Inspection on 04/07/07 for Estherene House

This inspection was carried out on 4th July 2007.

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

Estherene House 13/07/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Estherene House 35 Kirkley Park Road Lowestoft Suffolk NR33 0LQ Lead Inspector Jane Offord Key Unannounced Inspection 4th July 2007 09:30 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 DS0000065125.V345168.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000065125.V345168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Estherene House Address 35 Kirkley Park Road Lowestoft Suffolk NR33 0LQ 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) 01502 572805 01502 580444 yvonne@estherenehouse.co.uk Estherene House Limited Mrs Yvonne Barbara Titterington Care Home 21 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (21) of places DS0000065125.V345168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2006 Brief Description of the Service: Estherene House is a privately owned care home providing personal care and accommodation to a maximum of 21 older people, situated in a residential area of Lowestoft, near to shops and other amenities. It is a three storey converted domestic dwelling, set in it’s own grounds with a garden at the rear and car parking to the front. Service users are accommodated on the ground and first floors of the building. There are eight single (one with en suite facilities) and six double bedrooms. There is a chair lift linking the two floors used by residents. Bathrooms and WC’s have been adapted to assist people with mobility problems. The home provides a comfortable and caring environment for older people, and benefits from being a small scale, family-run establishment, with the owners on site on a daily basis. Whilst the building has much character, the facilities are somewhat dated, and in need of refurbishment. The owners are aware of this, and there are plans for a new extension, which will include a refurbishment of the existing facilities, including the provision of a passenger lift. The home’s fees range from £341.00 to £439.00 but do not include the cost of items such as newspapers, sweets and snacks from the home’s shop, toiletries and hairdressing. DS0000065125.V345168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 9.30 and 16.00. The registered manager was present and assisted with the inspection process. This report is compiled from information available prior to the visit and evidence found on the day of inspection. During the day a tour of the home was undertaken with the manager but all parts were revisited later. A number of staff and residents were spoken with and the files and care plans of three recently admitted residents were seen. A selection of maintenance documentation, the medication administration records (MAR sheets), the duty rotas and three staff files were looked at. The serving of the lunchtime meal and care practice were observed and part of a medication administration round was followed. On the day residents were using the main lounge and conservatory or in their own rooms as they chose. They looked comfortable and relaxed. Interactions between staff and residents were friendly and cheerful. The meal served at lunch looked appetising and residents spoken with said they enjoyed it. The home was clean and tidy with no unpleasant odours noted. What the service does well: What has improved since the last inspection? DS0000065125.V345168.R01.S.doc Version 5.2 Page 6 The last inspection left only one requirement to attend to some refurbishment of the main house by this month. This was due to take place as part of the development of the planned extension. Work on the extension has not yet begun although the owners are hopeful it will start in August 2007. The registered manager has applied for and obtained a grant from the local council to refurbish the dining room as a separate project from the planned building work. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000065125.V345168.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000065125.V345168.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. People who use this service can expect to have an assessment of need prior to being admitted to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three residents’ files seen all contained a pre-admission assessment of need although it was not immediately clear that it had been done prior to admission. The document was headed ‘Assessment’ and not signed or dated. Discussion with the manager clarified that they had done the assessments and visited the residents in their own homes. This was confirmed in conversation with the residents. Areas of support that were covered in the assessment included physical health and well-being, diet, sight, hearing and mobility. Continence, medication, falls, lifestyle, cognition and self-care ability were also assessed. This service does not offer intermediate care. DS0000065125.V345168.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. People who use this service can expect to have health needs met and be protected by the medication practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On admission to the home the staff complete a forty-eight hour observation and assessment document. A record is made of the routine the resident prefers to follow and the amount of support they require for any activities of daily living (ADLs). A care plan to help meet the identified needs is compiled with the information recorded. Care plans were seen for the three residents tracked and mostly they covered the interventions needed for the individual. However one resident with Parkinson’s disease and a diagnosis of dementia did not have interventions for either condition on their plan of care. While the plans contained most of the information required to support the resident the information was not easily extracted in the format being used. DS0000065125.V345168.R01.S.doc Version 5.2 Page 10 This was discussed with carers and the manager who agreed and said they were trying to find a different way of presenting the information to make the care plans more user-friendly. Areas that were covered included personal hygiene, diet, continence, falls, pressure area care and bed rest required. The files contained life history work with details of family relationships and past careers. There were contact details for health professionals involved in the care of the resident including the GP, community nurse, chiropodist and optician. One resident confided that they had recently seen their optician and had new glasses. They said they were much better for reading and knitting. One resident had a leg dressing that was attended to by the community nurse and also needed regular blood tests as they were on Warfarin. There were records of all the visits and details of instructions for treatment and changes of dosage. Staff were observed knocking on doors prior to entering rooms and ensuring that clothing was properly adjusted when residents moved from place to place. Talk between residents and staff was friendly and respectful. Gentle encouragement was given to residents to manage as much independently as possible, whether it was walking, transferring or eating their meal. Carers spoken with were able to explain how their practice maintained the dignity of residents during personal care. All double rooms seen had screens to maintain privacy. The medication policy was looked at and it contained guidance on all aspects of managing medicines with the exception of altering medication from the format licensed by the manufacturers i.e. crushing tablets or opening capsules. Medication is stored in a locked cupboard in the staff room/office. The lunchtime round was followed and was mainly ‘as required’ (PRN) painkillers. Two carers undertook the round together. Residents were asked if they needed pain relief and how many tablets they wanted if there was choice of dose. MAR sheets were correctly completed with no signature gaps noted. The home does not have any resident on controlled drugs (CDs) at the present so there were none in the cupboard. DS0000065125.V345168.