had been recorded. At lunchtime two care workers gave and recorded the administration of medicines. They also asked and recorded if a resident had said they did not want a medicine prescribed to be taken when required. One care worker confirmed having had medication training. The manager said that the pharmacist had done medication training and some staff had completed a safe handling of medication course with local training providers. Staff were aware of the need to treat residents with respect and consider dignity when delivering personal care. Staff were observed to speak to Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 13 residents meaningfully and spend time with residents when they seemed confused. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of the home are planned around the resident’s needs and wishes so that there is flexibility in the service. Activities are offered and staff try to motivate residents into taking part. Residents are encouraged to maintain contact with their family and friends so that they so that they can satisfy their social and emotional needs. Home cooked food is provided to a good standard with choices of alternatives available. EVIDENCE: Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 15 Daily records are kept for all the residents living at the home, which show that the home is able to be flexible. Entries record visits by friends and relatives, taking part in activities and entertainment such as a musical show and enjoying the recent firework display. There is also some reverence to residents helping around the house, as an example “helping to dry the medicine pots.” The home has two cats and the Statement of Purpose and Service Users Guide explains the benefits of having pets as therapy for residents. On display in the hallway are posters advertising future events such as music for heath and the Christmas Spectacular. Information provided to the inspector prior to this visit reports that the home offer also has video afternoons, lunch trips out, visits to the garden centre, bingo and singing. There was also evidence of craft activities on display on the wall in the small dining area. The visitor’s book in the entrance hall records regular visitors to the home and the two completed care plans seen recorded social contacts and interests before moving into the home. The inspector spoke with the cook who commented about the good quality fresh products, which she is able to order. On the day of the visit she was cooking fish in batter and chips as the main meal but some residents were having fish in a sauce as an alternative. Residents can have their meals in the main dining room, the smaller dining room or if they choose can have their meals in their rooms. One resident spoken with in the privacy of her room commented that they liked to stay in their room because they liked their own company. They said that the standard of food was “ ok “and that there was opportunity to ask for something else if you didn’t want what was offered. All surveys returned to the inspector reported that residents were satisfied with the meals provided at the home. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and ensures that relatives and advocates have the confidence that their complaint will be taken seriously, however in practice there were no record of complaints log was available to demonstrate the effectiveness of the procedure. Staff have had adult protection training to ensure that they are fully aware of their responsibility to recognise and report abuse. The lack of Protection of Vulnerable Adult (POVA) and Criminal Record Bureau (CRB) records for new staff does not demonstrate that residents are being fully protected by the homes recruitment practice. EVIDENCE: There is a clear complaints procedure on display in the entrance hall and in the Service User Guide assuring residents, relatives and visitors that all complaints will be taken seriously and acted upon. It has also been published in a userfriendly format. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 17 On the day of this visit the inspector asked to see the format in which records of complaints should be recorded but these could not be located. Information provided prior to this visit to the home by the manager reported that there had been no complaints made. Questionnaires returned to the inspector show that if someone is not happy about something or people want to make a complaint then they would speak to the manager. Staff have attended adult protection training and the home has its own guidelines for staff to use at the home, which are used alongside the West Sussex Multi Agency guideline for reporting abuse however the recruitment records within the home did not demonstrate that sufficient Criminal Record Bureau checks and Protection of Vulnerable Adult checks had been undertaken for new staff employed. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an ongoing maintenance plan to improve the decoration of the home, which is providing the residents living at the home with homely, safe, comfortable surroundings. Bedrooms are comfortable and meet the needs of the residents. Residents are encouraged to contribute to making their bedrooms their own by having their own personal possessions around them. EVIDENCE: Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 19 Since registration with the new owners, Cobham Care Ltd, work has begun to improve the laundry facilities and food store area at the home. There are plans to increase the outside space for use by residents at the front of the home. During this visit the inspector saw all communal areas and visited twelve bedrooms at random. The décor of the home was observed to be homely and clean. Furniture and fittings are of a good standard. The owners are redecorating and replacing bedroom furniture and carpets as bedrooms become vacant and residents and their families have personalised rooms by displaying ornaments, pictures and photographs. The pre inspection questionnaire provided by the manager prior to this visit showed that the majority of maintenance to services have been recently carried out and a notice on display on the inner door of the entrance hall informs visitors of future maintenance to services which included gas, the lift and electrical wiring. