Inspection on 13/10/06 for Forest Home

This inspection was carried out on 13th 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 but made no statutory requirements on the home.

Other inspections for this house

Forest Home 06/06/07

Forest Home 27/01/06

Forest Home 24/08/05

Forest Home 09/02/05

Forest Home 15/09/04

Forest Home 22/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Forest Home 58 Swan Street Sible Hedingham Halstead Essex CO9 3HT Lead Inspector Jane Offord Key Unannounced Inspection 13th October 2006 12:15 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 Forest Home DS0000017820.V306722.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. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Forest Home Address 58 Swan Street Sible Hedingham Halstead Essex CO9 3HT 01787 460361 01787 463232 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) St Giles Homes Limited Mrs Tanya Jelley Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 34 persons) 27th January 2006 Date of last inspection Brief Description of the Service: Forest Home is a privately owned home situated in the village of Sible Hedingham. It is registered under the Care Standards Act 2000 as a Care Home to accommodate 34 older people. The registered manager is Tanya Jelley. The building is a detached listed property, with a more recently built fourteenbed extension to the rear of the building. There is a driveway to the front of the property with car parking facilities and a large garden and patio area to the rear of the property. The local amenities include a post office, church, newsagents and a supermarket. Residents accommodation consists of 20 single bedrooms and 7 shared rooms, which are located on the ground and first floor. There is a passenger lift between the two floors. There are a number lounges and a large dining room with access to a patio area and the gardens. Fees for the home range between £426.00 and £505.00 per week. The cost of hairdressing, chiropody, newspapers and toiletries is not included in the fees. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key, unannounced inspection took place on a weekday between 12.15 and 16.00. The registered manager was not on duty but the administrator helped with the inspection process. In the course of the inspection three residents’ files, care plans and daily records were seen as were the files of three newly appointed staff, the policy folder, some maintenance records, the complaints log and the statement of purpose. Part of a medication administration round was observed and some medication administration records (MAR sheets) were inspected. A tour of the home was undertaken and a number of staff, residents and visitors were spoken with. Residents looked well dressed and relaxed. Several lounges were being used by different groups. Some residents had preferred to remain in their own rooms although most came to the dining room for lunch. The home was clean and tidy with no unpleasant odours present. The meal at lunchtime looked appetising and was attractively served. What the service does well: What has improved since the last inspection? The external façade of the building has been recently rendered and repainted. The building is listed and the agreement to repaint has taken some time to negotiate but the result is very attractive. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 6 There has been some new carpets laid and some rooms in the home have been redecorated. Staff who administer medication have received updated medication administration training from a recognised training agency. 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. Forest Home DS0000017820.V306722.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 Forest Home DS0000017820.V306722.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): 1, 3, 6. Quality for this outcome area was good. People who use this service can expect to have sufficient information to make an informed choice and have their needs assessed prior to moving into the home. The home does not offer intermediate care. This judgement was made using information available including a visit to the home. EVIDENCE: The statement of purpose was seen and contained all the information required by standard 1 of the national minimum standards. In the admission section it refers to a pre-admission assessment of need. Three new residents’ files were inspected and each one contained a detailed assessment dated prior to the date of admission to the home. The assessments covered past medical history and the present medication regime, in addition areas of care such as mobility, continence, personal hygiene, communication, pain, orientation and sleep pattern were assessed. There was also information recorded about interests and family contacts. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 9 One resident and some family members spoken with explained how they had found the home and the reasons for the resident moving in. They said they had been given ample information and visited the home prior to the resident being admitted. They had found staff very open and welcoming. Forest Home DS0000017820.V306722.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 for this outcome area was good. People who use this service can expect to have a plan of care to help meet their needs and be treated with respect but they cannot be assured that all medication storage and practice will protect them. This judgement has been made using information available including a visit to the home. EVIDENCE: Three new residents’ care plans and daily records were inspected. Each care plan had interventions related to the assessed needs of the resident. So areas of care that needed support such as mobility, personal hygiene, continence and night needs had details of how the resident wanted support to manage these care needs. There was evidence that care plans were regularly reviewed. Each file also contained some life history work, details of the next of kin and contacts for any health professional involved in the resident’s care. There were risk assessments for falls and moving and handling, Waterlow tissue viability scores and a record of health care appointments. In addition social needs were recorded. One resident had brought a pet bird into the home with them, another enjoyed music and the intervention said, ‘encourage XXXX to listen to their music and sing’. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 11 Other information recorded included known allergies, any religious persuasion and in some cases the resident’s final wishes. Each file had a recent photograph of the resident. Staff were observed knocking on doors before entering rooms and offering residents choice about where they wanted to spend their time. Residents spoken with said the staff were very willing, ‘nothing is too much trouble for them’. Part of the lunchtime medication administration round was observed. Generally practice was safe with residents being offered ‘as required’ (PRN) medication and helped with tablets and inhalers. The carer omitted to change their protective gloves after administering eye drops to one resident before moving on to the next. One dose of ibruprofen from the previous day was still in the blister pack but the MAR sheet had been signed as if it had been administered. No signature gaps were noted in any other MAR sheets. Medicines that require temperatures lower than room temperature are stored in a refrigerator in the staff room. There is keypad entry to the staff room but the medication is not in a locked container within the domestic refrigerator. Medication stored there included some eye drops and insulin. The temperature of the refrigerator is not checked to ensure it maintains the correct level for safe storage of medication. The medication administration and storage policy needs to be expanded to include guidance on managing ‘homely remedies’, administering medication covertly and giving medication in a form not licensed by the manufacturers i.e. crushing tablets. Forest Home DS0000017820.V306722.