Inspection on 09/10/06 for Ethel Road (7)

This inspection was carried out on 9th October 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ethel Road (7) 21/04/10

Ethel Road (7) 28/10/09

Ethel Road (7) 23/10/08

Ethel Road (7) 22/11/07

Ethel Road (7) 03/05/07

Ethel Road (7) 03/02/06

Ethel Road (7) 21/10/05

Ethel Road (7) 24/01/05

Ethel Road (7) 11/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Ethel Road (7) 7 Ethel Road Ashford Middlesex TW15 3RB Lead Inspector 1Damian Griffiths Key Unannounced Inspection 9th October 2006 10:00 Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ethel Road (7) Address 7 Ethel Road Ashford Middlesex TW15 3RB 01784 240646 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) Mrs Victoria Charlton Mr Vaughan Charlton Mrs Victoria Charlton Care Home 1 Category(ies) of Learning disability (1) registration, with number of places Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be 18 - 35 years The gender of those accommodated will be Male Date of last inspection 3rd February 2006 Brief Description of the Service: The home is registered as a care home within the service user category: Learning Disability. The home is registered for a maximum of one male resident. The service is privately owned, provides a caring and supportive environment and is run as an ordinary domestic household. Cost of residency approximately £500 per week. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Lead Regulation Inspector Damian Griffiths was assisted throughout the inspection by the Registered Manager, Mrs Victoria Charlton representing the establishment. The IBL process involves a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. A new Inspection record is compiled from details received from a preinspection questionnaire from the home and notifications of significant events known as regulation 37. Comments and complaints received and previous inspection reports are all considered for inclusion prior to the inspection visit. For more details of ‘IBL’ please visit the Commission for Social Care Website details can be found on the last page this Inspection report. The inspector was at the home with Mrs Charlton and the resident at their home for a period of 4 hrs. This time was spent sampling resident’s care need assessment, care plan, contract, and activities and talking to the resident and Mrs Charlton. A tour of the premises was completed to ensure there was a reasonable balance of care, the active promotion of health and safety and the provision of a homely environment. The inspector would like to extend thanks to Mrs Charlton and the resident for their assistance and hospitality. What the service does well: What has improved since the last inspection? A written fire risk assessment had been completed and water temperatures were being recorded on a daily basis and compiled and the home was aware of the risk of legionella. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 6 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. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose in place at the home required reworking. The resident benefited from a resent care assessment that confirmed the consistency of care within this small family home setting should continue. EVIDENCE: A good Statement of Purpose was in place providing useful information about the home but it had not been printed in a way that could be understood by the resident who was very familiar with pictures and symbol representation. It was recommended that that the manager and resident work together to reproduce the Statement of Purpose using a format familiar to the resident. The Social Care Team had recently completed the resident’s care assessment and the local authority continues to support the resident in this capacity however there was no allocated worker. The resident had originally been fostered to this address a number of years ago. This has evolved into a permanent residential placement and meets the approval of the resident, family and social care authorities. Please see the recommendation section of this report. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents benefited from the ease of family living and was able to make individual choices that were respected however events of daily living and care that formed the basis of the residents care needs were in need of continued risk assessment. Other records of a confidential nature were in need of secure storage. EVIDENCE: The residents social and health care needs had been recorded initially by a Social services care plan. The manager however had an exceptionally good understanding of the care needs required to ensure the health and welfare of the resident. The local Social Care Team had recently reviewed the residents care plan and it reflected the needs for a regular routine of daily prompting the resident to maintain all areas of personal care and assistance with specific tasks. There were no daily records of activity kept as this did not seem to be conducive to family living however the manager did maintain an ‘encounter log’ detailing significant events such as: GP visits, holidays, and care plan Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 10 reviews. This documentation had not been updated for a number of months although details were included on the family calendar; therefore it was recommended that this be done on a weekly benefit with the resident. Evidence of risk assessment must also corresponded and reflect events that the resident has` recorded as appropriate. It is not the intention of the regulation to stifle spontaneity but to show that reasonable consideration is being taken. The resident was able to make full use of the local amenities preferring to visit the local adult education centre rather than college and would meet friends and family regularly. Risk assessments were in need of completing and were a requirement from the last inspection such as: resident doesn’t manage crowded places well. This had been acknowledged and recorded by the manager but the residents’ capacity for choking on food had not been recorded and also sometimes, having to wait for the manager to arrive home in the afternoon, had caused the resident to explain to the Inspector, that he had some concerns about the lack of seating in the porch area. It was emphasised that the waiting time was only for a matter on minutes however the timescale could not be guaranteed, The resident’s records containing confidential information were kept in an area that was fully assessable and open to family scrutiny, therefore, it was recommended that a lockable storage area be provided. Please see the requirements and recommendation section of this report. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,1315,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident enjoyed an ordinary family lifestyle that provided a good level of independence while meeting care needs and promoting regular contacts with family and friends. EVIDENCE: The resident was able to maintained his independence but be a part of a family unit and to benefit from the experience that this opportunity has made possible such as: access to the community and developing life skills alongside other family members. The resident was able to visit his own family every weekend and regularly meet friends to go bowling and shopping. The resident was free to enjoy choices of occupation with leisure and personal adult education. The resident sees his female friend and often eats out at the local restaurants and enjoyed regular holiday breaks including a trip to Majorca that had been arranged. The resident had an ‘independent advocate’ who had been recruited by the home in order for the resident to be able to seek assistance from someone Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 12 independent from the home. The independent advocate works within the social care arena and as such had received a criminal record check (CRB) from their own local authority, however, he home needs to provide the Independent Advocate with a new CRB. The resident has difficulty with his swallowing reflex therefore rushed meal times can be an ordeal. In order to be able to finish a meal comfortably and safely the manager has geared the resident’s day to start later enabling a leisurely breakfast time that avoids the family crush. All activities are planned later on in the day to ensure the greatest benefits for the resident, but all other meals were taken with the family including trips to local fast-food restaurants. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident was able to benefit from regular and consistent health care support that promoted his understanding and confidence. EVIDENCE: The manager had ensured that the resident regularly attended his GP for health care monitoring and ensured the community nursing team were able to visit and treat accordingly. The residents care needs were being met in a manner that was acceptable to him. Health care practitioners and the manager were sensitive to the resident’s needs and this enabled him to understand his disability better and manage it with some confidence. The resident had no need of administering of medication by the manager at this time and in the past there has been no need of medication and there was no record of need for the occasional use of medicines such as mild painkillers. The resident confirmed that he did not take these. The provision of ‘Safe Administration of Medicines’ had been a requirement at the last inspection: it is necessary for the home to show that the resident could receive prescribed medication safely if needed, from a person with certifiable proof of experience. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 14 Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints procedure was available and the manager had an awareness of the issues surrounding the safeguarding of vulnerable adults however a training update was required. EVIDENCE: The resident had no complaints to report and their had been no complaints recorded. The Statement of Purpose had written details of the complaints procedure available and the resident had access to an independent advocate. The manager was aware of the Surrey Multi-Agency Procedures and had an updated copy available for reference. The manager had been unable to attend recent safeguarding vulnerable adults training sue to cancellation however their had been time for rebooking attendance on this course. The previous inspection report detailed the same prevailing circumstances around the need for training. The manager supervised the resident’s money management and a receipt book was kept. Unfortunately there had been no recent transactions recorded therefore a requirement was made to ensure that all financial transactions are recorded and audited periodically by a social care practitioner or advocate. The manager of the home had arranged for the resident to and support from an independent advocate therefore it falls to the manager to ensure that the advocate has obtained an enhanced certified clearance from the Criminal Records Bureau (CRB). The manager was aware the advocate currently works in a position whereby they have received a CRB check relating to their current employment. However, due to the role specified by the manager as an Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 16 independent advocate it remains the responsibility of the manager to ensure that all reasonable care has been taken to protect the resident. Please see the requirements section of this report. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 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 the following standard(s): 24, 26,27,28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was fit for purpose offering a family home environment that was comfortable and benefited the resident. EVIDENCE: The premises consisted of an average size family home. The resident had his own room on the ground floor with bathroom next door. All ground floor facilities were shared including the living room and gardens. The home showed evidence of being ‘lived in’, was clean and without obvious hazards to health and wellbeing. The home was in the process of planned improvements to the living room décor. A fireplace feature was nearing completion and new carpets were to be provided. The residents own room was of modest size but filled with the residents DVD collection and personal interests. Bathroom and WC was on the ground floor next door to the residents’ bedroom. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service providers do not employ staff but are reliant on each other for support. The quality of care was consistent and enabled the residents to engaged fully within his local community. Training was proving to be difficult due to the lack of the homes training resources. EVIDENCE: The family environment that benefits the resident does not employ any paid staff. The manager and her husband who is also a manager within the public care sector have ample experience that is shared and will ensure the well keeping of the resident of this care placement. It is, however the responsibility of the manager of the home to show that she is up to date with current understanding of the agreed Surrey Multi-Agency Procedures to ensure the protection and safeguarding of staff and vulnerable residents from abuse. This was a requirement of the previous two inspection reports, also featured in section 20 of this report, and was training for: Safe Administration of Medicines. It is also recommended that Health and Safety and Food Hygiene be timetabled for consideration and to start a NVQ training plan. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The record of a continuous care received by the resident has meant that health and safety issues have not posed any serious threats to health and welfare however evidence was required to show that reasonable measures had been undertaken to ensure potential risks had been reduced. EVIDENCE: The manger had not attained level 4 of the National Vocational Qualification and it was recommended that she apply for training that matches the needs of the resident, however, her husband is a manager of a day care centre for adults with learning disabilities therefore the issues relevant to the residents continued health and welfare were actually being overseen. There was evidence however that some areas of management were in need of attention if the home wished to maintain a reasonable level of care as required by the national minimum standards. Actively seeking regular input from health and social care practitioners, advocates, and others known and involved with Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 20 the resident. Therefore, the home must complete a ‘Quality Assurance review’ to establish the overall quality of care provided at the home. It was recommended that the home review the quality of care by completing a Quality Assurance review. A daily record of water temperatures had been recorded and a fire safety drill had been risk assessed and recorded and reasonable care had been taken to ensure that hazardous chemicals were stored in a place of safety. There was no contingency plan in place in case of emergency and the current situation at the home becomes inoperable, due to accident or illness. It is recommended that the manager liaise with the commissioning authority to ensure that arrangements are in place to assist with the continuous care of the resident in this event. The homes insurance cover was not distinguishable from an ordinary household policy, therefore, may not comply with the National Minimum Standards. The home managers must show that the home has adequate insurance liability to ensure it is able to cover its contracted responsibilities as set out in the Care Homes Regulations (2001). Please see the recommendations and requirements section of this report. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 2 3 X Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 22 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 YA9 Regulation 13, (4) Requirement That the residents Risk Assessment is reviewed and updated as appropriate. This was the second time that this requirement had been made as the original timescale of 15/03/06 had not been met. A new timescale for completion was agreed. That the manager attends updated training regarding medication, or another person with certifiable evidence of training and attached to the home can be confirmed. This will be the third time this requirement has been made (Previous time scale of 01/04/06 not met.). A new timescale for completion has been agreed. The manager must ensure that arrangements are made by training to prevent the resident from experiencing harm or suffering abuse or being placed at risk of harm or abuse by attending the next available DS0000013530.V315023.R01.S.doc Timescale for action 09/12/06 2. YA20 18, (1) (c) (i) 09/12/06 3. YA23 9(2)(b)(i) 09/12/06 Ethel Road (7) Version 5.2 Page 23 4. YA23 Sched4 para’(9)(a) 4(3) 19(1) (c) Schedule 2 para’2 and 7. 25 (2) (e) 5. YA34 Safeguarding Vulnerable Adults Training with Surrey County Council details of booked training to be sent to CSCI. The manager must ensure that 09/12/06 accurate record of residents financial transactions are made and receipts kept and recorded. The manager must ensure that 09/12/06 volunteers or advocates recruited by the home have CRB Clearance. That the manager checks with its insurers to see if its current liability certificate provides adequate cover for the service provided to the resident. This was the second time this requirement has not been met. (Previous time scale of 10/11/05 not met.) new timescale 09/12/06 6. YA43 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA1 Good Practice Recommendations It was recommended that that the manager and resident work together to reproduce the Statement of Purpose using the format familiar to the resident. It was recommended that the home update encounter records and also include a record of risk assessment. It was recommended that the residents care plans and other documentation be kept in a locked storage area. It is recommended that health and safety and food hygiene be timetabled for consideration and training updates for NVQ. It is recommended that the manager liaise with the commissioning authority to ensure that arrangements are in place to assist with the care of the resident in the event of an emergency. DS0000013530.V315023.R01.S.doc Version 5.2 Page 24 YA9 YA10 YA35 YA42 Ethel Road (7) 6. YA39 It was recommended that the home review the quality of care by completing an Quality Assurance review. Ethel Road (7) DS0000013530.V315023.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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