Inspection on 05/03/08 for Bywell House

This inspection was carried out on 5th March 2008.

CSCI found this care home to be providing an Good service.

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

Bywell House 26/05/09

Bywell House 07/05/09

Bywell House 10/03/09

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

CARE HOMES FOR OLDER PEOPLE Bywell House 2 Longfellow Road Worthing West Sussex BN11 4NU Lead Inspector Mrs Diane Peel Unannounced Inspection 10:00 5 March 2008 th 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 Bywell House DS0000070052.V360615.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. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bywell House Address 2 Longfellow Road Worthing West Sussex BN11 4NU 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 236062 01903 236062 Hazelwood Care Ltd Mrs Michaela Ridley Care Home 20 Category(ies) of Dementia (0), Mental disorder, excluding registration, with number learning disability or dementia (0) of places Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 2. Mental disorder, excluding learning disability or dementia (MD). The maximum number of service users to be accommodated is 20. Date of last inspection N/A Brief Description of the Service: Bywell House is a care home registered to accommodate up to 20 older people in the categories dementia, (DE), and mental disorder (MD). The property is a detached building situated in a residential area on the outskirts of Worthing. The town centre and seafront are within walking distance and there are local shops and other facilities nearby. Buses and mainline trains are easily accessible. People living at the home are accommodated in twenty single bedrooms, which are located on the ground and first floors. A vertical lift provides access to each floor. Communal accommodation consists of a lounge and a dining area, which are located on the ground floor. There is an enclosed garden to the front and side of the property for people to use. This service is privately owned by Hazelwood Care Ltd. The Responsible Individuals who act on behalf of the company is Mr. Manvinder Singh and the Registered Manager, who is responsible for the day-to-day running of the care home, is Mrs Michaela Ridley. The fees for this care home currently range from £485 to £535 per week. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. On this unannounced visit to Bywell House our inspector, Mrs Diane Peel was accompanied by an ‘expert by experience’: An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. We use information from experts by experience to help us triangulate evidence and verify any issues. During this visit the intended outcomes for 31 standards were assessed; these included the key standards for care homes providing a service to older people. The Annual Quality Assurance Assessment (AQAA) was returned to The Commission for Social Care Inspection (CSCI) prior to this visit to the home and this was used to address areas of improvements with the manager. Have Your Say surveys were returned to us by seven relatives of people living at the home, sixteen staff working at the home and three health/social care professionals who visit Bywell House prior to the visit. Everybody returning surveys had positive things to say about Bywell House praising the level of care and homely environment. During the course of the visit we met many of the people living at Bywell House and spoke with those who were able to converse with us. A case tracking exercise for three people living at the home was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met. Staff were spoken with during the visit and observed during their interaction with people living at the home. The ‘expert by experience’ joined the people living at the home to experience the main meal of the day and spent time talking to people living at Bywell house and staff working there. What the service does well: Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 6 The home is comfortable and has a homely, clean, friendly environment. Over 50 of staff have an NVQ level 2 or above with further staff undertaking an NVQ qualification. Other training is readily available and undertaken. The recruitment procedures are thorough and protect people who use the agency. Care plans and associated records are clear and person centred. Relatives and health and social care professionals visiting Bywell House told us: “it is a very friendly home. The atmosphere is more like an extended family than staff and residents.” “wonderfully patient and kind.” “residents and their individual needs are addressed respecting their privacy.” “ a clever manager who supervisors staff well and uses their skills to provide good care to residents.” What has improved since the last inspection? What they could do better: The manager has agreed that to promote more privacy and dignity for people whilst using the bathrooms accompanied by staff, she will look at options for fitting suitable locks or a way of alerting people that bathrooms are in use. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 7 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. Bywell House DS0000070052.V360615.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 Bywell House DS0000070052.V360615.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): 1,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is information for people to help them decide if they want to live at the home, they have opportunities to visit and have their needs assessed before moving into the home so that they know that the home will be able to meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide were on display in the hallway and the registered manager told us that she has been updating information in it. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 10 The Annual Quality Assurance assessment returned to us in February 2008 stated, ““We have a pre admission assessment so that prospective residents are seen prior to admission. The pre assessment is carried out by the manager and a senior to ensure that we can provide the level of care, which is required. I also meet with the family or next of kin/ friend to discuss care needs and put them at ease” and “we encourage them to visit Bywell House and have a look at the room to ensure that they are happy with the home”. During our visit we saw enquiry forms in use and pre assessments carried out for the person who has most recently moved to the home. The homes own needs assessment, which we saw, was supported by a care management assessment carried out by a social services care manager. We were shown questionnaires that the manager sends to relatives and next of kin to find out about prospective people moving into the home. The manager told us that a trial period is offered for the first month and a written assessment is provide at the end of the period for relatives or next of kin. Some people come to the home for a respite period and decide to stay, the manager gave an example of when someone had been at the home for a respite period but decided that it was not for them and returned home. Information provided in the homes Annual Quality Assurance Assessment (AQAA) returned to us prior to the visit to the home reported that there are both male and female care staff working at the home of various ages between eighteen years of age and sixty five years of age and who are from diverse social, cultural, and religious groups. Bywell House does not offer intermediate care. Bywell House DS0000070052.V360615.