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. People who use this service can expect to be encouraged to maintain contact with family and friends and be offered meaningful pastimes and a balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files seen all had contact details for the next of kin and other family members. The home has an open visiting policy and visitors were seen to come and go during the day. They were greeted by staff and residents and spent time with their relative/friend where the resident preferred. One resident said their daughter visited regularly and would do any shopping for them for clothes or birthday presents. The home employs an activities co-ordinator who organises a variety of pastimes and outings. They and the manager had recently attended some training given by a group called ‘Art link’ that shows how creative dance, art and writing can stimulate and engage older people including people with a diagnosis of dementia. DS0000065125.V345168.R01.S.doc Version 5.2 Page 12 Since the training the co-ordinator has held a session of craftwork for residents when they made and decorated rattles or shakers to use to accompany music. They had also helped residents knit some mats using cut up plastic bags. The rattles and mats were on display in the dining room. The co-ordinator had also done a session on creative writing and two residents had produced some very interesting poetry that contained some personal reminiscences. One resident spoken with said they had enjoyed the knitting most. Another resident who prefers to stay mainly in their room said they enjoy the view of the garden and watching all the birds out there. However they said the staff sometimes take them into Lowestoft by car and then, ‘we have a lovely day out’. A third resident said they had had their hair done the previous day and a member of staff had painted their nails for them. On the day of inspection the co-ordinator was preparing to take the home’s ‘shop’ trolley round to the residents. The coordinator buys sweets, snacks, toiletries, cards and soft drinks, often ‘buy one get one free’ offers, so they can sell items cheaper than the shops but still make a small profit for the activities fund. Outings to the beach or places of interest such as the Norfolk Broads are arranged during the good weather. One resident said they had been taken to the beach by a carer the previous day, as the weather had been good. Other activities organised included playing board games and dominoes, doing crosswords and word searches, having sing-a-longs and planting pots for the garden. The co-ordinator showed off the runner beans and tomato plants that had been done by the residents and were flourishing at the back of the conservatory. The menus were seen and showed the meals are organised on a six-week rotation. There was a choice of main meals such as chicken chasseur or steak and kidney or mushroom pie followed by cherry pie or lemon mousse. Each Sunday there was a different roast with the sixth Sunday offering salmon as the main dish. Lunch on the day was cottage pie with carrots and peas followed by fruit crumble and custard. Residents could choose to eat in the attractive dining room or in their own rooms. Help was offered sensitively where it was needed. Residents clearly enjoyed the meal and some had second helpings. The kitchen was visited and food stores inspected. Some food stores and freezers are kept in the cellar, which is dry and airy. All food seen was correctly stored and there was a wide range of ingredients. Temperatures for refrigerators and freezers were recorded daily and showed they were functioning within safe limits for food storage. DS0000065125.V345168.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. People who use this service can expect to have their concerns taken seriously and be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints policy that is displayed in the entrance hall of the home. The complaints log was seen and showed no complaints had been received by the service since before the last inspection. CSCI have not had any complaints or concerns raised about the service either. Residents spoken with knew that they could approach the manager if they had any concerns or issues to raise. The manager said that any issue that arises from their quality assurance surveys they will address with the resident immediately. Survey forms seen later contained written notes of what was discussed with the resident and how they wanted any issue dealt with. The home has a protection of vulnerable adults (POVA) policy that is crossreferenced to the guidelines issued by the protection of vulnerable adult committee of Suffolk so that correct referral procedures are available to staff if they have any concerns. Staff spoken with were clear about their duty of care and the home also has a whistle blowing policy to protect staff. One resident said they felt very safe in the home. DS0000065125.V345168.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is adequate. People use this service live in a comfortable environment but cannot be assured that all areas of the home will be decorated to a high standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Estherene House is an imposing building that was once the family home for a local boat builder and evidence of that remains in the amount of wood finish in the building. The main staircase rising out of the entrance hall has photographs and pictures all the way up to reflect the past connection with the sea and boats. A second stairway has a chair lift for residents with poor mobility to reach the first floor. The manager said that with the planned extensions a passenger lift will go into the building and by altering the use of some rooms two residents’ bedrooms will gain en suite facilities. DS0000065125.V345168.R01.S.doc Version 5.2 Page 15 The home on the day of inspection was clean and tidy with no unpleasant odours noted. A tour of the house was undertaken with the manager but all areas were revisited later in the day. The dining room had tables laid attractively with matching tablecloths and napkins. The gardens need some attention although still looked pleasantly overgrown. The