Inspection on 31/10/07 for Bath Road, 85

This inspection was carried out on 31st October 2007.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bath Road, 85 09/10/06

Bath Road, 85 30/03/06

Bath Road, 85 28/10/05

Bath Road, 85 09/11/04

Bath Road, 85 18/05/04

Bath Road, 85 22/01/04

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Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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Polesworth Group 68 Long Street

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

CARE HOME ADULTS 18-65 Bath Road, 85 85 Bath Road Worcester Worcestershire WR5 3AE Lead Inspector Debra Lewis Key Unannounced Inspection 31st October 2007 and 12th November 2007 15:00 Bath Road, 85 DS0000018626.V347361.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 Bath Road, 85 DS0000018626.V347361.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. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bath Road, 85 Address 85 Bath Road Worcester Worcestershire WR5 3AE 01905 360439 01905 360447 bathrd85@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) Mr David George Broadbent Miss Josephine Mary Fowler Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is for people with a learning disability who also have a hearing impairment. 9th October 2006 Date of last inspection Brief Description of the Service: 85 Bath Road is a large terraced house in Worcester, within walking distance of local amenities and the facilities of the city. The home provides accommodation in five single rooms for five younger adults with learning disabilities and profound hearing loss. Communal lounge, dining room, bathroom and toilet facilities are provided. Residents need to have good mobility to negotiate stairs to their bedrooms. The service aims to enable them to lead a normal life and gain fulfilment through support to develop skills in communication, social and daily living activities and to participate in further learning opportunities. The registered provider is Mr David Broadbent, who maintains a regular link with and oversight of the home and supervises the registered manager, Ms Josephine Fowler. Information about the home is available in a service users’ guide. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection of 2007-8. It was a Key Inspection. This means that the inspector checked all of the standards which have most impact on service users. This report includes findings from the visit to the home, as well as any relevant information that has been received about the home since the last inspection. This includes details from a report on the home provided by the registered manager. The inspector was in the home on 2 days, from 3pm till early evening and from 2pm till 6pm. The inspector met and talked with 2 of the 5 service users; with several staff on duty; and with the registered manager. The inspector was helped by a sign language interpreter, who enabled the inspector to communicate with deaf staff and people living in the home. What the service does well: What has improved since the last inspection? Written plans for people’s care, especially health care, have been improved. The home now provides paper towels in WCs and bathrooms, to improve hygiene. Staff have had some training in how to react to potential abuse, and the home’s policy has been improved. Some safety issues have been improved. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 6 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. Bath Road, 85 DS0000018626.V347361.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 Bath Road, 85 DS0000018626.V347361.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home worked with families, social workers and people living in the home to ensure that they could provide a suitable service for people who lived there. EVIDENCE: During the past year, one person had moved out of the home to more independent accommodation. The home had worked with him for several years towards increasing his independent living skills, and liaised with him, his family and social worker in arranging the move. The home had ensured they took into account his wishes, e.g. contact with old friends, and had arranged for an advocate to make sure his views were fully represented. Another person had moved into the home earlier in the year. The home had an updated assessment from 2006 from their previous home. The move had been agreed between the home, the service user, their family and social worker. The social worker had not completed a full assessment as it was felt that the one from the pervious care home was sufficient. Ideally this should have been done as their assessment could differ from that of the care home; in future staff at Bath Road must ensure an up to date assessment is obtained from the social worker. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 9 Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was aware of people’s care needs, and supported them to make choices where possible. The home was aware of risks to people living in the home and worked to reduce risks while ensuring people living in the home were not unnecessarily restricted. Records of care needs and risks need updating to ensure they are accurate and comprehensive. EVIDENCE: Service user plans were in place, though not in a consistent form. Some had been reviewed in-house, others dated back to 2006 or 2004. Their formats and the frequency of review varied. Some had good personalised details, for example one describing exactly how and when one person needed help with personal care; this meant it was likely to be given in the way best suited to that person. Some were brief and were little more than an assessment. There was a general tendency to focus more on practical needs, such as use of hearing aid, use of washing machine. It would be good to see more covering people’s social and emotional needs. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 11 People living in the home had varying levels of ability to understand and make choices. In most cases staff offer a range of options, as people living in the home are unlikely to initiate changes. However there was evidence that, if the service user had the capability, they made their own decisions e.g. some people living in the home described choosing clothes, hairstyle and bedroom furnishings. One person said they had keys for their rooms. The home had individual risk assessments for service users, some of which needed to be reviewed (some were dated from 2005). Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The staff work hard to enable a range of activities for people living in the home. Family relationships are valued and supported by staff, enabling people living in the home to keep regular contact with relatives. Routines in the home are relaxed. People living in the home like the food and can choose meals, although more healthy options could be provided. EVIDENCE: From talking with people living in the home and from care records, there was evidence that people living in the home took part in a range of activities in and out of the home, such as going to college, hairdresser, family visits, gardening, drama groups, swimming, painting, and cooking. Service users used community facilities such as restaurants and sports centres. The needs of the people living in the home meant that finding accessible activities was sometimes not easy, but staff continued providing varied activities. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 13 One person said they liked to stay at home during the evenings. Another said they would like to go out. The home should investigate this and provide extra staff on occasions to ensure this person can go out of the home some evenings. Service users had regular contact with their families, sometimes at the family home and sometimes at Bath Road. 4 relatives completed a CSCI (Commission for Social Care Inspection) comment card. 3 said they were always kept informed of important issues, one said sometimes. Comments were generally positive about the home’s relationships with families, with a few minor reservations. Bedrooms had flashing light “doorbells” so people living in the home knew when staff wished to enter their rooms; they could lock their doors. Staff spoke respectfully to people living in the home. People living in the home chose meals from a range of pictures showing different foods. People living in the home usually ate the same main meal, but were able to choose something different if they wished. People living in the home said they liked the food. The records of food did not always record snacks e.g. fruit, and suggested the home was not always providing the recommended 5 portions of fruit and vegetables per day to help maintain service users’ health. This was discussed during the inspection, and the registered manager agreed the home could develop this area in the future. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff take care of people’s personal and healthcare needs, and medication is handled safely, thus protecting the health of people living in the home. EVIDENCE: Service user plans contained details of the personal care and support needed by people living in the home. People living in the home described how staff helped them, and said they liked staff. Healthcare records were now kept in separate health action plans. Those seen were up to date and included details of various medical appointments. The inspector saw medication records, policy and storage. Records and storage were satisfactory. The home’s policy was in need of review as it suggested keys could be stored in a potentially unsafe way, described giving suppositories with no supplementary guidance [although none were in use] and was generally rather vague. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 15 Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are open to people living in the home showing signs of discontent, and are clear about the need to act appropriately to ensure anyone’s concerns are addressed. EVIDENCE: It was not clear whether people living in the home understood questions about raising concerns. However they said they liked staff. Relationships appeared friendly and staff described how they were aware of differing ways in which people living in the home showed their feelings. The home had a complaints record and their policy was satisfactory. The home had revised their adult protection policy and it was now satisfactory, ensuring clear and correct guidance was there for staff. Most staff had had training in adult protection. Staff asked were clear about the need to report any possible concerns to the appropriate authorities. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, homely and well maintained. Service users have suitable bedrooms, bathrooms and shared facilities. Adaptations are provided as needed, e.g. flashing light doorbells. The home is clean and hygienic. EVIDENCE: The inspector was shown around the home. The home was generally clean, homely and well maintained. Bedrooms were clearly personalised to reflect individuals’ tastes and interests, and were lockable. There were sufficient toilets and bathrooms, and they were lockable. Disposable paper towels were now provided for hygiene reasons. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 18 Shared space was adequate, with a comfortable lounge and a dining area; there was a lack of private areas for seeing visitors, but this would be difficult to resolve in the existing layout of the building. The lounge was used for this, or sometimes visitors took their relatives away from the home e.g. for a meal. Suitable equipment was in place for the service users, including doorbells (on the front door and bedroom doors) and fire alarm systems, all of which used flashing lights. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well qualified and people living in the home like them. The home does proper recruitment checks to reduce the risk of employing unsuitable staff. Staff training is mostly good, with some areas where more training could improve the service given to people living in the home. EVIDENCE: Staff on duty demonstrated that they were knowledgeable about and interested in the service users’ lives and needs. All had completed training in British Sign Language at level 2. Three quarters of the care staff had a NVQ (national vocational qualification) level 2 in Health and Social Care, and the others were working towards this, which is commendable. Two staff had significant hearing impairments. The inspector spoke with them and they said their communication needs were understood and met, e.g. the home used an interpreter for training sessions, and she carried a vibrating alert for contact by other staff. The presence of deaf staff is good practice as their experiences can add to the team’s understanding of service users. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 20 The inspector did notice hearing staff on occasion talking to each other without signing, which could exclude the deaf staff and people living in the home who were present. The inspector was told that staff spoke, with a sign language interpreter, in staff meetings; the inspector wondered why signing was not the first choice for communication. The registered manager explained that less experienced staff with less developed sign language skills may not be able to fully understand a meeting using sign language only; also, some issues and concepts discussed were complex, and she felt that staff whose first language was not BSL may not be able to communicate complex issues in sign language, hence reducing the quality of information shared (whereas the skilled interpreter would be able to translate fully). There were sufficient staff for most care needs and activities, but staffing levels had been tight for a number of reasons this year. This had resulted in the registered manager needing to undertake care shifts. However it was hoped that staff levels would now be able to improve again. At least one person who lived in the home said they would like to go out in the evening, which would not be easy with current levels of care staffing. The home had obtained CRB (Criminal Records Bureau) disclosures for all existing staff and was aware of the need to obtain a full disclosure before any new staff began working in the home. The inspector saw application forms, interview notes and 2 written references in staff files sampled, indicating that the home took care to reduce the risk of recruiting unsuitable staff. However records pertaining to a staff member transferred from their “sister” home were still with the registered provider. These need to be kept in the home. The staff team was generally well trained, but with some relevant gaps. In addition to NVQs (national vocational qualifications) and BSL training mentioned above, they undertook a range of suitable training with the aim being for all staff to undertake all relevant training. Training was recorded and planned in a systematic way. Two staff had not been trained in Protection of Vulnerable Adults procedures or Disability Equality, and 4 had not had Total Communication training. These should be prioritised. In addition, moving and handling training was still needed by most staff and only one person had training about autism. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a good manager but staff shortages have impeded her progress this year. The home checks what it does, but not yet in a regular and systematic way. The home is basically safe for people living there, but more work is needed to make sure it is always as safe a possible and that staff are very clear about fire procedures. EVIDENCE: The registered manager had worked at the home for 13 years, for 2 years as the deputy and then for the past 6 years the registered manager. She held the Advanced Management for Care certificate and had completed the Registered Manager’s Award. Unfortunately her management hours had been limited this year due to a variety of staffing shortages, which had limited the progress she had made since the last inspection. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 22 The home was not yet fully implementing a quality assurance (QA) procedure. They had used a range of tools which could contribute to this e.g. checking the home’s progress against the NMS (national minimum standards), surveys of service users and their relatives. The inspector was told that the registered provider intended to produce an action plan every 6 weeks during 2008, covering different areas which he had looked at. The inspector advised that the evidence needed to be collated and a development plan drawn up for the home; the QA procedure still needed to be implemented fully. The home’s risk assessments were generally in place as required and mostly up to date, but there were some areas listed in NMS (national minimum standard) 42 for which assessments could not be found, such as COSHH (control of substances hazardous to health), gas safety, electrical safety, and security of the premises. One risk assessment for window restrictors dated from 2001. The home was carrying out required fire safety checks and tests and maintenance. However staff training in fire safety was being done only about twice a year, as opposed to the recommended 4 times. Fire drills had not been taking place twice a year, and not all staff took part in a drill once a year. Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 23 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 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X 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 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 24 No 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 YA6 Regulation 15 Requirement The home must develop service user plans of care which cover all aspects of service users’ lives, as described in NMS (national minimum standards) 2 and 6, and which are comprehensive and up to date. This will ensure that all staff are consistently aware of what care and support is currently needed by each individual service user. A complete written development plan for the home must be produced. This will ensure the home continues to improve its service, based on feedback from people living in the home and their relatives and other supporters. Timescale for action 31/03/08 2 YA39 24 31/03/08 3 YA42 13(4) Comprehensive and up to date 31/01/08 risk assessments must be in place, covering all relevant areas including those listed in NMS (national minimum standard) 42, and covering all potentially hazardous activities which people living in the home participate in. DS0000018626.V347361.R01.S.doc Version 5.2 Page 25 Bath Road, 85 This will ensure all possible steps are taken to reduce risks to people living in the home, without unnecessarily restricting their freedom. 4 YA42 23(4) All staff must take part in a fire drill at least once a year, and drills must be carried out in the home at least twice a year. This will ensure all staff are confident of the correct procedure in case of fire. 31/03/08 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 YA2 Good Practice Recommendations The registered manager should always ensure that a full social work assessment is completed before a new person moves into the home. The home should consult a dietician to see if they can improve provision of a healthy amount of fruit and vegetables. The registered manager should continue to arrange further staff training to ensure all staff receive training needed for their work, including Protection of Vulnerable adults; Disability Equality; Moving and handling; and Total Communication. 2 YA17 3 YA35 Bath Road, 85 DS0000018626.V347361.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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