Inspection on 09/09/05 for First Choice Care Ltd 18 St Andrews Ave

This inspection was carried out on 9th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. 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

First Choice Care Ltd 18 St... 09/08/06

First Choice Care Ltd 18 St... 17/01/06

First Choice Care Ltd 18 St... 09/03/05

First Choice Care Ltd 18 St... 01/09/04

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

CARE HOME ADULTS 18-65 First Choice Care Ltd 18 St Andrews Ave 18 St Andrews Avenue Sudbury Middlesex HA0 2QD Lead Inspector Mr Ram Sooriah Unannounced Inspection 9th September 2005 10:00 First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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 First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service First Choice Care Ltd 18 St Andrews Ave Address 18 St Andrews Avenue Sudbury Middlesex HA0 2QD 020 8904 5250 020 8904 5250 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 Divya Gandhi Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2005 Brief Description of the Service: Mosaic House is run by a private company called First Choice Care Limited. The home is a semi-detached house, which has been extended on the side and back. It is situated in a residential area of Sudbury and is easily accessible by public transport. There is a garden to the back of the house, which is accessible to service users from the lounge and the kitchen. Mosaic House is registered for five adults with mental health needs. The statement of purpose states that it caters for Asian, African and Caribbean service users. All service users have single bedrooms. The accommodation is on two floors with two bedrooms, lounge/dining area, an office, a toilet/shower and kitchen on the ground floor. There are three bedrooms, one bathroom with bath and toilet; and the sleep in room on the first floor. Service users normally have been inpatients or users of other services before being admitted to the home. The aim of the home is to provide rehabilitation and support to service users and to develop their independent living skills with regard to being discharged back to live independently in the community. Some service users in the past have benefited from this approach and have achieved the goal of going back into the community. However this may be difficult for other service users who may have to stay in the home for a longer period of time, during which time they receive on-going support. At the time of the inspection there were five service users in the home. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is one of the two statutory inspections for the period 20052006. It started at about 1045 and finished at about 1545. The inspector met Priya Halai, the member of staff on duty during the inspection and was joined later by the proprietor, Mr Gandhi. Since the last inspection the registered manager has left the home and a new manager, has been appointed to the home. He was not on duty in the home at the time of the inspection. During the course of the inspection the inspector spoke to service users, Ms Halai and Mr Gandhi. He also looked at a number of records, inspected some of the premises and checked for compliance with previous requirements. The inspector would like to thank all the service users, Mr Gandhi and Ms Halai for a kind welcome and for their cooperation during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be reviewed at least six monthly or more often as the needs of service users change. The provider must consider having a redecoration and refurbishment programme with time scales, to address areas in the home, which have started to look dated. Without this the standard of the premises, fixtures and fittings First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 6 could deteriorate and cease to provide an environment conducive to the care of the service users. 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. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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 First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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): 2 and 3 In the past all prospective service users have had comprehensive preadmission assessments of their needs prior to admission to the home. Prospective service users in the future could expect the same practice. EVIDENCE: The home has not had any new admissions since the last inspection. In the past the inspector has noted that appropriate information was provided to service users to decide if they wanted to stay in the home. They had also been encouraged to visit the home prior to admission. All service users have been given a service users’ guide and a statement of terms and conditions. Care plans of service users contained comprehensive information about the needs assessment of service users. The care plans also contained information about the aspirations of service users and action plans about helping service users meet these aspirations. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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 and 9 Care plans of service are comprehensive. They contained a range of plans to meet the needs of service users. They also contained appropriate risk assessment to promote the independence of service users while looking at their safety and that of others. EVIDENCE: All service users have an individual care plan, which was in good order and kept securely in the manager’s office. There was evidence that the plan was drawn out with the involvement of service users. It contained a range of risk assessments aimed at promoting the independence of service users and at building their confidence to engage in the community. The plan followed closely the desired outcomes and actions plans formulated in Care Programme Approach (CPA) meetings, for those who were under CPA. Care plans were however not always reviewed six monthly. The inspector observed that service users were encouraged to make decisions for themselves. One was asked about the food that he would like to eat and another was asked about how he wanted to spend the day and about taking responsibility with regard to doing things for himself. All service users in the home manager their own finance except for one. Any limitations with regard to First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 10 independence and any restrictions with regard to freedom are clearly dealt with within the risk assessments. Service users are encouraged to take part in shopping. A service user described how he accompanies staff to do the shopping on Saturdays. The care plan of another service user described his participation in the preparation of meals and in taking part in completing the house chores. The inspector was informed that all risks are discussed with service users and within the CPA meetings for those who are under CPA’s. The risk assessments are signed by service users and are normally reviewed with care plans on a six-monthly basis or more often if required. Risk assessments were clear and contained actions plans with regard to dealing with the risks, while promoting the independence and dignity of service users. