Inspection on 23/11/06 for Chasewood Lodge

This inspection was carried out on 23rd November 2006.

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

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

Other inspections for this house

Chasewood Lodge 23/03/10

Chasewood Lodge 06/01/10

Chasewood Lodge 17/01/09

Chasewood Lodge 12/12/07

Chasewood Lodge 13/04/06

Chasewood Lodge 02/02/06

Chasewood Lodge 09/06/05

Chasewood Lodge 04/10/04

Chasewood Lodge 18/05/04

Similar services:

Coton Hill House

Doddington Lodge

Far Croft

Churchill House Nursing and Residential Home

Field Farm House

Church Terrace Nursing & Residential Home

Fountain Court

The Forbury

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

CARE HOMES FOR OLDER PEOPLE Chasewood Lodge Mcdonnell Drive Exhall Coventry West Midlands CV7 9GE Lead Inspector Yvette Delaney Key Unannounced Inspection 23 November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chasewood Lodge DS0000004215.V316693.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. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chasewood Lodge Address Mcdonnell Drive Exhall Coventry West Midlands CV7 9GE 02476 644320 02476 644320 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) Chasewood Care Ltd Ms Maria Christine Edwards Care Home 107 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (95) of places Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The initial number of residents accommodated will be limited to 10 on the blue unit. All building work and furnishing is completed in the blue unit prior to service users being placed and documentation showing evidence of completion is provided to the Commission All further increases in occupancy up to a total of 107 must be staged and agreed in writing with the Commission and may be subject to further site visits. The drive way and the moat must be risk assessed and be made safe for staff, service users and relatives prior to opening of the new unit. These are also subject to a notice of proposal, which had not been determined at the time of inspection. Date of last inspection 13th April 2006 Brief Description of the Service: Chasewood Lodge Care Home is registered to provide care to 107 elderly men or women with varying levels of dementia. At present, the first floor and twelve bedded unit of the new extension are being completed. Residents have started occupying and living on the ground floor of the new extension. Assisted bathrooms and toilet facilities are provided. There are currently three lounge/dining areas and two quiet lounge rooms available for residents to use. Chasewood Lodge is situated in a cul-de-sac and lies next to the M6. There are local shops, which are accessible and the nearest town is Bedworth. There is local bus service to the home. There is a car park at the front of the home and limited car parking by the entrance to the building. The manager has advised on 21 November that the current fees for a place in the home is £400 to £410 per week paid by the local council with an additional top up fee for residents who occupy bedrooms in the new extension. Other additional charges include the hairdresser, chiropody, personal toiletries, newspapers and magazines. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This unannounced inspection was carried out by two inspectors and took place over two days. Thursday 23 November between 9:30am and 4:35pm and Friday 24 November between 8:30am and 6:35pm. Four residents were ‘case tracked’. This involves establishing an individual’s experience of living in the care home. The outcome of residents experiences are explored by meeting or observing them, discussing their care with staff, looking at their care files, and focusing on outcomes for residents. The care plans of four residents were also examined to assess the preadmission process that had been carried out and these were found to be absent or lacking information. Inspectors had the opportunity to meet some of the residents and talked to four of them about their experience of the home. General conversation was held with other residents along with observation of working practices and staff interaction with residents. Some of the residents were able to express their opinion of the service they received. Some residents found it difficult to engage in conversation due to their medical condition but were able to express their feelings through verbal and non-verbal communication. Conversations were also held with three visitors and a visiting nursing auxiliary about their experience of the home. Before the inspection, a random selection of residents and relatives were sent questionnaires to seek their independent views about the home. The response was good and showed a mix of both positive and negative comments. The registered manager of the home completed and returned a pre-inspection questionnaire containing further information about the home as part of the inspection process. Some of the information contained within this document has been used in assessing actions taken by the home to meet the care standards. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 6 An inspection of the environment, which includes all of the new build, was undertaken. A conversation was also held with staff from the local building control department, who were assessing the new extension to the home on its suitability to be occupied. Records were sampled, which include staff training, health and safety, rotas, complaints and fire records. Since the last key inspection on 17 July 2006, we have received two complaints, which were forwarded to social services for investigation under Protection of Vulnerable Adults (PoVA) procedures. The issues raised are varied and include allegations of poor standards of care, institutional physical and verbal abuse, misappropriation of residents’ monies, poor infection control and poor cleanliness of the home. A number of concerns relating to standards of care in the home over the current year have resulted in ongoing Multiagency PoVA meetings being held. Meetings have served to monitor progress made in the home to improve the standards of care. What the service does well: What has improved since the last inspection? Care records show that some residents had been referred to other health and social care professionals as appropriate. There was evidence of the follow through and monitoring of the outcome of instructions from professionals. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 7 The home has an open visiting policy that takes into account the individual needs and wishes of residents. Two residents spoken with confirmed that visiting is flexible and that their visitors are made to feel welcome. 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. Chasewood Lodge DS0000004215.V316693.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 Chasewood Lodge DS0000004215.V316693.