Inspection on 01/09/06 for Ferndale House

This inspection was carried out on 1st September 2006.

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.

Other inspections for this house

Ferndale House 02/10/07

Ferndale House 31/01/06

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Ferndale House 38-40 Grove Road Hardway Gosport Hampshire PO12 4JL Lead Inspector Mrs Michelle Presdee Unannounced Inspection 1st September 2006 09:00 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 Ferndale House DS0000064121.V309287.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. Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferndale House Address 38-40 Grove Road Hardway Gosport Hampshire PO12 4JL 02392 524918 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) Mr Andrew Sidney Bowles Mr Sidney Ernest Bowles, Mrs Jacqueline Amelia Bowles, Mrs Theresa Jane Bowles Mr Sidney Ernest Bowles Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31.1.2005 Brief Description of the Service: Ferndale House is set in a residential area close to local amenities on the outskirts of the town of Gosport. It provides residential care for up to 20 elderly residents, some of whom have mild dementia. The home is on ground and first floors and there is a stair lift between these. There are a variety of aids and adaptations to allow residents to move about more independently. Sixteen of the bedrooms are single and two are doubles. All of the bedrooms have en suite toilets, and the two double bedrooms are provided with screening for privacy. There is a communal bathroom and toilet on the ground floor and a further communal bathroom and toilet on the first floor. There is a large garden with a small number of car parking spaces to the rear of the property. The fees for the home range from £266.00 - £375 per week. Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this unannounced inspection time was spent talking to service users and staff members. All areas of the home were seen and all service users bedrooms. A range of policies and procedures, assessments, care plans and other paperwork were looked at. It was not possible to view all necessary paperwork as the manager was unavailable and the senior on duty did not have access to all records. What the service does well: What has improved since the last inspection? What they could do better: Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 6 Assessments could be improved to give clearer details of the service users needs and abilities. Care plans need to give more detailed information to carers to enable them to assist service users in an appropriate manner. Medication records need to be more accurate. Medication should not be dispensed from the dossett into pots before it is due to be administered. Staff need to receive training in core areas including protection from abuse, infection control, moving and handling basic food hygiene and first aid and records should demonstrate what training each member has undertaken. Radiators, hot water pipes and windows on the first floor must be risk assessed and action taken as necessary to protect service users. Staffing records must be available at all times and it should be possible to establish all necessary checks have been carried out on staff. Health and safety issues could be improved in the kitchen and laundry room. 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. Ferndale House DS0000064121.V309287.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 Ferndale House DS0000064121.V309287.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current assessment system does not identify the needs and abilities of all service users. Service users can spend time in the home prior to moving in to ensure it is the correct home for them. EVIDENCE: The senior on duty explained the assessment process and storage of information is just being changed. New files are being created, which have a photograph of the service user on the front and the file is divided into many sections. This process has been completed for two service users and will be completed for all service users. Both new files were examined. They contained an admission form, which gave basic details on the service user and stated who was involved in the care of the service user before they moved into the Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 9 home. An assessment had been completed which included a matrix and barthel assessment, which identify the physical and mental health needs. Separate sheets had been created for dental and hygiene visits, optician, district nurse, chiropody and hospital visits. An inventory of all items brought into the home was available. The records of two other service users were examined who had recently moved into the home. It was found these did not contain as much information. An admission form had been completed but there was no assessment form for one service user. For the second service users the assessment had been started but had not been completed. Risk assessments and moving and handling assessments had not been completed for these service users. Service users are invited to spend some time in the home before they move in. If this is not possible the inspector was advised the manager or a senior would visit the service user in his or her own home. Service users spoken to confirmed they had viewed the home before moving in. The home does not provide intermediate care. Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans do not give a clear account of the help required to enable care staff to assist service users in a manner, which helps improve service users independence. Health needs are met in the home by a range of services. Medication procedures increase the risk of errors occurring and could put service users at risk. Privacy is upheld in the home and service users feel they are treated in a respectful manner. EVIDENCE: All four-service users files that were checked contained care plans for the service users. It was agreed these did contain useful information but needed expanding on to give more detailed information. One example was the service user needed assistance with washing and bathing, as she was prone to falls. The care plan did not give any detailed information on what assistance was required; staff did not have specific information to meet identified needs. Risk assessments were not in place. It was agreed more information would be recorded. It was also agreed more information should be recorded on service Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 11 users social needs and state how these are being met on an individual basis. Care plans were not being reviewed on a monthly basis and there was no evidence of service user involvement in the plans. The inspector was advised a range of health professionals visit the home. Evidence was seen in service users files where all visits are clearly recorded. The home will arrange for a dentist and optician to visit the home as needed. The home has a medication policy and care staff that are responsible for the administration of medication have received training. The home has a locked drugs trolley and uses a monitored dosage system. Medications, which cannot go in the cassettes