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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): 11,12,13,15,16 and 17 Service users have ample opportunity and support to engage in appropriate recreational and leisure activities, to get involved in the local community and to engage in educational activities for personal development according to their rights and choices. Meals are provided to service users according to their choices. The practices with regard to storing food items in the fridge/freezer did not always guarantee the safety of service users. EVIDENCE: There was evidence that service users have been encouraged to attend classes for their personal development. Some service users have displayed their certificates in their rooms. The manager stated that at times staff link up with local colleges to find appropriate classes for service users. In the past service users have attended courses in computing, English and horticulture. A number of service users in the home attend day centres or the drop in centre. On the day of the inspection one service user had gone to Chessington World of Adventures with the manager of the home. Three other service users were either at the day centre or at the drop-in centre. Another service user First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 12 went for a walk and to the local shops. The inspector noted that each service user has a plan of activities in their care plan. The provider clarified that there is now an emphasis on service users taking part in appropriate leisure and recreational activities to develop their independence and confidence in the local community, so that they may one day be independent and function as a responsible member of the community. The home continues to encourage visitors to the home to see the service users and service users also mentioned that they go and visit their friends and relatives. The home has a menu system, which it uses as a guide. However most of the time, service users decide what they want to eat and staff in the home cater for them. Records about the meals cooked in the home, showed that a range of meals were cooked for service users according to their wishes. The inspector noted that there were fresh vegetables in the fridge and some fresh fruits. Service users were happy with the meals that they receive in the home. The inspector noted that a number of items in the fridge needed to have an opening date on them and that the fridge and freezer temperatures were not always monitored on a daily basis. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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 21 Staff in the home ensure that the healthcare needs of service users are met. Care plans did not always address the wishes and instruction of service users with regard to ageing, illness and death of service users. EVIDENCE: Care plans showed the involvement of service users in determining the action plans to meet their needs. Service users in the home have a key worker. Support for service users involves one-to-one session with the key workers or with the manager. The provider clarified that support provided is individual to the needs of the service user depending on their needs and their abilities. There was evidence that service users saw relevant healthcare professionals as required. Staff in the home monitor and ensure that service users attend their appointments, while encouraging the service users to take responsibility for their own healthcare needs. At times staff in the home liaise with the relevant healthcare professionals to identify the best possible way to support the service users. The standard with regard to medicines was assessed by Jane CSCI pharmacy inspector on Monday 5th September 2005. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 14 Care plans still need to address areas of ageing, illness and death of the service users in consultation with them or their representatives. While service users normally receive support with regard to fulfilling their aspirations, the part about the future of service users with regard to getting old and their wishes and instructions with regard to that process are not always documented. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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 The home offers the opportunity for service users to express their views and takes complaints as well as allegations and suspicions of abuse seriously. EVIDENCE: The home has updated its complaint procedure to include details of the Commission for Social Care Inspection. The procedure was available in the service users’ guide and in the foyer of the home. One service user said that he would approach the manager or the provider of the home if he had any concerns. The home has an abuse procedure. The provider stated that new members of staff are informed during the induction period about the actions to take and the procedure to follow when there are allegations or suspicions of abuse. A new member of staff spoken to by the inspector was familiar with the actions that need to be taken in cases where abuse is suspected. The home has appropriately dealt with one recent allegation of abuse. The provider stated that members of staff are then sent on further training on abuse when this becomes available. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 16 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, 25, 28 and 30 The home provides a safe environment for the service users. Some areas of the home are starting to look dated. Redecoration of these areas will ensure that the home continues to provide a high quality environment for the service users. EVIDENCE: The front area of the home was mostly tidy. There were some dried branches in a corner, which have been cut from the hedge. The provider stated that he would clear these as soon as possible. The back of the home was also mostly tidy, but could have been made more attractive, by planting more flowers and shrubs. The building was generally in good order. The crack, which was in the wall facing the back, has been made good. The home did not have a plan for redecoration and refurbishment. Some areas of the home are beginning to show its age and will need to be redecorated soon. These include the corridors, the staircases and at least one bedroom with wallpaper, which looks dated. The home has a through lounge/dining area. There is a breakfast area in the kitchen. Furnishings in the communal areas are in good condition. The lounge/dining area looks a little dark and consideration must be given to ‘brightening’ up these areas. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 17 Bedrooms of service users were also clean and some of them have been personalised to suit the needs of the service users. Progress in this area must be commended. However as mentioned above the décor in some of them seems to be getting dated and the provider must consider redecorating these with the involvement of the service users who live in these rooms. There were locks on the doors of the bedrooms of service users. However, if these are locked by service users from the inside and if they leave the keys in the locks, it would not be possible for staff to open the doors. The provider stated that he has considered this requirement and has assessed all the service users and will provide appropriate locks if the service users require them. The home was mostly clean. There was only a small area on the wall in the staircases, which seemed slightly stained with some spillages. The bathroom on the first floor and the shower on the ground floor were also clean. The inspector strongly recommends the use of disposable paper towels instead of cloth towels in the communal bathrooms/toilets areas to dry hands in order to prevent cross infection. The provider stated that he was looking at a number of options to address this recommendation. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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 Staff in the home were sufficiently competent to ensure that service users were appropriately supported and cared for. Recruitment procedures were not thorough enough to ensure the safety of service users. EVIDENCE: A number of staff working in the home are from overseas and are trained in areas related to healthcare. Members of staff spoken to by the inspector were familiar with the healthcare needs of the service users and the areas of personal support required by them. Service users also knew the members of staff and related appropriately to them. They also had identified key workers. The provider stated that all members of staff receive supervision at least once every two months. Two staff files were inspected. They contained all the necessary documents as required by Schedule 2 of the Care Homes Regulations 2001, except for the outcome of an enhanced CRB check. The home had three new members of staff at the time, and while there was evidence that a PoVA check has been initiated, the members of staff were working in the home at times on their own, while not being supervised and not in possession of a PoVA First check, as per guidance given by the Criminal Records Bureau and the Commission for Social Care Inspection. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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 and 42 The management approach in the home is open and involves the service users. Practices in the home safeguard the Health and Safety of service users. EVIDENCE: The previous registered manager has resigned and a new manager has been appointed. He has previously worked for the same company in a management role and has demonstrated experience in the area of care that the home provides. He has started the Registered Managers Award, and in the past has shown an interest in training and in keeping himself updated with good practice in the area of providing service users support and care for service users with mental health needs. The inspector looked at the Health and Safety records kept in the home and the maintenance records. These were all up to date. There were appropriate records of fire tests and fire drills. A fire risk assessment was however not available for inspection despite one having been the subject of a requirement during the last inspection. The provider stated that he has booked a half-day training in First Aid for his staff. He should now ensure that the training First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 20 provided is suitable to ensure that designated staff on duty are sufficiently trained to be the person responsible for First Aid. First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x 3 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x 2 3 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x 2 Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 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 YA6 Regulation 15(2)(b) Requirement Timescale for action 30/11/05 2 YA17 13(3,4) 3 YA21 15(1,2) 4 YA24 23(2)(d) The registered person must ensure that all care plans are reviewed at least six-monthly with the involvement of the service user as required. The registered person must 30/11/05 ensure that items of food which have been opened and stored in the fridge have an opening date on them and that the fridge and freezer temperatures are monitored on a daily basis (Previous requirementTimescale of 30/4/5 not met). The registered person must 30/11/05 ensure that care plans addressed the future and aspirations of service users with regard to ageing, illness and death as well as providing guidance to staff about dealing with these issues (Repeated requirementtimescale of 31/5/5/ not met) The registered person must 31/12/05 consider redecorating areas in the home, which are becoming dated such as the corridors, the staircases and some bedrooms of service users. DS0000017493.V250793.R01.S.doc Version 5.0 First Choice Care Ltd 18 St Andrews Ave Page 23 5 YA34 19 Schedule 2 7 YA42 13(4) The registered person must ensure that all new employees have an enhanced CRB check before starting work in the home. In circumstances where the home is short of staff, the registered person must ensure that the result of a PoVA first check has been received and that once this has been judged to be satisfactory, the person can work in the home if supervised, when in contact with service users (Previous requirement- Timescale of 30/4/5 not met). The registered person must ensure that there is a fire risk assessment available for inspection. 30/11/05 31/12/05 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 YA24 2 YA26 Refer to Standard Good Practice Recommendations It is recommended that the home develop a plan with regard to the redecoration of the home and with replacing the fixtures and fittings in the home. It is strongly recommended that the home provide disposable hand-towels for service users and staff in the communal toilets, instead of cloth towels, which can be a source of cross-contamination The registered person should consider making the lounge/dining areas brighter and more airy. The registered person should ensure that designated staff for first aid, have been sufficiently trained to undertake this task. 3 4 YA28 YA42 First Choice Care Ltd 18 St Andrews Ave DS0000017493.V250793.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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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