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): 3, 4 and 5 Quality in this outcome area is poor. The service’s pre-admission assessment system is not robust enough to demonstrate that the home can meet the needs of prospective residents’. This judgement has been made using available evidence including a visit to this service. Standard 6 is not included in this judgement, as the home does not provide intermediate care. EVIDENCE: The care files for the most recent residents admitted since the last random inspection in July 2006 were examined. Four residents were identified from the Pre-inspection questionnaire received by the Commission. Three care files were examined solely to determine whether pre-admission assessments had been carried out before residents were admitted into the home. One of the files was also followed through the case tracking process. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 10 Applications to the home are made by either social services or privately if selffunding. Individuals referred by social services have a care management assessment carried out before moving into the home. Private applications for admission are agreed without reference to a care needs assessment, or consideration of the skills, ability or knowledge of the staff that will be caring for them; for example, initial care needs assessments for two recently admitted privately funded residents were not available. As a result care plans had not been developed to detail all the care needs of these residents. The personal profiles of four residents identified for case tracking were read and showed that staff at the home had completed a pre admission assessment for three of the four residents. Information recorded in the assessments was limited and did not include all the information necessary to determine whether the individual’s needs could be met. For example, the date pre admission assessments were completed was not recorded and initial care needs failed to include details of current medication. Further Information identified residents’ need for assistance with personal care but failed to include details of what is required of staff. Staff also failed to make use of information supplied by other care services. One resident had a history of falls, information for another resident detailed how best to manage and prevent their challenging and aggressive behaviour. The information provided was not included in the homes initial care needs assessment. A visiting relative spoken to said he was not aware of someone from the home visiting his relative before they moved into the home but had visited the home to look at the service and facilities. He was also able to confirm that a brochure and other literature had been supplied by the home. Two visitors spoken to said they had been involved in planning their relative’s care. The home does not currently formally inform prospective residents or their families, that they can meet the needs of a prospective resident. The home does not provide intermediate care. Chasewood Lodge DS0000004215.V316693.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 and 10 Quality in this outcome area is poor There is insufficient detail in the recording of individual health, personal and social needs to demonstrate that needs are being met. The standard of medicine management within the home is poor, which may affect the health and welfare of residents. This judgement has been made using available evidence including a visit to the home. EVIDENCE: The care plans, daily records monitoring records and medication records of four residents identified for case tracking were read and some of the outcomes identified are as follows: Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 12 Regular care reviews occur and a number of risk assessments were carried out for activities that might place residents of risk of harm or injury for instance bathing and falls. A resident was assessed as being at risk of climbing out of the window. Observations in the resident’s room showed the window was fitted with restrictors and the resident was no longer ambulant and being cared for either in bed or in a chair. A hospital type bed with height adjuster and propad mattress was used to reduce risk of developing pressure sores. Bed rails with protectors were in situ to reduce the risk of falling out of bed. The absence of a risk assessment for the use of bed rails is unsafe and places the resident at risk. The care plan includes has no problems with her bowels as this is controlled by medication. There is no mention of the need for staff to encourage a high fibre diet including fresh fruit and vegetables necessary to reduce the risk of constipation. Daily records note that on several occasions, the resident was wet and had to have pants changed there is no reference as to how incontinence is to be managed. Under the heading, Challenging behaviour staff note, … is content and settled” daily records include can become quite stubborn about going to bed. Daily records show the resident prefers to sleep in a chair in the lounge. This behaviour was not included in the care plan. The care plan shows that one resident has a swollen left foot and leg and identifies the need for staff to make sure the leg is elevated when the resident is sitting. On day, one of the visit staff failed to remind or to assist the resident to elevate her leg until mid morning. The resident was spoken to and said her leg was very painful. Observations on day two showed the resident sat all day without the leg being elevated and did not therefore receive the care and attention needed. Examination of Medication Administration Records (MAR charts) belonging to this resident showed paracetamol tablets one or two tablets to be taken four times each day were prescribed. Records indicate the resident refused paracetamol until day one of our visit when paracetamol was given. The MAR Chart failed to indicate the dosage i.e. how many tablets were administered. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 13 Other medication identified on the MAR chart includes Cetraben Emollient Cream to be applied as directed. Staff advised the inspector this was four times each day. The MAR show the cream was not applied on two consecutive days and staff had signed to indicate not required there was no recorded information to indicate why the cream was not required or why it wasnt applied in accordance with the pharmacist’s instruction. The MAR chart included Trimethroprim tablets, which can be prescribed for a urinary infection. A senior carer and a care worker responsible for looking after the resident were unaware of why the resident was taking Trimethroprim. Daily records showed the GP had visited and prescribed the course of treatment for a urinary tract infection. MAR chart show that medication was not administered as prescribed for example; tablets were given at 09.00hrs and 1700hrs and not every twelve hours as prescribed. The care plan of the second resident identifies the need for two carers to provide assistance with bathing but fails to include the action to be taken by staff to make sure the resident’s care needs are met safely and appropriately. The care plan does provide staff with some information, which would support the resident to maintain some areas of their independence for example, give …soaked flannel and prompt … to wash. The resident is assessed as being at risk of displaying challenging behaviours and can be restless at night and walks about touching other residents. The care plan fails to include how this behaviour presents and how the resident is to be managed at night so that the home can be sure all residents are safe and not placed at unnecessary risk. Care plan documentation identifies the need for the resident to have regular weight checks. Records of weights were held for July, August and October and show significant weight loss. Records of visits made by health care professionals show that the GP was informed of the weight loss and investigations into the possible cause commenced. Other records examined show that weight monitoring records held were not dated. The absence of a date does not provide an audit trail for monitoring improvement or deterioration in the resident. Medication records of the second resident identified for case tracking also found gaps in the recording and administration of medication and therefore the home cannot be sure medication was administered as prescribed. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 14 Ferrous sulphate tablets were administered but the MAR records failed to include the time the medication was administered therefore the home cannot be sure practices are safe. Failure to administer medication to residents’ as prescribed could result in deterioration of their health and wellbeing and is an omission of care. Comments made by a visiting health care professional include; staff appear caring and follow the instructions left by the nurse. The health care professional talked about the arrangements for health care consultations and treatments, which are provided in privacy. Observations during the visit found staff attended to residents’ personal care needs in private. Further comments made by a nurse expressed concerns about moving and handling techniques used in the home. The nurse had observed four care staff attempting to transfer a resident from a chair to a bed. All care staff were unaware of how to use the hoist correctly and were using the wrong size sling. Care plans identified that the resident was to be transferred using the hoist at all times. Incorrect use of the hoist and using the wrong size sling put the resident at risk of falling out of the hoist and possible entrapment. A third resident case tracked was seen to use his Zimmer frame incorrectly when mobilising. The frame was been pushed a distance away from his body and affecting his balance. Although supported by a member of staff they failed to help him use the frame safely to minimise the risk of loosing the frame and possibly falling. Discussions were also held with the registered manager as daily records detailed concerns about the resident continuously using the Zimmer frame to come down the stairs when first admitted to the home. The resident had originally been admitted to the first floor of the old building of the home. A pre-admission assessment had not been completed before the resident’s admission in September 2006. An initial assessment of his mobility needs was not identified. A risk assessment had been completed but was not specific as to what preventative measures were to be taken by staff and whether the resident was able to acknowledge the danger of using the frame in this way. It was also not acknowledged until a month following admission that the resident needed a bedroom on the ground floor where they are presently accommodated. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 15 A bath book is held and used by staff on one of the units in the home therefore information about personal care is not appropriately held. A staff hand over book is also used to convey information to staff coming on duty. Documentation held in respect of individual residents must be held on their personal record files to maintain data protection and facilitate any requests for access to personal records. One visitor also commented that their relative’s spectacles were missing and they were not aware of any arrangements to have these replaced. Care plans and visiting professionals seen on the day demonstrate that residents have access to health and social care professionals. A visitor said residents do see other health professionals but on one occasion when she was concerned about her relative, she asked staff several times to arrange a GP visit and heard nothing for 12 days. The time when this occurred was not available. Comments on comment cards received related to care include: Ive been in Chasewood Lodge for …… and my family feel the care has been poor. “…Within a couple of years they had her back to normal, eating and carrying on a normal life…” “Sometimes I feel my mother is uncomfortable and needs changing more.” “Not enough individual care.” Records kept have improved slightly since the last inspection in that they are more organised. However, care planning is still inadequate and fails to clearly identify the care needs of individual residents and the actions staff need to take to meet those needs. Failure to improve care plans was also identified to be due to the lack of monitoring and auditing by the registered manager. The manager confirmed that there are plans are to involve the services of an external trainer to help with the improvement of care plan documentation. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 16 Care review records do not evidence consultation with the resident or their relative. Care plans and other care file documentation is not always dated, timed and signed to provide an effective audit trail for monitoring care records written by staff. Daily records tend to be repetitive and fail to detail consistently how individual needs have been met. An example of this is provided in the care plan of one of the resident case tracked, which shows that the resident is reluctant to have personal care or to have their dirty clothes changed. Staff fail to identify how personal care is provided or how the residents reluctance is to be managed. Daily records include assisted with personal care but fail to identify what was provided. Three staff spoken to were aware of care plans but not fully familiar with the information held on the care plans for example one carer couldnt say whether a named resident was continent. A number of residents with dementia were unable to express their views and opinions, but those who could say the staff treat them well and are both kind and patient. There was evidence of institutional practices, for example; toiletries belonging to two residents in a shared room were stored together and unnamed therefore the home could not be sure personal items were being used appropriately and individual choices and preferences respected Some residents looked well presented but a number of residents did not wear stockings or tights. Residents were unable to communicate whether the reason for not wearing of tights was based on choice. One resident wore a cardigan that was out of shape and creased and the not of a an acceptable standard. Shortfalls identified during the last inspection have not been addressed as the inspection found some residents continue to wear clothes belonging to someone else. Comments from relatives in reference to clothing include: “I complain every time I visit my mum about her clothes going missing and that other residents are wearing her clothes and my mother is wearing somebody’s old clothes.” Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 17 Most residents private rooms were locked therefore privacy and security was promoted and protected. A number of bedroom doors were unlocked and easily accessible. The inspector was advised that the reason for this was to enable residents who are independent easy access to their rooms. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 18 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 and 15 Quality in this outcome area is adequate. The home does not provide sufficient opportunity for residents’ to participate in stimulating and meaningful activities or to exercise choice and control over day to day life in the home. Families and friends are made welcome to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an open visiting policy that takes into account the individual needs and wishes of residents. Two residents and three visitors spoken to confirm visiting is flexible and visitors are made to feel welcome. Therefore, shortfalls identified during the last inspection have been met. Visitors were observed visiting their relative in the privacy of their own room or in communal areas of the home. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 19 Care plans selected held a pen picture of the resident and although limited provide staff with some knowledge of the individual. The home does not employ a dedicated activities worker. The provision of appropriate social and therapeutic activities is the responsibility of the care staff who generally plan activities on a daily basis. There are no details of regular activities displayed or evidence of consultation with residents about the programme of activities to be arranged in the home. Daily records held very little information about how residents spend their time. Written entries for one resident followed through case tracking include walking around, really enjoyed her day folding up tea towels. Observations in the old part of the home found a resident playing a game of dominoes with a carer and a number of books and coloured floor skittles were available for use. In one of the units a carer was encouraging a group of residents to participate in a ball game. Residents have the opportunity to attend a church service in the home. The majority of residents spend their time sitting in the lounge/dining areas or walking about. The care plan and daily records of a resident with dementia failed to show how and where she spends her time and what suitable options were open to her in terms of daily life activities. Consideration should be given to the introduction of tactile boards and other items that are safe to touch and which encourage finer dexterity skills. The environment lacks stimulation and failed to engage residents with dementia and who spend long periods with little or nothing to occupy them. Three relatives spoken to said there were little or no activities going on in the home. Two residents spoken to also said, there is not much to do. One relative said some residents went out in the summer to local places of interest and sometimes had a pub meal. Comments noted on residents’ comments cards related to activities in the home include: There are drawing activities but I am unable to join in with that, Im not sure what else they do. “I would like to see more physical activities for the residents that would help to stimulate and amuse them.” Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 20 A visit to the kitchen found a cleaning schedule in place, which is used to ensure all areas and kitchen are regularly cleaned. Food preparation areas were generally clean and tidy. The storerooms, fridges and freezers held a range of provisions including fresh fruit and vegetables. Menus were examined and found to provide a varied and nutritious diet that offered alternatives. Observation at mealtimes showed two alternatives were available and food was hot and nicely presented. Blended food was also nicely presented but residents requiring a blended diet were not offered choices and all were served sausages and vegetables. The choice of blended meals is made by the cook on a daily basis and is not necessarily either of the choices offered to other residents. Residents do not generally have access to menus although a menu is displayed in the dining area of the old home this is generally for staff use. The home caters for a number of different diets including diabetic, soft and blended. Breakfast is served flexibly according to individual preferences. The choices include cereals; toast a cooked breakfast and drinks. The practice of care staff is to reheat the cooked breakfast in a microwave oven this may be unsafe and residents could be placed at risk. Information held in care plans includes resident’s dietary needs. Observations showed that a resident assessed as requiring a ‘liquidised diet’ was served sausage and chips. This practice did not reflect the dietary needs written in the residents care plan and could place the resident at risk of choking. A number of residents needed assistance to eat their food. Staff support was generally provided in an appropriate manner, for instance one carer sat next to a resident while assisting them to eat their food and was encouraging. Another carer remained standing and used a fork rather than a spoon to help the resident to eat their food. The practice of not sitting with residents could indicate a lack of respect and may affect the residents sense of self worth. Staff practice of using a fork rather than a spoon without first carrying out a risk assessment is unsafe and places the resident at risk. Some residents left the table having only eaten a small amount of food therefore snack meals should be available and easily accessible for residents with dementia so that they can have something to eat when they like. Staff asked residents what they would like from the menu but choices for residents with dementia was limited because they were dependent on memory. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 21 Choice for residents would be helped if residents were shown the food or picture images to enable them to make a choice in the moment rather than relying on memory. Staff spoken with were unaware of the content of a fruit pie and when asked could not inform residents. Comments noted on one resident questionnaire survey include my family feel the quality food is not that good. A visiting relative spoken with said her mother had advanced dementia and was no longer able to make informed choices. She felt the food was quite good but had complained about her mother always being given yoghurt for pudding. On her mothers birthday staff had supplied a birthday cake. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 22 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 and 18 Quality in this outcome area is adequate. Residents and their families are not confident that their concerns will be listened to and acted upon in an objective and timely manner. Residents are not fully protected from abuse through poor recognition and actions in cases of neglect and omissions of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy for the home was displayed in the reception area of the old build of the home. Two relatives spoken with were not aware of the complaints procedure but would complain if dissatisfied with any aspect of the service. One relative said she had complained on two occasions when she felt her relative was not receiving the care and attention she required. The relative felt staff were sometimes slow to respond to concerns raised. Other comments received in comment cards from relatives and residents include: “I think there is a lack of communication between change over of shifts and I never get any feedback from my complaints from staff or management.” Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 23 “They always seem to listen but don’t always seem to act on it. I often enquire as to where items of clothing are and have to repeat the enquiry on my next visit. “Sometimes they are in such a hurry to listen. A couple of senior staff can be very sharp! Very few staff say good morning, afternoon or evening. Manners are sadly lacking! The staff spend too much time sitting down drinking tea and using mobile phones.” The commission has received two complaints since the last key inspection. The issues raised allege poor standards of care, institutional physical and verbal abuse, misappropriation of residents’ monies, refusing residents food, poor infection control and poor cleanliness of the home. The complaints have been referred to social services for investigation through Protection of Vulnerable Adults (PoVA) procedures. The home has an adult protection policy, which lacks detail but provides staff with some direction in how to respond to suspicion, allegations or incidences of abuse. A copy of the local multi-agency policy was not available. Sixteen staff have received recent training in PoVA. Three staff spoken with said they had attended training in adult protection and were able to give examples of what actions may constitute abuse. All were aware of the ‘Whistle blowing’ policy and would raise any issues of concern with the senior carer on duty. The care file of one resident followed through the case tracking contained a letter confirming Court of Protection arrangements. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 24 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, 21, 23 and 26 Quality in this outcome area is adequate. There is failure to demonstrate that some areas of the environment are safe and well maintained. Residents and their families have no confidence in the system for the laundering and safekeeping of clothing and infection control is not managed well. Inadequate practices places residents’ health and well being at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The environment remains generally unchanged since the last inspection. A tour of the premises showed the old part of the building is in need of refurbishment and redecoration. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 25 The lounge/ dining area lacks natural light and the electrical lighting is poor. Some areas of the home particularly in the old building are considered somewhat institutional and do not feel warm or homely. A full tour of the new extension to the home was carried out with the Registered Manager and the Provider. The tour involved viewing all the rooms on the ground floor, first floor, a twelve-bedded unit and the second floor of the home. The ground floor is divided into three units and is currently occupied by elderly residents with varying degrees of dementia. The first floor is currently being furnished and remains unoccupied as required by a recent statutory enforcement notice served on the home. Building work remains in progress in the twelve bedded unit intended for younger adults with early onset dementia. The second floor comprises of five flats for tenants three of these are occupied. Access to the care home cannot be gained from the second floor and a separate intercom system has been installed for any visitors of tenants. Residents rooms varied, some were sparse while others were more personalised with items including photographs, ornaments, and plants and in one-instance small items of personal furniture. Some furnishings and fittings supplied by the home in the old building were of a poor standard and in need of either replacing or repairing for example; in a shared room, a number of beds had thin fitted sheets that barely covered the mattress. Furnishings in the new area of the home are of a higher standard. Adaptations and equipment were available to meet the assessed needs of residents and include handrails fitted along corridors, grab rails and raised seats in the toilets. There was a hoist and a staff call system. Some signage is available on bathroom and toilet doors but more effort is needed to help residents to orientate themselves and to move around the home independently. One resident spoken with said they had a key to their room and were free to come and go as they chose. Some residents’ rooms have carpets fitted while others have a washable floor covering. There were some offensive odours in the home notably in the reception area and corridor close to the communal lounge dining area in the old building. Responses given in comment cards to the question: Is the home fresh and clean? Include: Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 26 There is a smell of urine now when entering the building (new part). “…My mother is always wet through incontinence and I have to change her every time I visit its not surprising the home smells very strong of urine. No it does not smell fresh and clean.” “Hygiene could be better.” “When we visit mum at various times on different days the home is always fresh, clean