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Inspection on 27/09/05 for Dovecote Nursing Home

Also see our care home review for Dovecote Nursing Home for more information

This inspection was carried out on 27th September 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff are committed to providing a caring environment for people living at the home and try to support them sensitively. Some service user`s said: ` They look after me really well,` ` If I want anything I ask them for it and they politely say yes or no,` The relationship with families is good and they confirmed that they are kept informed about anything to do with their relative: `They ring me at home if (service user) is not well,` `They always let me know about what`s happening`.

What has improved since the last inspection?

The home is much cleaner and many parts of the home have been redecorated. The problem of odour on the first floor has been largely solved. Routine maintenance is carried out promptly and all equipment was serviceable in areas such as the kitchen and laundry. Empty bedrooms are redecorated before anyone else moves in and are individual in style and colour. Some of the carpets have been replaced with non-slip laminate flooring, which helps to break up corridors areas.Effort has been made by staff to improve the meal time experience for service user`s by setting tables with cloths, condiments, sugar bowls and milk jugs. In addition, the timing of the mid-day meal was re-arranged to fit in with the service user`s daily routines. The new manager has introduced a key working system to help improve the standard of care delivered to service users. Service users are dressed appropriately and look well cared for. This was confirmed by relatives who said, `They keep her hair nice and her clothes are co-ordinated`

What the care home could do better:

A small number of minor maintenance issues need to be addressed for example a new seal on the small kitchen fridge. Although improvements have been made to care plans and other documentation further work needs to be done to bring this up to standard. More thought needs to be given to further improving the mealtime experience. This is a busy time for staff who have to support service users while seeing to basic time consuming tasks, such as bringing up the food trolley from downstairs. This meant that service user`s still had some time to wait before meals are served. Staffing levels and tasks need to be reviewed to take account of this. Care staff are spending time on tasks such as table setting and folding napkins when this time would be better spent with service users. None of the service user`s on the first floor have keys to their rooms. They need to be assessed to see if it is possible for individuals to have a key and where they cannot, the home should demonstrate why not. Further work needs to be done to the environment to support people who are confused, have dementia or have problems with sight and hearing.