or are spare and creams are stored in a locked drugs cupboard. Discussions were held on the way the home is using the dosage system. Currently the home dispenses the medication from the cassettes into named and lidded pots for lunchtime, teatime, suppertime and morning time. Medication, which is not in the cassettes, is added to the pots. It was agreed this increases the room for error and if a service user refused or spat out a tablet the carer would have difficulty identifying the medication. When the medication records were looked at it was found there were inaccuracies; in one example medication had been signed for when it had not been administered and in another example it could not be established if a certain medication had been administered or not as the records were not clear and signatures had been crossed out and then put back. No service users were managing their own medication. No controlled drugs were used in the home, but staff were aware of how to store and record controlled medication. From observations on the day staff were seen to work in a manner, which promoted service users privacy and in a respectful manner. All staff were observed to knock on service users doors and toilet doors before entering. All bathrooms had appropriate locks. Service users can have a key to their room door, but the inspector was advised none have wanted a key but some service users have a locked draw or box in their room, which they use. Service users spoken to stated the girls were always helpful and worked very hard. Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 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, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a variety of social activities, giving service users the choice to join in when they wish. Visitors are made welcome to the home and can visit at any time. A varied menu is served to service users in the dining room. EVIDENCE: Service users spoken to felt the home matched their expectations although some service users stated they were not sure what to expect. Service users enjoyed the homes activities and looked forward to the bingo sessions twice a week. One service user stated they would like to go out more but was grateful staff were able to take her out on occasions. Service users spoke of their enjoyment of going out with family members, who they stated are always made welcome at the home. Visitors are welcome at any time and can see their relative/friend in private. The home has church services in the home every two weeks. The library visits the home on a regular basis. Service users spoke of their enjoyment of being able to sit out in the garden, which has suitable furniture. Service users felt they had choices in their daily living activities. Two service users had fridges in their rooms where they stored a small selection of fresh food, which was supervised by staff. Some service Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 13 users chose to spend time in their room whilst others preferred the lounge and conservatory. The home has a four-week rotating menu. Meals are served in the dining room. The menu demonstrated meals were varied and service users confirmed a choice is available if they do not like the main choice. The menu is not currently displayed in the home. Comments from service users regarding the meals were varied. Some service users stated they thought the food was lovely whilst some felt the meals were average, but felt it was difficult to please everyone and confessed they were fussy eaters. It was difficult to establish if fresh vegetables were used in the home based on the menu and in discussion with service users and staff. One carer stated they were and another stated they were only used on a Sunday. No fresh vegetables were available on the day of the inspection but the inspector was advised they would be delivered the next day. The fridge and freezers were well stocked and there was plenty of frozen vegetables. Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 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, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users felt confident their complaints would be listened to and acted upon. Staff do not have adequate knowledge on dealing with suspected abuse, which could put service users at risk. EVIDENCE: The home has a complaints procedure, which detailed all the necessary names, addresses, telephone numbers and timescales. Service users spoken to stated if they had a problem they would speak to who was in charge and felt confident their complaint would be dealt with. The commission has received no complaints and the senior on duty was not aware of any complaints being made to the home. The home has a policy and procedure relating to adult protection, which is available to all staff. It was not possible to establish if and when staff had received training in adult protection. Staff spoken to could not remember undertaking any specific training. Two of the three members of staff spoken to had very little knowledge of what to do if abuse was suspected in the home and did not know about procedures to follow. The third member of staff did have some knowledge and was aware of procedures. Training records were not available so it was not possible to establish what training had taken place. Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 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, 20, 24, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home provides a clean, pleasant and homely environment for the enjoyment of service users. Health and safety issues have not been completed to ensure the safety of service users. EVIDENCE: The home has a lounge, which leads onto the conservatory, which opens onto the home’s attractive garden. A separate dining room is available which is next to the kitchen. The home is decorated and furnished to a standard, which creates a homely ambience. On this visit all bedrooms were seen. All areas of the home were clean and no unpleasant odours were detected. Bedrooms had been personalised by service users. It was noted in some bedrooms and in the en-suites, radiator covers and hot water pipes had not been covered. It was also noted window restrictors had not been fitted to all first floor windows and Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 16 in two rooms where they had been fitted they were not working. Risk assessments were not available and the inspector was advised the senior was not aware of any risk assessments being carried out in these areas. The general décor of the home was adequate, but certain areas were identifies as needing painting. These areas included the lounge, the main bathroom on the ground floor and the en suite in one bedroom. The inspector was advised the lounge was going to be painted later this month during the nighttime to minimise the disruption to service users. The home has a separate laundry. All staff are involved in the laundry and do the ironing when they have time. The laundry is equipped with an industrial washing machine and dryer. The flooring in the laundry needs replacing, as it is needs to be impermeable to stop the risk of cross infection. Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 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, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has adequate staffing levels ensuring service users needs can be met. Training in the core areas would ensure staff members have the knowledge and skills to improve their practice. The lack of accessible records did not confirm if the home was following a robust recruitment procedure to ensure the safety of service users. EVIDENCE: Duty rotas were seen, which demonstrated three carers work in the morning and two carers work in the afternoon. A cleaner works five mornings a week and a cook works six mornings a week. Two staff work a night duty, one working a waking duty and the other a sleep in duty. From observations on the day staff were seen to have time to talk to service users and assist in an unhurried manner. Care staff and service users spoken to on the day felt there was adequate staff on duty to meet service uses needs. Service users felt the care staff worked very hard and were always there to help. The inspector was informed the registered manager calls in on a regular basis, but it is two of the registered providers who are in the home on a day-to- day basis. The home employs twelve care staff and two ancillary staff. It was not possible on this visit to check staff records, as the senior on duty did not have access to staff records. At the last inspection a requirement was made to ensure all staff Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 18 have a CRB (criminal records bureau) check. It was not possible to establish if this had been undertaken. Training records were not available on the day of the inspection so it was not possible to establish what training had taken place and when. Staff on duty stated they had recently received a two-hour session of training on Dementia. Carers thought this training was useful, but were unsure who had carried out the training. Information sent to the Commission stated staff had received training in food and hygiene, dementia, medication and fire training. It was possible to establish all staff had received training on fire issues. Information sent to the commission also stated three members of staff have NVQ (National Vocational Qualification) Level 2 or above. Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 19 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, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by two of the registered providers. It appears the home does not manage any of the finances of service users, but records should be available to demonstrate this. Health and safety issues are not always promoted in the home, which could leave service users at risk. EVIDENCE: The inspector was advised the running of the home is managed on a daily basis by two of the registered providers, with the manager calling in on a weekly basis. Service users stated they felt the new owners and managers were doing a good job and some recognised it was hard to accept changes as the previous owners had had the home for a long period of time. The senior on duty acted in a very professional manner and was able to call in extra staff to Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 20 enable her to assist with the inspection. Discussions were held on her being able to access documents if she was left in charge. It was clear service users are consulted on the day-to-day running of the home but the senior on duty was unsure if service users or visitors are consulted in a formal way. The inspector has been advised by telephone the home has recently sent out questionnaires to service users and visitors to get feedback from service users and visitors. The senior on duty was unsure if the home managed any service users finances or personal allowance. From information sent to the Commission it would appear the home does not manage any service users finances or personal allowance. A wide range of Policies and procedures were available in the home. Obvious hazards in the home have already been discussed, including radiators, hot water pipes, window restrictors and the laundry floor. Whilst walking around the home it was noted cleaning materials are locked away. Gloves and aprons were available for staff. It was noted in the kitchen health and safety issues could be improved. The fridge and freezer temperatures have not been recorded since January 2006 and the inspector was advised the fridge is not working too well and a new one is on order. Food was being stored appropriately in the fridge. The probe thermometer recordings had recently stopped and it was agreed these should be restarted. It was not possible to establish if staff had received training in moving and handling, infection control and food hygiene. Two members of staff have first aid certificates. From records seen it was possible to establish all staff had received one session on fire training this year from an outside agency. All necessary tests were being carried out in the agreed timescales. All fire equipment; fire alarm and emergency lighting had been serviced in March 2006. The gas boiler had been serviced in June 2006. Ferndale House DS0000064121.V309287.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 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 3 2 X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 14 Requirement Assessments must be of the same standard for all service users and contain risk assessments and moving and handling assessments. Service users plans need to be more specific on the care needed to enable carers to assist correctly. Details of each service users social needs must be recorded. Records must accurately reflect when medication has been administered. All medication must be administered from the original pharmacist container and must not be placed in a secondary container for later administration. Staff must receive training to prevent service users being at risk of abuse and to train staff o relevant policies and procedures. Radiators, hot water pipes, opening windows must be risk assessed and action must be taken to protect service users. Staffing records must be available at all times. A previous DS0000064121.V309287.R01.S.doc Timescale for action 30/11/06 2 OP7 15 30/11/06 3 OP9 13 (2) 30/11/06 4 OP18 13 (6) 30/12/06 5 OP24 13 (4) (c) 30/11/06 6 OP29 17 (2) (3) 30/11/06 Ferndale House Version 5.2 Page 23 7 OP30 18 (c) (1) 8 OP38 23 requirement regarding criminal record bureau checks needing to be carried out for all staff was unable to be checked. Staff must receive training in the key areas of first aid, infection control, moving and handling, basic food hygiene and abuse and records should be available. Health and safety issues in the kitchen regarding temperatures of the fridge, freezer and probe thermometer must be recorded. 30/11/06 30/11/06 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 Refer to Standard OP15 OP38 Good Practice Recommendations Menus should be displayed in the home and should demonstrate what vegetables are to be served. The laundry floor should be changed to ensure the flooring is impermeable. Ferndale House DS0000064121.V309287.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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