manager and the activities co-ordinator both said there were plans when the extension is done to make a patio area outside the conservatory with level access for wheelchair users, also to build some raised beds so residents can do some light gardening. The accommodation consists of seven double rooms and seven single rooms some with some en suite facilities. For those without there are adequate numbers of bathrooms and toilets around the home. Residents’ rooms that were seen were personalised with pictures and photographs. One resident had a budgerigar in a cage that was given a biscuit by the carer who delivered morning coffee to the resident. During the visit it was noted that the décor throughout the home is ‘tired’ and in need of refurbishment. This matter is outstanding from the last inspection and the manager said it would be addressed during the extension work, which is due to start in August 2007. One bathroom downstairs has a badly worn cork floor that needs replacing and the pipe casing under the basin was broken. There were also toiletries and body scrubs left in the bath area. The hand washbasin had liquid soap but no paper towels for the carers to use. The laundry was visited and contained washing machines with a sluice wash programme. Carers spoken with were able to explain the management of soiled linen to prevent cross infection. DS0000065125.V345168.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. People who use this service can expect to be supported by adequate numbers of suitably trained staff but cannot be assured that all the documents for recruitment will be retained in staff files. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed the home has three carers on duty during the day and two at night. They are supported by a domestic, an activities co-ordinator and a cook. The registered manager and one of the directors are in the home on a daily basis offering personal input for residents, visitors and staff. Staff and residents spoken with said they felt there was enough staff to meet the needs of the present group of residents. One resident said, ‘staff look after you 100 ’. Another said, ‘Staff are very good, nothing is too much trouble’. Three staff files were seen and contained a photograph of the staff member and two references. Two files did not have any documentary evidence of identity checks but documents must have been seen as all the files had POVA 1st checks and criminal records bureau (CRB) checks, but copies of the identity documents were not kept on files. Two files also did not contain a full work history or evidence that had been explored at interview. DS0000065125.V345168.R01.S.doc Version 5.2 Page 17 There was evidence of the training undertaken by the members of staff and areas covered included first aid, fire awareness, moving and handling, dementia awareness, food hygiene, managing diabetes and medication courses. Carers spoken with confirmed the training they had done adding that they were looking for a course to help them with care planning. The home has fourteen staff in the care team of whom seven hold or working towards an NVQ in care at level 2 or above. When these have all achieved the award the home will meet the standard of 50 required by national minimum standards (NMS) for care of older people. A number of the ancillary staff have also obtained NVQs in their field of work. DS0000065125.V345168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is good. People who use this service can expect to have their opinions sought and their finances protected but cannot be assured that all fire protection doors are maintained to a safe level. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has some years of experience in the management of care homes and holds a Diploma in the Management of Care Services NVQ level 4. Staff said the manager was approachable and they felt they could take any concerns to them. Residents could identify the manager and the manager demonstrated knowledge of individuals’ preferences. DS0000065125.V345168.R01.S.doc Version 5.2 Page 19 The home undertakes quality assurance surveys and recent ones for the residents and visiting health professionals showed that people were happy with the level of service provided. A community nurse, diabetic nurse and physiotherapist had all completed a questionnaire about their visits to the home and covered greeting from staff, assistance given by staff from information to equipment. All the responses were positive. The residents’ survey covered how personal care was delivered, the daily routine, the premises and any improvements that could be made. Any responses that indicated less than complete satisfaction were highlighted and the manager then spoke with the resident to ascertain what they wanted done. Notes were made on the questionnaire of how issues were managed. The system for managing residents’ personal monies is managed by the activities co-ordinator. They explained the process and records were seen that showed there was a clear audit trail. A random sample of cash was checked and tallied with the records. Some maintenance records and service records were inspected and showed that the stair lift had been serviced in March 2007, the home had a clinical waste certificate valid until July 2008 and that the gas safety certificate had expired in May 2007. The director said the engineer had been extremely busy but was booked to attend the home that week. Hoists had been loler tested and serviced in June 2007. The fire log was seen and showed that fire alarms and fire extinguishers were tested weekly. It was noted that early in July 2007 some fire doors were not closing fully when the door guards were released. Three doors were found on the day of inspection that did not close properly. An immediate requirement in respect of this was left at the home. DS0000065125.V345168.R01.S.doc Version 5.2 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000065125.V345168.R01.S.doc Version 5.2 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. Standard OP19 Regulation 23 (2) (b) Requirement The planned refurbishment of the poor areas in the home must go ahead, including replacement of the identified defects in the downstairs bathroom, to ensure residents live in a pleasant, well maintained environment. This is a repeat requirement. Copies of the required recruitment documents listed in Schedule 2 must be retained in staff files and available for inspection to ensure residents are protected by correct recruitment procedures. Fire doors must be correctly maintained and repaired as soon as a fault is identified to protect residents and other people in the home. Timescale for action 31/01/08 2. OP29 19 (1) (b) (i) Sch 2 31/07/07 3. OP38 23 (4) (c) (iv) 04/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000065125.V345168.R01.S.doc Version 5.2 Page 22 No. 1. Refer to Standard OP7 Good Practice Recommendations Some care plan writing training should be accessed to help staff write more user-friendly care plans that would offer better support to the residents. DS0000065125.V345168.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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