Inspection on 30/08/05 for Compass Grove

This inspection was carried out on 30th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Compass Grove 09/05/06

Compass Grove 21/02/06

Compass Grove 23/03/05

Compass Grove 18/01/05

Compass Grove 17/03/04

Compass Grove 07/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Compass Grove 92 Abbs Cross Lane Hornchurch Essex RM12 4XW Lead Inspector Roger Farrell Unannounced Inspection 30 August 2005 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 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 Stationary 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. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Compass Grove Address 92 Abbs Cross Lane, Hornchurch, Essex RM12 4XW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01708 475915 Compass Residential Homes Ltd Ms Christine Mitrovic CRH Care Home 2 Category(ies) of LD Learning disability 2 registration, with number of places Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 23 March 2005 Brief Description of the Service: Compass Grove is registered to provide accommodation and support to two people who have a learning disability. At present there is one resident who has been at the home since it opened in June 2001. This small terraced cottage has a delightful contemporary interior, with good attention to comfort and homemaking. Next door is Compass Cottage, a three-place care home operated by the same owners, but they are registered as separate services. There is a third home in this group further along Abbs Cross Road called Compass Lodge. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 30 August 2005, between 6 and 8pm. The manager Christine Mitrovic had been on duty earlier in the day, but returned to help the inspector with the checks. Jo Smith, who is manager of the other two Compass homes is the same road was also present as she is responsible for supervising Christine Mitrovic. The service user was at home during the visit, including being assisted by the staff member on duty prepare her evening meal. This last report said that this home continued to provide a good level of domestic and social support to the long term resident. However, it raised a range of concerns, notably – poor practice around the assessment and move-in of a prospective new resident; mistakes with medication; an instance of fraud; and a poor record of staff retention. There was also concern at the delay in submitting an application to register the new manager. As a consequence, the report set a significantly increased number of requirements. The registered persons were served with a legal notice instructing them to implement better staff training on the safe administration of medication. They were asked to respond to the report with a sufficiently detailed action plan saying how they would carry out the improvements. Christine Mitrovic’s registration as the registered manager has been confirmed, and commitments were made regarding her management training and supervision. An ’action plan’ was received, but the inspector said that in future this needed to be better presented, cover all requirements including those that had been carried forward, and not to sidestep issues such as the problem of keeping staff. The checks carried out at this visit followed the areas where requirements had been set in the last report, including how assessments and move-ins will be arranged; adult protection awareness; safe systems for dealing with medication, including training staff; having a stable staff team; tighter systems for handling money; staff vetting and training; having a correct registration certificate on display; and ensuring that the manager had a working knowledge of the main ‘Standards’ (NMS) covering care homes. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 6 What the service does well: 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. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 and 5. Assurances have been received that a considerably better approach will be taken in future to the assessment and introduction of a new person. The inspector will monitor that this takes place in line with the home’s guidance. EVIDENCE: Apart from a three-month period in 2003, the existing resident has not shared this home since she moved in June 2001. Although described as initially successful, a second person’s placement ended in difficult circumstances in July 2003 due to deterioration in her mental health and problems with medication. The inspector was told that the vacant place would only be offered to a person with a mild learning disability, and fitting in with the established resident would be a major consideration. In October 2004 a prospective new resident began a trail stay. This only lasted one night, and again resulted in a traumatic incident requiring police assistance. At the announced inspection in January 2005 the inspector examined the circumstances of this attempted placement, and the report set out major concerns regarding how it was planned. The report concluded “These circumstances demonstrate a significant failure to adhere to safe practice. The registered persons must review their assessment procedures, and the arrangements that govern how prospective residents are introduced. This must involve a clear distinction between the roles of the owners and the manager….. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 9 Comment of how future assessments and introductions will be arranged needs to be covered in the action plan made in response to this report. Failure to make adequate arrangements for the assessment and introduction of prospective service users will result in legal action.” The registered persons were told that they must have a much clearer policy and procedure on assessment and move-ins, clarifying the central decisionmaking responsibility of the registered manager. The inspector has been given a series of documents covering these matters. These include a ‘pre-service and needs assessment’; ‘trial periods’; ‘admission procedure’; and move-in checklists, all adopted from the ‘Mulberry’ series. These set out a responsible approach to introducing a prospective resident. He was assured that this guidance would be closely followed in the future. The assessment standard is rated as ‘partially met’ as the Commission wants to monitor that the new guideline are followed in the future. The managers reaffirmed that the Compass homes do not accept emergency admissions. The service user’s file has an in-house contract agreed with the resident, and the standard contract issued by the sponsoring authority. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, and 10 This home continues to provide a good framework of support for the service user. This includes recognising her strong independence skills, whilst having support in more vulnerable areas, such as going out. This home has a good tradition of having suitable practice notes, and this is still evident. EVIDENCE: The service user’s file is being kept up-to-date, and is well arranged. This included a front index sheet, detailed up-dated care-plans; a CPA review, and a range of monitoring forms. There were also good records of involvement of health care workers, including a recent assessment, a psychiatric and medication review, and an occupational therapists report. Also included are a missing person’s form, copies of contracts the resident’s college certificates. The only problem was that some entries had been put on the wrong ‘medical tracking sheets’, therefore the requirement on this point has been carried forward. Otherwise the inspector said that a good standard was being achieved in this important area. The restrictions in place are limited to those necessary for the resident’s safety when away from the building, or for rule-setting around behaviour patterns. . Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 11 The service user has contact details for a named advocate, who she has seen in the past, and these details were also on the notice board. With some guidance the service user takes part in most household tasks, such as daily cleaning, making her bed, and clothes care. Whilst there is only one resident it is not seen as appropriate to have one specifically allocated key worker. All personal information is kept in the office, which is locked when not being used. The inspector has been shown evidence that the issue of confidentiality is included in the induction briefing, and has been covered in staff meetings. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 These areas were not fully tested at this visit. EVIDENCE: Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 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 standard(s) 20. The manager described how the required improvements covering the handling of medication have been introduced. She needs to continue to monitor that safe systems are being maintained at all times, including making sure all staff who deal with drugs are trained and competent. EVIDENCE: Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 14 A medication error last October led to the service user being admitted to hospital for observation. Assurances were given at that time to review the medication arrangements in this home. The report of the announced inspection for 18 January 2005 listed a range of concern about safety with medication. The registered persons were served with an ‘Immediate Requirement Notice’ for a failure to comply with Regulation 13(2) and 18(1)(c)(i) of the “Care Home Regulations 2001”. This included an instruction saying that staff responsible for handling medication must receive adequate training to ensure they are competent to carry out these duties. At the unannounced visit on 23 March 2005 improvements were found. This included the staff member on duty describing the training she had received, and giving informed answers about safe practice. Considerably improved information has been inserted in the medication administration file explaining the purpose and effect of each drug, and the necessary precautions. At this recent visit the manager gave an update on medication arrangements. The printed recording sheets now have full instructions. Three of the four care assistants who cover shifts at this home had attended medication training, and completed the in-house assessment. The other person was booked to attend the course regularly provided by the supplying pharmacy. The manager described the system she uses to monitor liquid medication, limiting the supply available to check on correct measuring. The only known problem reported was when a psychiatrist increased one drug, but the GP had not been informed. There was correspondence covering this matter. The manager could locate the report of the last detailed inspection by the Commission’s pharmacy inspector, and understands her responsibility to make sure all the recommendations are being followed. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 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 standard(s) 22 and 23. It has again been necessary to stress the need for the manager to have an adequate understanding of what to do if there is a suspicion of abuse. She must familiarise herself with the guidelines on this matter, and fully understand the need to keep the necessary agencies informed about significant events. EVIDENCE: The inspector was shown the revised basic complaints policy covering the three homes, that now includes contact details for the Commission. There is a complaints book available. Assurances were repeated about there being better accounting and safeguards of the resident’s money, including checks at handovers. The last report said that the manager was not clear about the guidance and actions that must be followed if there is an allegation of abuse. The registered persons were told that she must be provided with instruction on this important matter, and this was covered in their ‘action plan’. At this visit when asked about guidance and reporting responsibilities, the responses were not correct. The wrong guidance was presented, and when found, the ‘adult protection file’ had information that was considerably out-of-date’. It is of concern that this important requirement has not been adequately addressed. The inspector is aware that there have been failures to keep others informed of significant events. The requirements on this matter have been repeated. A failure to demonstrate and adhere to protection and reporting procedures will result in legal action. The inspector saw a record where longer serving staff have signed to say they have attended briefing and video sessions on adult protection and are familiar with the whistle blowing responsibility. A training session for more recent staff Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 16 was planned for the following week. All staff have signed to say that they have been given a copy of the main ‘code of practice’, and those who met with the inspector gave good answers about their responsibilities, including on whistle blowing. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30. The house is well maintained and suitably furnished – having been extensively up-graded in a contemporary style. It is neatly arranged throughout, suiting the resident’s choice to have a neat and ordered living environment. EVIDENCE: The ground floor is a spacious open plan lounge-diner, with a well-fitted kitchen. The resident’s bedroom is suitably furnished and reflects her tastes and interest, including the items she collects. There is a spacious bathroom with a shower beside the bedrooms on the first floor. The rear garden has a patio with furniture. The premises were again found to be bright, airy, clean. An independent infection control and hygiene audit was carried out last year, achieving the commendable score of 91 . The last inspection by an EHO was on 7 April 2004. Three minor recommendations were made, but the report concluded that it was “a very clean well run home”. There is no need for any adaptations. A self-closing devise has been fitted to the kitchen door. Fire protection would be improved if this door automatically closed true with the frame. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35, and 36 This house has been less affected by the high staff turn-over that has been a problem for the Compass homes, though this is a key area that the registered persons still need to monitor. Overall, the steps to check staff before they start have improved. EVIDENCE: Recent inspection reports on this group of homes have raised concerns about staff retention, saying - “Staff turnover remains the prominent factor restricting the consolidation of {these homes}. At the announced inspection the manager gave a profile of each staff member, including each individual’s training and experience. The problem is illustrated by the fact that when the inspector returned ten weeks later almost 40 of established staff had left or were due to leave…the registered persons must carry out a critical analysis of this matter, and are invited to make comments in the action plan that has been requested in response to this report.” The brief responses received sidestepped this issue, saying nothing worthwhile about how this problem was to be addressed. At this visit the manager went through the staff list covering this home. At present there is a core group of four workers in addition to the manager. One had started maternity leave, and two regular bank workers were covering that slot. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 19 The staffing profile is typical of the group overall – with one or two exceptions, most care assistants have been with the company for less than six months. The inspector was told that about three months ago the owners did a staff questionnaire. However, no outcome or proposals were known, including about the issue of how wages are paid. Nevertheless, the area manager said that the signs are that the rate of throughput is slowing. The resident has said that she is not particularly bothered by the changes, enjoys ‘new faces’, and says that she is listened to if she is not happy with a particular person as cover is often ‘one-to-one’. Whilst at the main house the inspector checked a range of staff files. The company have improved how they carrying out the required range of vetting such as getting two references, a CRB certificate, and checking permission to work. They also have an interview record, induction checklist and copies of course certificates, and supervision notes. Additional checks were done at this visit. Overall, the same good standard was found. However, this manager was told of the need to obtain a quick ‘Pova-first’ clearance, and that new staff must not be left unsupervised until the full CRB certificate has been seen. The manager was also advised to have a ‘training grid’ covering core topics for each person in addition to having copies of certificates. Nevertheless, the inspector is appreciative of the improved way that records now maintained and presented at inspections. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 42 and 43. The manager is continuing her training working towards the required qualification. The requested records were available to show good management systems, including safety certificates. EVIDENCE: Christine Mitrovic has worked for the company for nine years. She was previously the senior support worker at Compass Lodge. She took on the manager’s job at Compass Grove in February 2004.Her registration has been confirmed. It has been recommended that she be supported attend management development training. She is currently doing the NVQ level 3 award. She is aware of the need for managers to work towards achieving the RMA/NVQ L4. The owners and managers do carry out spot-checks, including at nights, and take action where they find deficiencies. The owners use a tick and comment ‘monthly report’ format produced by the NCHA, and have done business plans. At announced inspections the owners have made available information from their accountants confirming the viability of the business. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 21 The inspector asked to see a range of records and certificates covering health and safety. This included tests of the battery alarms and the monthly fire drills; contractor tests of the extinguishers; electrical and gas certificates; and information on Coshh materials. These were all satisfactory. The last time a fire safety inspector visited was in June 2004, and he reported no problems. Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x 2 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Compass Grove Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 3 G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 14 Requirement Ensure that an appropriately detailed assessment is carried out with prospective residents. This must take into account the areas set out in Standard 2.3 of Care Homes for Adults National Minimum Standards. The expectation is that the registered manager plays a central role in determining the appropriateness of the placement. Maintain accurate records of all medical consultations and tests. Ensure that all staff are aware of the system for recording these in the service user’s file and make entries on the correct sheet. Ensure adequate liaison with health and social care staff, including informing them of all significant events affecting the welfare of the service user. Provide the manager with training on the main guidance covering protection issues, and ensure that she is aware of the procedures to follow. Provide staff with sufficient training to ensure that they are qualified and competent to Timescale for action 21/10/05 2. 19 17(1)(a)/ Sched 3(3)(m) 23/9/05 3. 19 12(1)(2) 23/9/5 4. 23 10(3) 21/10/05 5. 32; 35 18(1)(c) 21/11/05 Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 24 support the needs of service users. Maintain a clear record of each staff member’s qualifications and training. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI Compass Grove G55 S0000027840 Compass Grove V246072 300805 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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