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 good. This judgement has been made using available evidence including a visit to this service. People’s health care needs are being met and they are protected by the homes policies and procedures for dealing with medication. EVIDENCE: There were fifteen people living at Bywell House during the time of this visit to the service. The registered manager told us that everybody had a care plan and we chose to look at three care support plans at random during our visit to see how the needs assessment had been used to develop a plan of care. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 12 The three plans observed showed how people’s needs were to be met by staff. They identified problems, which people might have, and how best staff could help people but continue to encourage people to remain independent for as long as possible. The manager showed us a completed questionnaire, which she sends to prospective residents relatives and next of kin to gather further information about each person so that they are involved in the care planning process from the beginning. The care plans which we saw were person centred and included information about people’s childhood and family background. Daily records were observed to being used to monitor the wellbeing of the people living at the home and there was documented records of regular monitoring of weight, blood pressure and were applicable blood glucose levels. Manual handling risk assessments, fall risk assessments, pressure care risk assessments and nutritional assessments were observed to be being used. Records of visits by other healthcare professionals were being kept and regularly updated these included visits by doctors, district nurses and chiropodists. Three healthcare professionals returned Have Your Say survey to us, which gave us some information about the access to healthcare that people have who live at the home. A GP confirmed that the service seeks advice and acts upon it to manage and improve individual health care needs and one person said “ quite often staff inform us if families have raised any issues about health problems of residents and we jointly discuss issues raised with the staff /families. A relative returning a Have Your say survey to us told us “ the home is very good at keeping me informed when he is not very well and if they have called a doctor” and another person commented, “we are always kept informed of any health problems.” We were told that no- one living at Bywell House on the day of our visit was able to safely manage their own medication so we looked at the arrangements which the home has in place for making sure that people get their prescribed medication administered by staff. We looked at medication records, which included sampled of signatures for those staff having the responsibility of administering medication. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 13 Medication records sheets were clear and when medication had not been given for some reason this had been recorded. Medication in use was being stored in two metal cabinets attached to the walls in two different areas of the home. Additional store of medication was also being stored in a locked cupboard and the manager told us that medication opened and not used is by the time of the next delivery is returned for disposal. On the day of our visit a medication training course was due to be held later in the afternoon, which has been organised with the supplying pharmacist. When health care professionals were asked “ does the care service respect individuals privacy and dignity,” two of those responding said always and one said usually. Further comments about privacy and dignity received from the health care professionals were,” residents and their individual needs are addressed respecting their dignity and residents are examined in the presence of a chaperone in their rooms”. We discussed with the manager the absence of locks on the bathroom doors used by people living at the home. We were told that this would be a high risk for some individuals who might lock themselves in the bathrooms without staff presence. The manager has agreed that this is an areas of privacy and dignity which could be improved by the use of an override lock and had agreed to re assess the risks and look for suitable locks to be fitted which staff could override Bywell House DS0000070052.V360615.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 interests of people living at the home are recorded and they are provided with opportunities to take part in recreational activities and maintain contact with their family and friends. EVIDENCE: We were told in the AQQA returned to us in February 2008 “ we offer a wide range of opportunities for social and recreational activities to match the residents cultural, social and religious needs”. Examples given included: entertainment from outside agencies, bingo, reminiscence therapy, poetry, discussion groups, dancing, puzzles and softball games. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 15 The AQAA also told us that they have an arrangement with the local church and they come to the home on a monthly basis to hold a service and sing hymns and hold a small discussion group. During our visit we saw regular outside entertainment advertised in the lounge and we saw evidence of art products produced by residents, such as paintings on display on the walls in the lounge and Easter bonnets which had yet to be completed. There were photographs on the walls in both the lounge and the bottom of the stairs recording special events and parties which people had taken part in. There were also activities records in the care plans, which we saw recording what each person had taken part in. On the day of our visit staff played bingo with the people living at the home whilst they were waiting for their lunch. A relative returning a Have Your Say surveys told us “ the home is very good for the happiness and stimulation they provide for the residents, with music, singing and attention.” During our visit to Bywell House we saw that a visitors book in use recording regular visits to the home and the manager told us that no visiting restrictions are in place. Relatives retuning surveys to us commented, “ we are free to call or visit at any time ”, “ I make random visits,” I have always been welcomed and found my relative comfortable” and “we can always call or visit any time. We are also invited to parties and celebrations. Everybody spoken with about the quality of food provided at Bywell House thought the standard was good. The home has a four weekly meal plan. There is a roast dinner on Sundays and Wednesdays, a choice of fried or steamed fish on Fridays and the menus showed a variety of dishes on the other days. There was always two vegetables and potatoes. For supper there is a variety of hot dishes and we were told that tea and coffee with biscuits and cakes are provided mid morning mid afternoon and during the evening. Bywell House DS0000070052.V360615.