and tidy.” The absence of soap and disposable hand towels in some toilets and bathrooms is unsafe and place residents at risk of infection. The laundry facilities are sited in two areas, one in the old part of the home and one in the new build. The laundry facilities in the new area of the home have a washing machine and a dryer. A dedicated laundry person carries out some laundry tasks and care staff incorporate this activity into their routines at other times. Two disposable razors, a handbag and a carriage clock had been left in the laundry room. Personal items not returned to residents must be held safely and securely and disposable razors when left unattended may place residents at risk. The laundry was clean but the absence of disposable hand towels and liquid soap is unsafe and increases the risk of infection and cross contamination. Comments received in one relatives comment card of one of the residents’ case tracked include details of a complaint originally made to the manager of the home. Some elements of the complaint were about the poor quality of the laundry and include: I have found clothes in her wardrobe that have been washed and dried, but was still very damp and not suitable to wear. This resulted in me bringing them home to wash, dry and iron. “I have on a number of occasions found clothes in her wardrobe and drawers that do not belong to her, including mens underwear. She has on occasion been dressed in clothes that do not belong to her. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 27 One relative spoken to said she had complained following a number of occasions when she found her mother wearing clothes that had not been ironed. The relative said the quality of the service varies depending on who was on duty in the laundry. The inspection found that shortfalls in the laundry service identified during the last inspection remain outstanding. Disposable gloves and aprons were available in various locations throughout the home and staff were observed to wear disposable aprons and gloves when providing personal care and when handling or preparing food. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 28 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 and 30 Quality in this outcome area is adequate. Staffing levels were being maintained at adequate levels to meet the needs of residents. The lack of a robust ongoing training programme for all staff does not ensure continuing development of skills to meet the changing needs of people living in the home. Recruitment practices and procedures are not followed consistently to ensure the safety of residents at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Working staff rotas were requested at the time of inspection and rotas covering the four week period before the day of inspection were examined. At the time of this inspection there were 39 residents living in the home. The working rotas and the number of staff on the day of inspection show that staffing levels were appropriate for the number of residents. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 29 Residents’ and relatives expressed concerns about the level of staffing in comment cards received by the Commission. Overall, service users felt that there was not sufficient staff especially at lunchtime when residents needed support with eating or at times when family members had questions, which needed answers. Comments in one resident comment card include: My family visits at tea-time as they work during the day and if queries need answers there are no staff that can answer them. Training records show that four staff had attended recent dementia care training. Two care staff had attended a three-day course and two staff a one day study day. Topics covered in the training were not available and discussions with staff identified that they were unable to describe what was meant by ‘reality orientation’ and could not give examples of when it may be appropriate to use reality orientation methods. The majority of staff have attended training in safer moving and handling and PoVA. Further training, for 2006 and attended by a few staff includes food hygiene, fire and first aid. There are eighteen of the thirty-eight care staff with a National Vocational Qualification (NVQ) in Care at Level 2 or above. Training records show that staff have not attended regular training to ensure they have the skills and knowledge to meet the needs of residents in their care. Discussions with the management team identified that a consistent ongoing training programme needs to be developed in line with the specifications laid down by the Skills for Care Council. Information was seen detailing training planned for 2006/07 these include, further PoVA training, dementia care, infection control, safe handling of medicines and health and safety. Staff files were examined for five of the most recently appointed care staff. Improvements were seen, the files were organised and contained most of the information required. Signed temporary contracts were available in files. All new staff are commenced on temporary contracts for an initial period of 3 months. Records were available to confirm the outcome of Criminal Records Bureau investigations. One file showed that appropriate references had not been sort although there was a history of recent employment. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 30 One relatively new worker spoken with said she had received an induction by a senior carer, which lasted for two hours and included a tour of the building. The carer said she shadowed an experienced care worker for eight hours and received training on moving and handling including using the hoist. She had completed a form for a CRB check, had not been supervised and felt residents were well cared for. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 31 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, 32, 33, 35 and 36 Quality in this outcome area is adequate. Management, leadership and hence accountability roles are not clear. Some practices, plus a lack of direction and guidance from management, evidence that the welfare and wellbeing of residents are not consistently protected and safeguarded and could result in risk from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Management arrangements in the home are unclear. The day to day management role of the registered manager is not identified and the time the manager is in the home is not recorded. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 32 The deputy manager is responsible for a number of management duties, which include recruitment, training and the development of care plans. Quality outcome records following the review of infection control procedures and an analysis of accidents in the home were read. The records were not sufficiently detailed to describe what was assessed and the criteria used for the assessment. For example, information in the infection control audit said ‘shower good could do better’ and ‘laundry area satisfactory staff need to improve.’ There was no evidence available to suggest that effective quality assurance and quality monitoring systems, based on seeking the views of residents and other service users had been implemented. The registered manager informed that although planned resident/relative meeting are not well attended. One relative said in her comment card: “I was asked to attend a relatives meeting to discuss activities but I was the only one there.” Minutes of these meetings were not available. The minutes of the contents of one staff meeting was read. Monies are held by the home on behalf of a number of residents for safekeeping and are stored safely and securely in individual envelopes. Records are not held for all financial transactions and individual receipts held do not include monies spent on behalf of the resident. For example, receipts were not available for payments made to the hairdresser on behalf of a resident for the period July to September 2006 totalled £50. Therefore, practices are unsafe. The retention of individual receipts supports evidence that residents’ finances are protected and facilitate access to personal records, in accordance with the Data Protection Act 1998. One to one staff supervision take place but those records, which were read demonstrate that they are more disciplinary sessions rather than supervision and support. Supervision records do not evidence all aspects of practice, the philosophy of the home and career development needs are discussed and reviewed as part of the normal management process. Staff said that they had individual meetings with the deputy manager. A current certificate of public liability insurance is displayed in the reception area of the home. The absence of soap and disposable hand towels in toilets, bathrooms and the laundry is unsafe and increases the risk of infection and cross contamination. On two occasions during the inspection, a carer failed to wear a blue apron while assisting with meals. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 33 The environmental health officer visited the home on 27 September 2006 requirements were made for staff to wear white aprons for doing domestic duties and undertaking personal care tasks and blue aprons when serving meals. A review of health and safety was undertaken. The home confirmed in a preinspection questionnaire forwarded to the commission that health and safety checks had been completed. Records examined include maintenance, contracts and servicing documentation for electrical equipment and appliances, the nurse call system and the various hoists used for lifting and transferring residents. There was evidence that tests and services in these areas were up to date. Records were completed to confirm daily or as required checks of fire prevention systems. There was evidence that a fire drill last took place on 16 October 2006 four staff were present. The comment made on the outcome of the drill says “Good response.” There is no recorded evidence in the home to suggest that risks in working practice and activities are being reviewed regularly which is essential in health and safety management nor following any accident or incident in the home. Records of incidents and accidents are being recorded on home records but are not being forwarded, as required under Regulation 37 of the Care Home Regulations, to the Commission for Social Care Inspection. Information received from Warwickshire Primary Care Trust showed that between July and September 2006 there were 6 residents admitted to hospital from the home, which had not been notified to the Commission. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 34 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 X X 1 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X 2 X X 2 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 2 2 2 X 2 2 2 2 Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 35 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 Standard OP3 Regulation 14(1) Requirement Timescale for action 31/01/07 2 OP4 12 3 OP7 15 The registered person must ensure that a full pre-admission assessment is carried out on all prospective residents to ensure that their needs can be met. Previous timescales of 31/05/06 and 31/08/06 not met. After consultation with the service user or a representative, the registered manager must prepare a written care plan as to how the service users’ needs in respect of his health and welfare are to be met. The registered person must 31/01/07 demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the care home. The registered person must 31/01/07 ensure that individual assessments and care plans accurately reflect individual residents care needs and are subject to periodic review. Previous timescale of 31/05/06 and 31/08/06 not met. DS0000004215.V316693.R01.S.doc Version 5.2 Chasewood Lodge Page 36 4 OP8 12 5 OP9 13(2) The registered person must 28/02/07 ensure that the home is appropriately conducted to make proper provision to meet the care and treatment needs of service users. The registered manager must 31/01/07 ensure that all Controlled Drug transactions are recorded on the Medication Administration Record (MAR) chart and entered in the CD register directly following the transaction. This requirement was not assessed at this inspection previous timescale 19/07/06 The registered manager must ensure that the temperature in medication rooms does not rise above 25°C to safely store medication in compliance with their product licences. The installation of an air conditioning system/cooler should be considered. This requirement was not assessed at this inspection previous timescale 05/08/06 The registered manager must ensure that all Controlled Drug (CD) transactions are recorded in the CD register and witnessed by a second trained member of staff. This requirement was not assessed at this inspection previous timescales 30/03/06 and 13/07/06. 6 OP9 13(2) 31/01/07 7 OP9 13(2) 31/01/07 Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 37 8 OP9 13(2) The registered manager must ensure that all medicines that are available to administer are recorded on the MAR chart or returned to the pharmacist for destruction and not kept on the premise for use at a later date. Previous timescale of 30/03/06 and 13/07/06 not met. The registered manager must undertake audit to ensure that staff administer medication before signing the (MAR) chart and that the transaction is recorded accurately directly afterwards. Previous timescale of 21/07/06 not met The registered manager must ensure that all medicines that are to be administered to service users are prescribed and recorded on the MAR chart. The MAR chart must record the exact dose as the doctor intended to ensure that all service users are administered their medicines as prescribed. Previous timescale of 21/07/06 not met The right medicine must be administered to the right service user at the right dose and the right time and records must reflect practice. 