Inspection on 25/10/06 for Christmas Lodge

This inspection was carried out on 25th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Christmas Lodge 09/10/07

Christmas Lodge 15/03/06

Christmas Lodge 20/07/05

Christmas Lodge 02/03/05

Christmas Lodge 19/10/04

Christmas Lodge 18/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Christmas Lodge 196 Mount Vale York YO24 1DL Lead Inspector David White Key Unannounced Inspection 25th October 2006 09:00 Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Christmas Lodge Address 196 Mount Vale York YO24 1DL 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) 01904 647442 01904 675581 Mr Dale Andrew Graver Mrs Penelope Anne Graver, Mrs Lynne Dexter Mrs Carol Georgina Irvine Care Home 15 Category(ies) of Learning disability (15), Learning disability over registration, with number 65 years of age (15), Mental disorder, excluding of places learning disability or dementia (15), Mental Disorder, excluding learning disability or dementia - over 65 years of age (15) Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration is for 15 persons with a mental health disorder and/or a learning disability some of whom may be over 65. 15th March 2006 Date of last inspection Brief Description of the Service: Christmas Lodge is a care home providing personal care and accommodation for up to 15 service users with mental health needs and/or learning disabilities. The home is located close to the centre of York and is within walking distance of the city the amenities and leisure facilities. The accommodation provided is both single and double bedrooms, self-contained units and a variety of spacious communal rooms. Christmas Lodge is privately owned by Mr and Mrs Graver and Mrs Dexter and was registered in 1998. There is a small garden at the front and a pleasant courtyard with parking at the back of the house. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit undertaken on the 25th October 2006. This visit was carried out by one Regulation Inspector and took 6 hours with 4 hours preparation time. The home was able to return the requested information before this site visit. Three surveys were received from health and social care professionals who had contact with the home. Information was used from the Regulation Inspector’s inspection record, which detailed the history of the home and relevant information about what had been happening in the home since the previous inspection visit. The site visit comprised of an inspection of the premises. The care records of three residents were looked at which included residents assessments, care plans and medication records. Staff rotas and health and safety documentation were inspected. Time was spent talking to five residents, two members of care staff, a senior member of staff who was on duty at the time of the site visit and the proprietors of the home. The activity in the home and the interaction between residents and staff was observed. The focus of the inspection was on a number of key standards and inspecting the case records of a number of residents to establish whether they corresponded with their experiences of life in the home. A senior member of staff was available throughout the inspection and the findings were discussed at the end of the inspection. The outcomes from the site visit were also briefly discussed with the proprietors who were present for a short period at the time of the site visit. What the service does well: Residents received a very good standard of care from an established caring, well equipped, well-motivated and understanding staff team. Residents were encouraged to make their own choices and maintain their own independence. Residents enjoyed a range of activities that enabled them to develop their social opportunities and have access to the local community facilities. The home had good relationships with specialist health care services and this helped to ensure that all the residents’ needs were met. The environment was homely, comfortable and well maintained and this made the home a pleasant and safe place for residents to live in. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 6 Relatives felt they were involved in the decision-making in the home and that their views were acted upon. The home was well managed and this ensured that concerns were addressed, resident interests were safeguarded and good standards of care were maintained. What has improved since the last inspection? 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. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Proper pre-admission procedures were in place to ensure that people were provided with the appropriate information to make a decision about moving into the home, and the home gathered a range of information about people to make sure they would be able to meet the person’s needs. EVIDENCE: A recently admitted resident said that he had been provided with a variety of information about the home prior to moving in there and had been able to visit the home and was “invited for tea” beforehand. The care records for the newly admitted resident showed that information had been obtained from other sources such as the placing authority and this included an initial assessment and care plan that detailed the individual needs of the resident. The home also carried out their own assessment of the person’s needs to ensure that they had the resources and facilities to meet the identified needs. Each resident had an agreed individual contract and a statement of the terms and conditions of residence. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area was good. Residents were encouraged to be independent and to make their own choices and this was promoted through good care planning systems that provided staff with the information to meet resident needs safely. EVIDENCE: The care records of three residents were looked at and these included a range of information about each person including a needs assessment from which a care plan was developed stating what actions were needed and by whom to meet identified needs. The care plans were specific and focused on the health, personal and social care needs and strengths of each resident and staff said that they found the care plans “easy to follow”. At the front of each record was a summary of the person’s care plan and staff commented that these were “very helpful” in assisting them to provide the right kind of support to residents. One resident had diabetes, which was being monitored closely by the staff team, and clear plans were in place so that staff knew what actions to take to address instances when the blood sugar levels were not within normal levels. Residents were involved in the planning of their care and all had a key worker and this ensured that they received some one to one support. The Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 