CARE HOMES FOR OLDER PEOPLE Dovecote Nursing Home Hugar Road High Spen Rowlands Gill Tyne & Wear NE39 2BQ Lead Inspector Mr Tom Moody Unannounced Inspection 27th September 2005 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 Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 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. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dovecote Nursing Home Address Hugar Road High Spen Rowlands Gill Tyne & Wear NE39 2BQ 01207 544 441 01207 544 171 dc1eurodeancare@aol.com 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) European Care (UK) Limited Care Home 61 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (61) of places Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th March 2005 Brief Description of the Service: Dovecote Care Home has 61 places for older persons. The home is split into two separate units; the first floor providing care for persons suffering from dementia and the ground floor for older persons only. Both units provide nursing and personal care. The home is purpose built and the internal space is generous. The bathrooms and communal WC’s have handrails and appropriate lifting equipment for disabled service users. The home is constructed in a traditional style of brick and tile and has a variety of lounge / dining areas. There is passenger lift access to the first floor. The access is level from the ground floor entrance. It stands in it’s own grounds, which are well kept. There is a generous amount of parking space. The home is located in a village, in a rural area. It is a quiet setting with local facilities close to the home including shops and a pub. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in September 2005 and was carried out by two inspectors. Records were examined and a tour of the premises took place. Discussion took place with the manager, who has only recently taken up his post. The midday meal was sampled and inspectors also spoke to service users, staff, and visitors throughout the inspection period. The feedback from service users and relatives was generally positive. The home is reasonably well equipped with aids and adaptations suited to the client group’s age and lifestyle preferences. The home has plenty of space in all areas. It is popular with service users and their families. What the service does well: What has improved since the last inspection? The home is much cleaner and many parts of the home have been redecorated. The problem of odour on the first floor has been largely solved. Routine maintenance is carried out promptly and all equipment was serviceable in areas such as the kitchen and laundry. Empty bedrooms are redecorated before anyone else moves in and are individual in style and colour. Some of the carpets have been replaced with non-slip laminate flooring, which helps to break up corridors areas. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 6 Effort has been made by staff to improve the meal time experience for service user’s by setting tables with cloths, condiments, sugar bowls and milk jugs. In addition, the timing of the mid-day meal was re-arranged to fit in with the service user’s daily routines. The new manager has introduced a key working system to help improve the standard of care delivered to service users. Service users are dressed appropriately and look well cared for. This was confirmed by relatives who said, ‘They keep her hair nice and her clothes are co-ordinated’ 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. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 All service users have a comprehensive assessment of need undertaken before admission and following admission to the home. Service users and their families are able to visit the home and are given enough information to judge if it can meet their needs. EVIDENCE: The home uses a system of initial assessment information that is completed as soon as possibly following admission, with vital information completed within 24 hours. These are fully completed and kept up to date, signed by staff and include some useful information about the person’s life, like’s and dislike’s, health and mental health needs. For example one file gave details about the earlier life of the person that provided some insight into how their dementia presents itself. This helped staff understand this persons’ behaviour and assist them to plan their support more effectively. Other assessment documentation is recorded about specific areas of need following this initial assessment and covers: Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 9 - nutrition moving and handling continence risks to safety risk of pressure damage, etc. This system was introduced fairly recently and staff received training in it’s use beforehand. However, assessment forms are completed indiscriminately and means that some unnecessary information is recorded, that has already been captured within the initial assessment. Visitors confirmed they were able to visit the home before their relatives were placed there. Staff confirm this and spoke of relative continued involvement in the home. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 A new care planning system is being introduced and is not yet fully developed but progress is being made. Until the system is working properly the care plans cannot fully demonstrate that the home is meeting all of service user’s healthcare needs. The homes medication systems are being adhered to and service users are protected by as safe system of medication that is properly operated by staff. Although staff generally respect service user’s privacy some aspects of care may not always support this on every occasion. EVIDENCE: The care planning and documentation has improved in many areas but there are still areas of weakness. Although assessment information covers widespread areas of need, they do not always inform care plans, which focus largely on physical aspects of care. For example one person who becomes quite distressed and agitated at mealtimes had no information in her plan to guide staff about how to deal with Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 11 this. Staff did cope however, but the strategies they use need to be recorded to ensure a consistent approach is followed. Life histories help to give a full picture of who the person was before they developed dementia and families are aware of and contribute to this process. However, while likes and dislikes are recorded, individual preferences are not. For example entries recorded ‘none’ where this question was asked and discussion took place with the manager about the importance of recording this accurately. In care plans monitoring and evaluation was confusing and often recorded interchangeably. Monitoring sheets did not record how well or poorly the plan was meeting the individuals needs, or where changes to the plan had been necessary but recorded daily events. Some documentation is not up to an adequate standard. The size and grade of pressure damage was not well recorded in one example seen. The manager is aware of these deficiencies and will address them. The design of care plans does not help the care planning process. Assessment information is located in separate part of the document from the plan of care and evaluation, rather than this being a part of the process. Drug storage is secure and clinical areas are well organised and tidy. Medication Administration and Recording (MAR) charts are well kept and there are few gaps in recording. Some gaps exist but the this has been identified as the fault of an agency nurse, by the manager. Controlled drugs are appropriately stored and stock balances are kept correctly. Service users were addressed respectfully by staff and staff were observed to knock at bedroom doors. However continence pads and plastic gloves were apparent in all bathrooms and toilets, even when cupboard space was available. This not only indicates communal use but detracts from the privacy and dignity of the service users. Bathrooms are not always secured when service users are being bathed and there is nothing to prevent other service users or visitors entering these rooms at this time. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Staff are sensitive to service users needs and an activities officer is in post but this service is not fully developed to ensure it meets the needs of people with dementia. There is family involvement in social events run by the home and with individual service users. Service users use community facilities and are able to feel part of the local community. Service users are given appropriate and sensitive support at mealtimes by staff. The dining experience has improved but staffing levels on the upper floor are insufficient during this period to provide adequate supervision to service users. EVIDENCE: There was a noticeable improvement in the mealtime experience for service users on the first floor. Tables were set with tablecloths, condiments, sugar bowls and milk jugs which gave a more homely feel to mealtimes. Staff were helpful and attentive and service users were given the choice of meat loaf or fish in cheese sauce, served with parsnips, carrots and mashed potatoes. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 13 One service user, who has a visual impairment, was given a plate guard to help her eat her meal independently. However, there was no colour contrast between the plate, the guard and the meal of potato, fish and parsnip, which made it difficult for them to see the food on the plate. The menu for each mealtime was displayed on a large menu board and staff reminded service users about what was available. The cook asks service users about their menu choice on the evening before. Food is served from a hot lock trolley, which detracts from the ambience of the dining experience. The cook confirmed he had received good support, in planning menus, from the previous manager and the current one. The kitchen is well ordered and cleaned although some surfaces, such as cupboard doors were worn and marked. Fresh vegetables were available in the kitchen and the cook confirmed that fresh vegetables were used for meals whenever possible. Service users commented positively on the meal at lunchtime which was appetising and well presented. Most service user’s confirmed that, “the food is good.” Some service users on the ground floor were engaged in individual activities within their room. One confirmed that they liked to read, “the peoples friend” and that they enjoyed, “doing puzzles and crosswords.” The music being played in the downstairs lounge was appropriate to the service users age and there was some level of interaction between service users. However one service user said, “it gets monotonous in here” and thought that there were, “very few” entertainers. Other service users, however, remembered that there were, “two singers in yesterday.” Staff confirmed this had taken place. There is an activities co-ordinator in post who is very enthusiastic about her role. She is exploiting community contacts to support social events in the home. It was observed that staff were so busy doing physical care tasks that they had little opportunity to talk and interact with service users. The manager was aware of this and spoke of trying to get volunteers to carry out some of the more routine tasks to allow staff to spend more time with service users. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Complaints information is accessible to service user’s and their families, and both are confident about using the process if needed. EVIDENCE: Information about how to make a complaint is visible in the entrance of the building and service user’s and their relatives were confident of the process. Comments included: - “I know how to make a complaint and would do so if I needed to.” - “There’s nothing to complaint about but I would if I had to” - “I generally just speak to the staff if I’m unhappy about anything and they sort it out. I know there’s a complaint procedure.” - “We got information when (relative) moved into the home but we haven’t had to use it.” Relatives and staff were at ease with one another and interacted in a relaxed manner. Relatives visiting on the day were able to speak to either the key worker or nurse in charge to discuss any concerns or ask for information about their relative’s progress. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 24, 25, 26. The home is well maintained and any problems are dealt with promptly. This ensures the environment is kept safe and pleasant for service users and others in the home. There are sufficient bathrooms and toilets and these have handrails and other mobility aids fitted. Service user’s rooms are pleasantly decorated and contain many personal touches. They reflect personal taste of the occupants and meet the needs of service users. Standards of cleanliness and décor are good but do not fully take account of people’s orientation or sensory needs. The standard of cleanliness is much improved and the home is more pleasant and comfortable as a result of this. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 16 EVIDENCE: The layout and décor of the building does not fully take into account the needs of people with dementia or sensory impairments. While the décor is regularly refreshed in bedrooms before new service users are admitted there are few cues to help orientate people around the home. Some simple measures could be taken such as the provision of large, and easily read, clocks. The new manager has approached the sensory impairment team in Gateshead and the Dementia Care Collaborative for advice. He is also investigating the possibility of introducing individual loop systems for people who have hearing loss. The home has mobility aids that can be used throughout the home and fixed in key areas such as bathrooms and toilets. The equipment in service areas, such as laundry and kitchen, are all working and staff confirm that maintenance takes place rapidly if there is a problem. Service users bedrooms are pleasantly decorated. Many contain personal items and family photographs. The rooms reflect the personality of the occupants and several service users prefer to spend the majority of their time in their own rooms. Staff have worked hard to improve the standard of cleanliness and remove odours. The manager is currently addressing the problem of residual odours caused by substances penetrating below the carpet and into material below the surface. Two areas, the main entrance and the first floor entrance, have benefited from new non-slip laminate flooring, which brightens the areas and substantially reduces the odours. The grounds of the home are substantial and well kept. There is a sheltered and secure garden area at the back of the home. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Although number staffing numbers meet the current NMS, they are insufficient to fully meet the needs of people during mealtimes. EVIDENCE: Staffing numbers are sufficient for most of the day but because of the high levels of support of some individuals, extra support would benefit service user’s quality of life and make mealtimes less task-orientated. For example during the midday meal on the first floor, some service user’s had be hoisted to their seats and the table and helped to eat their meal. Others had to be brought by wheelchair and transferred to their seats at the table. In addition, the meal trolley had to be brought from the ground floor and tables had to be set and cleared by staff. The manager has suggested using volunteers to specifically carry out some of the routine tasks like bringing the food trolley, to enable staff more time to concentrate on service user’s needs. The rescheduling of medication administration to before or after mealtimes may allow qualified staff to assist at this time. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 38 The home is well managed and staff morale has improved under the latest managers. This ensures that the service users are cared for in a safe environment by staff who act in their best interests. EVIDENCE: The last inspection report referred to the regrettably short tenure of the previous manager and the problems resulting from this. The home has had two more managers since that report. Fortunately the calibre of those employed has been such that the home has seen a number of improvements. Staff referred to this change and felt that just as they became used to one manager they left and another came in to replace them. The current manager is sensitive to staff’s feelings and staff expressed confidence in his abilities. Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 19 The senior management of the company must ensure stability in the management of the home and help expedite the registration of the current manager. It was evident that many of the weaknesses highlighted in the last report had been, or were being, dealt with either by the current manager or his immediate predecessor. Staff remarked on maintenance being carried out promptly and the improvements in the environment. Staff showed much improved morale in spite of the number of changes they had endured. This was confirmed by the views of families who said: “The staff have held the home together through all the changes.” Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 20 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 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP8 OP10 Regulation 15 12 Requirement Service user care plan must accurately reflect care delivered to the service user. Service users care must take into account the need to preserve the dignity and privacy of the individual. The service users must be adequately supported during mealtimes and these must take place in a congenial setting and at flexible times. The home must provide suitable equipment for service users with sensory deficits and those who are prone to confusion. The home must employ suitable numbers of staff to meet service users needs at all times. Timescale for action 30/11/05 30/11/05 3 OP12 OP16 15 30/11/05 4 OP23 22 30/11/05 5 OP18 27 30/11/05 Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 22 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 Dovecote Nursing Home DS0000018172.V250479.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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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