31/01/07 9 OP9 13(2) 31/01/07 10 OP9 13(2) 31/01/07 11 OP9 13(2) 31/01/07 Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 38 12 OP9 13(2) 13 OP10 12(4)(a) 14 OP12 16 The Medicine Administration Record (MAR) chart must be referred to before the medicine administration and the transaction recorded accurately directly afterwards. The reasons for non-administration must be recorded. The registered manager must ensure that the care home is conducted in a manner which respects the privacy and dignity of residents: Care staff must make sure residents are not dressed in clothes that do not belong to them. Previous timescales of 30/06/06 and 31/08/06 not met. The registered manager must ensure that: Records of activities that take place in the home are kept and staff maintain a written record of residents’ participation. The registered manager must consult with residents about the programme of activities to be arranged in the care home. Previous timescale of 31/07/06 not met. The registered manager must ensure that service users have the opportunity to exercise choice in relation to leisure, social activities, meals and other areas associated with daily living. Previous timescale of 31/07/06 not met. 31/01/07 31/01/07 28/02/07 15 OP14 12(2)(3) 28/02/07 Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 39 16 OP15 14(1) 17 OP15 14 18 OP16 22 19 OP18 13(6) 20 OP22 23 21 OP24 23, 16 22 OP26 16(2)(j) The registered person must ensure that care staff follows the specialist dietary needs of service users. Suitably qualified or trained persons must reassess changes to dietary needs. The registered person must ensure that the practice of reheating food in a microwave oven does not continue until the outcome of a risk assessment is known to make sure practices are safe and residents are not placed at risk. The registered person must ensure that any complaint is fully investigated and a timely response provided to the complainant in keeping with the homes complaints procedure. The registered person must review the Adult Protection Procedure taking into account the Local Authority procedure and the Department of Health guidance, No Secrets. The registered person must ensure that suitable adaptations are made which include the implementation of appropriate signage, which supports the orientation and independence of residents when moving round the home. The registered person must ensure that the furnishings in residents bedrooms are in good repair and suitable for use. The Registered person must ensure that systems are in place to control the spread of infection. This includes: • Suitable hand washing facilities are available. • Staff wear protective clothing when undertaking care duties. DS0000004215.V316693.R01.S.doc 31/03/07 31/01/07 28/02/07 31/03/07 31/03/07 31/03/07 31/03/07 Chasewood Lodge Version 5.2 Page 40 23 OP26 12 24 OP29 19,Sch.2 25 OP30 18(1)(c) 26 OP31 10 The registered manager must review the current arrangements for cleaning the home and appropriate action taken to make sure all areas of the home are clean and free of offensive odours. Previous timescale of 31/07/06 not met. The registered person must obtain full and satisfactory information on all employees. This must include professional references from the most recent previous employers. The registered person must develop an ongoing training programme, which covers appropriate induction for new staff, mandatory training and training related to conditions that affect the health and welfare of residents living in the home. The registered person must be able to demonstrate what management systems are in place to ensure the suitable running and management of the home. Evidence must be available to demonstrate the effectiveness of these systems. Previous timescale of 31/07/06 not met. 31/03/07 28/02/07 31/03/07 31/03/07 Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 41 27 OP32 10 28 OP33 24, 26 The registered provider must 31/03/07 ensure that the registered manager communicates a clear sense of direction and leadership, which staff and service users are able to understand and are able to relate to the aims and purpose of the home. The registered person must 31/03/07 establish and maintain a suitable system for reviewing and improving the quality of care, provided in the home and shall supply the CSCI a report in respect of any review. Previous timescale of 31/07/06 not met. The registered manager must 28/02/07 maintain records of the purpose for which residents’ money was used and retain receipts for items or services purchased on behalf of the resident. Previous timescale of 31/07/06 not met. The registered manager must 31/03/07 ensure that all persons working at the care home are appropriately supervised. Clear and informative records must be maintained and available for inspection. Previous timescale of 31/07/06 not met. The registered provider must 31/12/06 ensure that all areas of the home are safe from risk to residents. The items left in the bathroom, which includes a razor, must be safely stored. 29 OP35 9(a) 30 OP36 18(2) 31 OP38 13 Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 42 32 OP38 37 33 OP38 13, 18 The registered manager must 31/12/06 ensure that the Commission is notified of any accidents, incidents or events, which affect the well being of the service users accommodated in the home. Previous timescale of 31/07/06 not met. The registered person must 31/03/07 ensure safe working practices through the induction process and refresher training for all staff in moving and handling, fire safety, first aid, food hygiene and infection control Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 43 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 3 4 5 6 7 Refer to Standard OP12 OP12 OP14 OP15 OP15 OP19 OP30 Good Practice Recommendations Following consultation with residents and their relatives’ work should be undertaken to further develop individual life histories. Resident’s interests should be recorded and used to formulate activities. The registered manager should ensure that information related to advocacy services or other independent agent is available to support residents in expressing their views. Staff should be aware of the meal choices offered to residents. Care staff should be encouraged to sit with the residents when supporting them with eating. The registered manager should produce a programme of routine maintenance and evidence of renewal of the fabric and decoration of the premises. The staff induction process should include the staff code of conduct and residents rights. Chasewood Lodge DS0000004215.V316693.R01.S.doc Version 5.2 Page 44 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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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