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 good. This judgement has been made using available evidence including a visit to this service. There are policies and procedures in place for responding to complaints and allegations of abuse and neglect so that people can feel safe. EVIDENCE: The complaints procedure was on display in the entrance hall and is included in the Statement of Purpose and Service User Guide. Information provided by the manager in the AQAA returned to us in February and confirmed by the manager during our visit to the home told us that their had been no complaints received. No concerns had been brought to our attention either as a complaint or a safeguarding adults matter. No relatives returning Have Your Say survey to us told us about any complaints which they had made and fifteen out of the sixteen staff returning Have Your Say surveys to us that they knew what to do if a service users, their relative or advocate or friend has concerns about the home. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 17 During our visit to the home we told that the home has a copy of the revised West Sussex Multi Agency Safe guarding Adults procedures besides its own policies and procedures on safeguarding adults and the manager confirmed that she had attended the “road show” about revised policy. Staff training records showed that the majority of staff had already attended safeguarding adults training and for four staff this had been since the beginning of January 2008. For those people who are still undertaking their induction process they complete the Skills for Care Unit 5 as part of the induction: Recognising and responding to abuse and neglect whilst awaiting the formal safe guarding adults training. Bywell House DS0000070052.V360615.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. People live in a homely well-maintained environment so that they can feel comfortable and safe. EVIDENCE: On the day of our unannounced visit the home was clean and fresh and looked homely and comfortable. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 19 There is an ongoing redecoration programme being undertaken where vacant bedrooms are redecorated and a decorator was present in the house decorating a bedroom at the time of our visit. The manager told us that carpets in the hall and stairs are being replaced and the hallway upstairs is to be redecorated. We looked around the home and saw that people’s bedrooms are individually decorated and for the majority of people their own items of importance, such as photographs, painting and ornaments were on display. Two people had items reminding them of their own personal achievements on display. The communal areas included a lounge, a dining area and a quiet room all of which were comfortable. Bywell House DS0000070052.V360615.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 excellent. This judgement has been made using available evidence including a visit to this service. The wellbeing, health and security of people living at the home are being protected by the agency’s policies and procedures on recruitment. EVIDENCE: The manager told us that there are usually four care staff on duty in the mornings, four in the afternoon and two at night. A cook and a housekeeper support them. On the morning of our visit there were four care staff on duty and an additional person being inducted, the manager, and a cook. We were shown schedules of work allocation which the manager sets up days in advance for the staff to follow so that they can know who they are assisting and making sure that peoples needs are met. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 21 We looked at recruitment files of three people, two who had started work at the home recently. We saw that they had been asked to fill in an application form, provide identification of themselves, which included a photograph, and show that they were medically fit to work with living at the home and references had been requested from people who they had worked for before. There was also a Criminal record Bureau (CRB) and Protection of Vulnerable Adults (POVA) clearance for two people and a POVA first clearance for the third person who the manager told us was working under supervision. Sixteen staff returned Have Your Say surveys to us, which told us that everybody had an induction and that everybody returning surveys thought that the training being given was relevant to their role. We observed training records and schedules of training to be provided and the induction followed. The manager told us that the staff had agreed to have a copy their qualifications and training certificates in a file in the entrance hall so that people could see what skills they had. We saw the file in the entrance hall next to the Statement of Purpose and Service User Guide. The AQAA, which we received from the manager in February, told us that 70 of staff working at the home have an NVQ qualification at Level 2 or above. Bywell House DS0000070052.V360615.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): 31,33,35,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from the leadership and management of the home. The views of the people living at the home and their relatives are sought so that they know that the home is run in best interests of the people who live there. EVIDENCE: The registered manager has many years experience of working in care homes. Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 23 She undertook the fit persons process with us in December 2007 and had previously been the registered manager of another care home. She has NVQ qualifications at level 2,3,4 in social care and has the Registered Manager award NVQ level 4. A quality assurance process is in operation in the home and we were shown a replacement system, which is to be introduced soon. People living at the home, their relatives and next of kin are invited to complete quality assurance surveys which look at areas of the service such as: food choice, entertainment, personal service, management, the level of care and the environment. We were told in the AQAA returned to us that as a result of such feedback there is a new menu “adapted according to residents requests.” The manager told us that the home has a policy for not dealing with people’s monies. Services provided which are not included in the fees are invoiced from the company head office. For one person who has monies kept in the home receipts are kept and the forwarded to this persons advocate. All records observed on the day of our visit to Bywell House were clear and up to date. During our visit we observed that one bedroom door opened a different way to all the others and that a bolt high up on the window on the stairway had not been fixed back in place properly after decorating. The manager agreed to call in the maintenance person to make the adjustments. Bywell House DS0000070052.V360615.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 X 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 Bywell House DS0000070052.V360615.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bywell House DS0000070052.V360615.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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