10 residents were all fully aware of who their key worker was and said that they had regular meetings with them to discuss their care. Care plan reviews were held to look at the progress of each resident and to address any changing needs and the resident’s relatives and care manager were invited to attend these with the agreement of the resident. The care plans focused on encouraging the independence of each resident and this was supported by a number of risk assessments in relation to aspects of daily living. A resident said he enjoyed being able to “do what I want within reason without being limited by constraints”. One resident was at particular risk from excessive use of alcohol when out in the local area and measures had been put in place to reduce the risks from this. It was also noted that although there was a designated smoking area in the home, one resident in particular had been found on occasions to be smoking in his bedroom and a risk assessment had been undertaken to manage this situation safely. Staff were observed to be encouraging residents with their independence and residents said that they were encouraged to make their own decisions and live their life as they wished and felt that they were involved in decision-making about how the home was run. Daily record diaries were detailed, up to date and reflected the care that had been given. Any actions taken by specialist health care professionals was clearly documented so that staff were clear about other care and treatment that had been provided to residents. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents enjoyed a fulfilling lifestyle both in and outside of the home and were part of the local community. EVIDENCE: Resident preferences about their social lives and daily routines were detailed within their care records. Whilst some of the residents enjoyed spending most of their time within the home others liked to attend a local social club and day centre and some of the residents did some gardening work. One resident was a very enthusiastic member of the local cinema and often visited the library to access the internet in order to keep updated with film reviews, cinema news and to access music websites. Some residents were able to safely go out into the centre of town on their own and visited the local pubs whilst staff supported other residents to be able to have the same opportunities. A resident commented that he particularly liked the home for its locality because it was so close to the town centre and this enabled easy access to all the local facilities. Regular outings were organised by the residents with the staff team and some residents had been on holiday to Skegness earlier on in the year. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 12 Visiting arrangements were flexible and residents could see family and friends whenever they wanted to and residents had access to a telephone in the home so that they were able to contact family and friends if they wished to do so. Residents said that the food was “very good” and they were able to make a drink whenever they wished to do so and there was a water machine for those residents who preferred a cold drink. Most of the food was fresh produce and home cooked and vegetarian options were available on the menus for residents who preferred not to eat meat. One mealtime was observed and residents could be seen enjoying their meal in an unhurried and relaxed environment. The menus and the quality of the meals were regularly discussed within the resident meetings. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area was good. This judgement has been made using all available evidence including a visit to this service. Residents’ personal and health care needs were well met with good access available to specialist services when required. EVIDENCE: Staff could be seen to be interacting well with residents, providing support in a dignified manner and addressing people by their preferred names. One resident commented that “support was always on hand if needed” and another said that the care “couldn’t be any better”. Another resident had been able to move bedrooms following his request to do so because he felt that the change in bedroom would provide him with more privacy. Each resident had a General Practitioner (GP) and access to dental, chiropody and optical services when required. One resident had recently experienced some visual difficulties and had attended the local opticians service and been prescribed some new glasses. A number of residents had mental health problems and received support from mental health services. One resident had developed dementia and it was observed within the resident’s bedroom that on the wall there was a large board that provided information to the resident about the day, date, her family and friends and the staff on duty at the time. Alongside the information were photographs to assist the resident with her Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 14 individuality, memory and orientation. Inputs from specialist services were clearly recorded within the care plans and daily records. Three surveys were received from health care professionals who had contact with the home and all commented about the good quality of care provided by the staff team at the home. The medication systems were found to be satisfactory. Medication Administration Records were accurate and up to date and medication was being stored properly. Some residents administered their own medications and had locked facilities within their bedrooms to keep the medications secure. All the staff had received appropriate medication training and some insulin training had been provided by a lecture practitioner from the local hospital and this enabled staff to administer insulin which had been prescribed to one of the residents. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area was good. This judgement had been made using available evidence including a visit to this service. Complaints and adult protection policies and procedures were in place and understood by staff to ensure that residents were safeguarded from harm. EVIDENCE: The home had a complaints procedure that was openly on display in the home and was summarised within information provided to residents and their relatives. Residents knew to whom they would need to speak to if any concerns arose and had “total confidence” that any areas of concern would be dealt with properly by the management of the home. Some residents had communication difficulties, however staff said they would be able to recognise any issues of concern from the behaviour of residents and would act on this. Since the previous inspection visit neither the home or the Commission for Social Care Inspection (CSCI) had received any complaints. Staff had a good understanding of what would constitute abuse and what to do if it was suspected or had occurred. All the staff had attended abuse awareness training and staff knew about the adult protection and whistle blowing policy and where to access it if they needed to. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The standard of the environment was good and provided residents with a homely, pleasant and comfortable place in which to live. EVIDENCE: The home had a friendly and welcoming atmosphere. Residents commented that they were pleased with the standard of their accommodation and particularly liked the location of the home meaning that access to all the local amenities was very easy. Accommodation was over three floors and could be accessed by stairs in the main part of the home and within the grounds there were two self-contained units. There were two bedrooms on the ground floor so the home would not be suitable at the present time for people with a mobility problem if the ground floor bedrooms were not available. However there was ramped access to the home enabling people visiting the home with mobility problems to have access to and from the building. Residents had access to all the communal areas and there was patio area at the back of the home where people could sit. A number of residents smoke and one of the lounge areas was designated for this purpose. Following a recommendation made at a previous inspection visit the staff smoking policy had been reviewed and as a result staff do not smoke inside the house. The general standard of Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 17 décor was of a high standard and there was an ongoing planned maintenance programme. Bedrooms were personalised and residents were involved in the choosing of the décor for their bedroom and residents had easy access to bathrooms, showers and toilets on all floors. Residents had keys for their bedrooms and said that staff did not enter their bedroom without their permission. The home was clean and tidy and there were separate laundry facilities where residents’ personal clothing and bed linen were attended to. The kitchen was well maintained and regular checks were carried out to promote safe food hygiene practices. The environmental health authority had undertaken a recent visit to the premises and all the necessary actions had been taken from this and the requirements of the fire authority had been met. A random check of the water temperatures was found to be within safe limits. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area was good. This judgment has been made using available evidence including a visit to this service. Residents received a good standard of care from a well-equipped, enthusiastic and committed staff team. EVIDENCE: The duty rotas showed that staffing levels were sufficient in meeting the needs of the residents. Residents commented that staff were always “on hand” to offer support if needed and the number of outings and activities indicated that staffing levels enabled residents to have their social needs met. The staff team was very settled and the staff on the day of the site visit were very committed and enthusiastic in meeting the needs of the residents and staff morale was good. Residents commented on how they found the staff team to be “helpful and supportive” and one resident said “it’s great living here, the staff can’t do enough to help you if you need it”. Staff received a range of training to equip them in meeting the needs of the residents and this included training specific to the needs of the resident group such as mental health training and staff said that they were due to receive some dementia training in order to develop their skills and knowledge in supporting one of the residents who had developed dementia. Most of the staff had either completed or were undergoing the NVQ programme to enhance their skills and knowledge in meeting the residents’ needs. An induction Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 19 programme was in place for all new staff and this was detailed and covered a number of aspects of working at the home. The staff files of two recently appointed members of staff were looked at and all the required checks had been undertaken and the required records were in place. Discussion was had with the proprietors of the home about how information disclosed within pre-employment checks was followed up and recorded and about the appropriateness of people carrying out interviews as part of the recruitment process in promoting equality and diversity. Supervision systems were in place and staff said they felt the supervision was “beneficial and helpful” and enabled them to spend individual time with the manager. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The home was well managed, residents were involved in decision-making about the home and proper attention was given to ensuring their health and safety. EVIDENCE: The registered manager was experienced in running the home and had completed courses aimed at further developing and enhancing her management skills. The manager was not working at the time of the site visit due to sickness was supported by four senior support workers in providing leadership to the home. Residents and staff were complimentary about the manager’s abilities with a number of residents stating that the manager was “approachable and helpful”. The staff team felt that the manager was “extremely supportive and fair”. Arrangements were in place to seek the views of the residents and others about the care and services at the home. Resident meetings were held on a regular basis and were chaired by one of the residents. Staff meetings took Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 21 place and this encouraged the staff team to give their opinions and voice their views about the home. Between shifts staff handover periods were used to exchange information about residents so that staff were clear about residents needs. One of the proprietors visited the home at least every month to monitor the conduct of the home and a report was produced from their findings and was available for inspection. All the record keeping and documentation looked at during the site visit was very well organised, clearly detailed and up to date. Arrangements were in place for the promotion of a safe and secure environment for residents, visitors and staff. A number of satisfactory certificates and reports were seen relating to the premises. All staff had received health and safety training and there were a number of individual and general risk assessments in place to promote a safe working environment. Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Christmas Lodge DS0000015802.V313100.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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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