Inspection on 22/05/06 for Charnwood

This inspection was carried out on 22nd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Charnwood 07/07/10

Charnwood 22/02/10

Charnwood 01/12/09

Charnwood 17/08/09

Charnwood 08/04/09

Charnwood 10/07/08

Charnwood 06/12/07

Charnwood 16/05/07

Charnwood 19/10/05

Charnwood 03/05/05

Charnwood 20/09/04

Charnwood 19/04/04

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

CARE HOMES FOR OLDER PEOPLE Charnwood 68 Bidston Road Oxton Birkenhead Wirral CH43 6UW Lead Inspector Peter Cresswell Key Unannounced Inspection 22nd May 2006 9:15 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 Charnwood DS0000018873.V288725.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. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charnwood Address 68 Bidston Road Oxton Birkenhead Wirral CH43 6UW 0151 652 1984 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 Ashcroft Mrs Sheila Margaret Ashcroft Mrs Sheila Margaret Ashcroft Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person over the age of 65 with mental disorder may be accommodated 19th October 2005 Date of last inspection Brief Description of the Service: Charnwood is a large, three storey detached house on a main road served by bus routes to Birkenhead town centre and other parts of Wirral. There are shops and other local facilities within walking distance of the home. Residents accommodation is in five single bedrooms and seven that are available for sharing. On the day of this inspection there were 13 residents in the home and six were in single rooms. One of the rooms is used as a staff sleep-in room and is therefore not available for residents. The home has a shaft lift that provides access to all floors, including the basement/lower ground floor, which provides access to the garden and houses the owners’ accommodation, the office and the kitchen. Charnwood has a large combined communal lounge and dining room. The lounge is divided into a TV watching area and a quieter area nearer to the windows overlooking the spacious and attractive gardens. There is car parking at the front of the home. Fees are £344 per month. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this unannounced inspection the inspector spoke to a number of residents and staff, including the Registered Manager (who is also one of the owners) and her deputy. He toured the building, including all of the bedrooms and the kitchen. The inspector checked the home’s medication procedures and examined a number of records, including care plans for three residents, safety records, recruitment records for new staff and the service user guide. The Registered Manager completed a detailed pre-inspection questionnaire before the site visit. Two questionnaires were sent to relatives and one of them responded, stating that Charnwood was ‘an excellent care home; professionally run’. None of the residents returned questionnaires. The visit lasted over six and a half hours. What the service does well: What has improved since the last inspection? What they could do better: Charnwood still does not employ any domestic staff. This has not affected cleanliness but inevitably draws care staff away from other duties such as arranging and supporting activities. Two new members of staff were employed before POVA First checks had been obtained. No written references had been obtained. This is unacceptable and recruitment procedures must be tightened to ensure the fitness of people employed at the home. A quality assurance process would help the Registered Person to identify the views of residents and Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 6 relatives on areas where the home might be improved further. The home does not have formal staff supervision or an adequate staff training programme. 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. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 7 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 Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is adequate. Residents are assessed before moving into the home and are encouraged to visit the home before making a final decision, helping them to decide if the home is the right one for them. The home’s service user guide is outdated, so prospective residents do not have an up to date guide to the facilities offered. EVIDENCE: Charnwood has a service user guide but it has not been reviewed since 2002. It is therefore out of date in some respects (for instance it refers to the National Care Standards Commission, which was replaced by CSCI in 2005). The Registered Person is obliged to keep the service user guide under review and should complete this as soon as possible to ensure that prospective service users have all of the relevant information they need to make an informed choice of home. No residents who have their care paid for by a local authority (that is, all but one) have a statement of terms and conditions. Although a contract is not appropriate in such circumstances, the resident should have a statement of terms. The most recently admitted resident had been fully assessed before admission by the Registered Manager who had visited the resident in her previous care home. A detailed written assessment was on file. The resident’s family had been fully involved in the admission process and the Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 9 resident herself said that she had been able to visit Charnwood before admission and had made her decision on the basis of what she saw as the welcoming, homely atmosphere in the home. Charnwood does not provide intermediate care so Standard 6 does not apply. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is adequate. Some care plans are detailed and regularly reviewed but others are out of date, meaning that staff do not have the up to date information available in order to provide appropriate care. Medication is on the whole well organised but some minor changes are needed to protect the welfare of the residents. EVIDENCE: The most recent resident has a detailed care plan which has been reviewed regularly by the Registered Manager. Other residents also have care plans but some of them are out of date and have not been changed for over a year even though the residents’ circumstances and needs have changed. Some reviews have been held and these do record changes in the resident’s needs, but the developments are not reflected in the care plans. An out of date care plan can be positively misleading so it is important that they are updated as often as is necessary. The Registered Manager said that she is in the process of fully reviewing all care plans and bringing them up to the standard of the one in place for the newest resident. The Registered Manager and her deputy both have detailed and up to date knowledge of each resident but this needs to be recorded on the care plan. Residents are registered with a local GP and visits by doctors and other medical professionals are recorded on the file. A daily record is kept for each resident. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 11 Medication is organised in NOMAD cassettes which are pre loaded and supplied by the pharmacist. The pharmacist has provided a checklist on PRN medication (administered as and when necessary) that gives helpful advice on when to administer such medication. Medication is well organised but some tablets received from another home following a temporary stay there had not been recorded. The deputy manager said that the medication received had been so chaotic that it had proved difficult to record it, so the stocks transferred had been used and then new prescriptions sought. This leaves no accurate record of whether all of the medication had in fact been properly used. It is essential that all medication received in the care home is accurately recorded. The Royal Pharmaceutical Society’s guide to the administration of medicines in care homes states that all medicines brought into the home – ‘from whatever source’ – should be accurately recorded. Those small amounts of medication requiring refrigeration are kept in a box in one of the kitchen fridges. Residents do not normally have access to the kitchen, but some means should be found of making sure that any such drugs are stored completely securely. When it is specified that medicines (such as eye drops) must be disposed of a certain time after opening, staff should sign and date the container when it is first opened. Personal care is provided discreetly in private and there are screens in those rooms which are shared. The new care plans record the wishes of the resident in the event of their death. All of the residents were very well dressed and those who spoke to the inspector said that the staff were very helpful and caring. One relative of a resident returned a questionnaire to the Commission and said that he was more than satisfied with the care his relative receives in the home. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The quality in this outcome area is good. Charnwood provides activities which enhance the lives of its residents and extending these would further improve residents’ well-being. The menu is well balanced and served at reasonable times, meeting the needs and tastes of the residents. EVIDENCE: Charnwood now employs an occupational therapist as an activities co-ordinator for two hours a week and a pianist visits the home most weeks for a couple of hours. The residents join in with singing and some dancing when the pianist visits. Residents said that they enjoy the activities and some of the pictures, including the ‘Welcome to Charnwood’ sign, they had made with the OT were on display. Staff also do their best to provide other activities and on the day of the site visit one of them played dominoes with two residents. Other residents said that they spent their time watching television and reading. One resident goes out of the home on his own to visit local shops and facilities; others said that their relatives are frequent visitors and are made welcome in the home whatever time they choose to arrive. In-house activities would be improved if additional activities co-ordinator hours could be provided. The Registered Manager said that a record is kept of activities but this was not available at the time of this visit. The main meal of the day is served in the early evening, with a lighter meal at lunchtime – usually soup and sandwiches on the menu, though on the day of Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 13 the inspection it was sausage rolls and rice salad. There is not usually a formal choice on the menu but the Registered Manager said that individual choices were always catered for. Not all residents seemed to be very clear about the situation regarding choice and it may be advisable to remind individual residents from time to time. Residents felt that the food was good quality – ‘good home cooking’ was one resident’s description. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Quality in this area is good. Charnwood has appropriate policies in respect of complaints. EVIDENCE: The Registered Manager said that she has not received any complaints in the last year. Concerns raised by residents or their families are dealt with informally. The home’s complaints policy should be revised alongside the review of the service user guide. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. The home is clean, well maintained, and free from offensive odours, providing a comfortable environment for its residents. Residents have well furnished, comfortable rooms though many of them are shared. Some longstanding, if relatively minor, items of maintenance need to be addressed to ensure residents’ continuing comfort and safety. EVIDENCE: Charnwood is clean, spacious, well furnished and homely in appearance. The home smelt fresh on this unannounced inspection and there were no offensive odours in any area. Work on improving the décor of the laundry has made no further progress. There has been a leak from a roof gutter for some time and several rooms on the second floor have water damage to the decor – quite severe in one case. The Registered Manager said that the guttering will be replaced when scaffolding is erected (during a dry spell) to repaint the exterior of the building. The vinyl flooring in several bathroom and toilet areas (including room 9, bathroom near room 3, toilet by room 7). The toilet on the ground floor – well used by residents – is in a poor state (the lock does not work, there was no toilet seat, the vinyl floor was lifting, no toilet roll). This Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 16 has not improved since the last inspection and must be brought up to an adequate standard as soon as possible. The ground floor bathroom is not used much by residents, who prefer to use one of the assisted baths, and the manager said that she is proposing to remove the bath and convert the room into a cloakroom/toilet. All bedrooms are bright, spacious and personalised, some containing old and much loved items of furniture brought in by residents. Three bedrooms are shared and although the residents have all agreed to share with another person there is no evidence that they have made ‘a positive choice to share with each other’ (National Minimum Standard 23). There was a discarded ‘bedleaver’ bar in one room and the Registered Manager said that it was no longer being used. Should such a device ever be used again a risk assessment must be completed. Charnwood no longer has a visitors’ room. The room once used for this purpose on the first floor is now a staff sleep-in room and the former room in the basement is being used to store junk. Neither room was ever used much by visitors and the Registered Manager said that she has alternative proposals in mind. In the meantime visitors see residents either in the lounge/dining room or in their own rooms. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is poor. The home does not have enough domestic staff and this reduces the time staff have available to spend with residents. Care staff are not yet appropriately qualified and the home does not have a current training programme. The home’s recruitment procedures are inadequate and potentially leave residents at risk of being cared for by unsuitable staff. EVIDENCE: The Registered Manager has appointed two new care assistants since the last inspection but Charnwood continues to rely on a very small group of long serving and hardworking staff. There are still no cleaning staff and the only designated domestic hours are allocated on the rota to a member of the family. Most domestic tasks are therefore carried out by care staff, inevitably limiting the time spent on activities, trips out and one to one contact. The Registered Person has not obtained CRB certificates or POVA clearance for the two new members of staff. The forms were submitted but have been delayed as the owner’s subscription to the umbrella body processing the checks was out of date. This is a breach of the Care Homes Regulations 2001 and is entirely unacceptable. Staff must not start work without POVA (Protection of Vulnerable Adults) clearance. This issue was also raised at the last inspection and it is unacceptable that it should have happened again. The Registered Person feels that other homes start staff without proper clearance but was advised that the Commission for Social Care Inspection takes such breaches very seriously, wherever they take place. Telephone references had been obtained, and a written record made, but no written Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 18 references had yet been obtained. The Registered Manager said that she was writing for them, this had not been done. One of the owners (the manager’s husband) is the chef. The Registered Manager arranges some training but was not able to show any evidence of recent training. No staff at Charnwood yet have NVQs but one member of staff has now completed her NVQ2 and is awaiting her certificate. At least one other carer is keen to start an NVQ and the Registered Manager and her deputy continue working towards NVQ4. Inevitably the home fails to meet the standard of 50 of care staff with NVQ2 and it is important that NVQ training continues and accelerates. The Registered Person may wish, as suggested at the last inspection, to check with the government agency NARIC if any of the qualifications of her overseas staff are equivalent to care sector NVQs. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36, 37, 38. Quality in this outcome area is poor. The manager is highly experienced but the home does not have adequate systems for staff supervision or quality assurance. There are therefore few systems available to monitor and protect the level of service to the residents. Fire safety procedures are in place to ensure residents’ safety. EVIDENCE: The Registered Manager (who the residents call ‘matron’) is very experienced and continues to study for NVQ4, as does her deputy. She is proposing to introduce a quality assurance system from an outside organisation but has not yet done this. Although some questionnaires are collected from time to time there is nothing resembling a quality assurance system in place. The inspector again discussed with the Registered Manager how this could be done. The Registered Manager said that she supervises staff informally but there are no records of this. The home does not handle residents’ finances and all of this is done by relatives. Records are stored securely in the manager’s office. Accidents are properly recorded and filed in accordance with the Data Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 20 Protection Act. Fire safety records were up to date. The home’s accounts are audited by Montrose Accountants in Parkgate and are available for inspection by the Commission for Social Care Inspection if required. Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 2 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 3 3 1 3 3 Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP1 OP7 Regulation 5, 6 15 Requirement The Registered Person must produce and keep under review, a service users’ guide. The Registered Person must prepare and keep under review a written plan (a care plan) for each service user. The Registered Person must make arrangements for the recording of medicines received into the care home, including those received from other establishments. The Registered Person must ensure that the home is in a good state of repair and in order to do so must: repair or replace the vinyl in those bathrooms and ensuites where it is lifting; repair the water-damaged décor on the first floor, especially in rooms 9 and 10; repair the seat, taps, lock and décor in the ground floor toilet. The Registered Person must employ additional domestic staff to meet the staffing standards set by the previous registering DS0000018873.V288725.R01.S.doc Timescale for action 01/08/06 01/10/06 3. OP9 13(2) 22/05/06 4. OP19 23(2) 01/08/06 5. OP27 18 01/08/06 Charnwood Version 5.2 Page 23 authority. (Originally required by December 2004.) 6. OP29 19 The Registered Person shall not employ a person to work at the care home unless they are fit to do so and have POVA clearance. The Registered Person must ensure that all people employed in the home receive training appropriate to the work they perform. The Registered Person must make arrangements to review at appropriate intervals the quality of care provided in the home by introducing a quality assurance system. (Originally required by December 2004). 24/05/06 7. OP30 18 01/10/06 8. OP33 24 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP2 OP9 Good Practice Recommendations Service users who are funded by a local authority should be provided with a statement of terms and conditions. It is advisable to mark the date of opening on the container of medications with a limited shelf life following opening (such as ear drops). The Registered Person should investigate other means of safely storing medication requiring refrigeration. The Registered Person should consider extending the range of activities provided for residents. The home’s appearance would be enhanced by the redecoration of the front porch area. Residents sharing a bedroom should be given the opportunity of moving into a single room when the opportunity arises. DS0000018873.V288725.R01.S.doc Version 5.2 Page 24 3. 4. 5. OP12 OP19 OP23 Charnwood 6. OP27 The Registered Person should continue the programme of NVQ training for care staff with a view to achieving 50 of staff with NVQ2. Staff should receive regular, formal supervision, of which a record is kept. 7. OP36 Charnwood DS0000018873.V288725.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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