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing numbers are set at a level, which appear to be meeting the physical and emotional needs of residents on the day of this visit. Recruitment procedures do not safeguard and protect residents at the home. Avon Manor has well-qualified staff so that residents are able to feel safe and cared for. EVIDENCE: Duty rotas showed that there are care assistants supported by ancillary staff during the day and care staff at night. Just under 50 of staff have an NVQ qualification and the manager has confirmed that a further three staff are to commence an NVQ in the New Year. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 21 The recruitment records for four staff were seen at this visit. It was identified that some staff have been employed at the home having a CRB or POVA check carried out by their previous employer. The manager could not demonstrate that current CRB and POVA First clearance has been applied for although she stated that they had all been applied for. A requirement has been made that all persons employed by the home have a Current CRB and POVA First clearance carried out by the organisation. Training records provided show that staff have a training programme that provided them with the combined skills to address the needs of residents and staff spoken with confirmed that the home has provided them with an induction and training such as Adult Abuse, Medication, Moving and Handling, First Aid, Fire training and Dementia Care. Future training recorded on the homes training plan includes: Health and Safety, Infection Control, Food Hygiene, and Diabetes. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management systems are not always in the best interests of residents living at the home. Quality assurance systems are in place to seek the views of residents and their families so that the organisation can measure its success in meeting the aims and objectives and statement of purpose. Systems for handing residents monies ensure that residents are assured that their financial interests are being safeguarded Some practices and lack of documentation do not protect the health, safety and welfare of the residents. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has worked at the home since 1995 and has been in the management role for just under two years. She has just completed her NVQ level 4 in care and has yet to undertake the registered managers award. Staff at the home had positive comments to make about the home and the providers. The home has a quality assurance system, which includes surveying residents and their representative about their views of the service. Samples of returned questionnaires were viewed at this visit an all showed satisfactory feedback. A recommendation has been made that once collated the outcome is provided to the Commission for Social Care Inspection and in the Service Users Guide. Where the home manages money on behalf of residents a system is in place to record transactions. Information provided to the inspector prior to this visit to the home records that no residents handle their own financial affairs and that twenty-two residents are subject to Power of Attorney. Resident’s interests are not been safeguarded by efficient record keeping. This has lead in some circumstances to increasing the risk of residents needs not being met by the lack of care planning and review of care plans. The lack of recent CRB and POVA First checks for recently employed staff is not in the best interests of residents. Medication keys were not routinely being assigned for safe keeping by senior staff on duty and a receipt of a controlled drug was not entered in the separate register. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 24 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 X 1 1 Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 OP38 Regulation 15 Requirement All residents must have an up to date plan of care, which includes the details of how their assessed needs are to be met. Medication keys must be kept securely at all times. Robust recruitment policies and procedures must be carried out. Timescale for action 01/02/07 2 3 4 OP9 OP29 OP18 OP38 OP37 13.2 19 Schedule 2 (1) (7) 17 01/12/06 01/02/07 All records detailed in Schedule 4 01/02/07 must be available at the home 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 It is recommended that a copy of The Statement of Purpose and Service User Guide be provided to the relatives or representatives of all new residents who come to live at the home. 2 OP9 It is strongly recommended that controlled drugs be stored DS0000067679.V319902.R01.S.doc Version 5.2 Page 26 Avon Manor Care Home in a controlled drugs cupboard and that any receipt be immediately recorded in the register for that purpose. Avon Manor Care Home DS0000067679.V319902.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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