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 for this outcome area was good. People who use this service can expect to be encouraged to maintain contact with family and friends, to be offered meaningful activities and have a balanced diet. This judgement was made using information available including a visit to the home. EVIDENCE: All the residents’ files seen had contact details for the next of kin and the life history work had details of relationships including grand children and great grand children. A number of visitors came and went during the afternoon. All were greeted by staff and offered any assistance they required. Visitors spoken with said they were always made welcome and could visit when it suited them and the resident. The home employs an activities co-ordinator who works four days a week. They were not on duty on the day of inspection but some of the carers organised a game of carpet skittles after lunch for any resident who wished to participate. The game caused lots of banter and laughter and was clearly enjoyed by those taking part or observing. Later a tape of well-loved hymns was played and a number of residents joined in the singing. Activities organised by the co-ordinator include board games, quizzes, cards, bingo and DVD games. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 13 Some entertainers are booked for the home and residents are supported to go shopping and take walks in the village. Some residents attend day centre and coffee mornings organised by the local church or Age Concern. One resident returned during the afternoon having attended a concert in the church. They said it had been lovely. Residents spoken with were complimentary about the meals they received. They said they were of a good standard and they were given choice. The lunch seen on the day of inspection looked appetising and was enjoyed by most residents. There was a choice of several desserts and the trolley was taken to each resident so they could see the options and make a selection. The menus seen showed that there was a cooked breakfast available if residents chose and a choice of two main dishes and at least two desserts each day. The kitchen was visited and the dry food stores seen. There was a wide variety of food stored, some in a cupboard in the kitchen and some in a cupboard in the new extension. The cupboard in the extension also housed some spare pillows, the carpet shampooing machine, saucepans and an open sack of water softener salt. The cupboard was not locked. In the kitchen the temperatures of refrigerators and freezers were logged daily and showed that they were within safe limits for food storage. Not all left over food stored in refrigerators was covered, labelled and dated. After lunch residents decided where they wanted to spend the afternoon. A number chose to return to their rooms for a nap, some went to one of the lounges and some wanted to go out onto the patio to enjoy the autumn sunshine. The carers were initially concerned that it was not warm enough but after going outside to check for themselves decided that with blankets around them residents would be comfortable. Two or three residents spent some time out in the fresh air admiring the pleasant garden. Forest Home DS0000017820.V306722.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 for this outcome area was good. People who use this service can expect to have their complaints taken seriously and be protected from abuse by staff knowledge but they cannot be assured that the up to date procedures for POVA referrals are available as reference. This judgement was made using information available including a visit to the home. EVIDENCE: The complaints log was seen and recorded three recent complaints from residents about one resident who interrupted planned activities and threatened people with their walking frame. It was recorded that the resident was spoken with about their unacceptable behaviour but staff said that advice was sought from a community psychiatric nurse (CPN). This action was not recorded. Staff said the interventions suggested by the CPN have alleviated the situation. Residents and visitors spoken with were all clear about who to approach if they had any concerns or complaints about the service. Records seen showed that all staff have received POVA training and staff spoken with were clear about their duty of care. The home has a whistle blowing policy. The POVA policy was seen but requires updating to bring it into line with the most recent guidance issued by Essex protection of vulnerable adults committee. Forest Home DS0000017820.V306722.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, 26. Quality for this outcome area was good. People who use this service can expect to live in a clean, comfortable environment but cannot be assured that all maintenance is up to date or that hand washing facilities are suitably equipped to meet infection control measures. This judgement was made using information available including a visit to the home. EVIDENCE: A tour of the home was undertaken and everywhere looked clean and tidy. There were no unpleasant odours anywhere. The communal lounges were furnished with comfortable chairs and the décor was attractive. All rooms seen had pleasant outlooks and were light and airy. Corridors in the extension were wide and had rails to assist any resident who was unsteady in walking. The provision of liquid soap and paper towels at hand basins was variable throughout the home. A wash basin in the downstairs bathroom had an ‘out of order’ sign on it but no indication that it had been reported or that anything was being done about repairing it. The ceiling lining paper in the same bathroom was peeling off. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 16 In the ground floor corridor and the corresponding toilet on the first floor some decoration and pipe boxing needs to be made good after a leaking pipe was repaired. The laundry was seen and was clean. The washing machines had a sluice programme and high temperature wash for soiled linen. The home has an infection control policy that requires the use of protective gloves and aprons for performing tasks that could spread infection. A carer was observed bagging up clinical waste using the protective equipment. Residents spoken with said their laundry was always returned to them in good condition. Forest Home DS0000017820.V306722.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 for this outcome area was good. People who use this service can expect to be supported by adequate numbers of well trained staff but they cannot be assured that evidence of all the recruitment checks made will be retained in staff files. This judgement was made using information available including a visit to the home. EVIDENCE: Staffing rotas were seen and showed that a senior carer was rostered for each early and late shift. Four carers on the early shift and three carers on the late shift supported them. Three carers covered nights. In addition the manager worked some supernumerary shifts and three days a week the home had an administrator covering the office. Ancillary staff consisted of two domestics daily, a cook and kitchen assistant and a kitchen assistant for the evening to manage the teatime meal. Staff and residents spoken with said there was enough staffing to meet the needs of the residents under the present regime. The files of three newly appointed members of staff were inspected. They each contained two references, a contract with terms and conditions of employment and a criminal record bureau (CRB) check. Two of them had evidence that checks had been made on the identity of the staff member. The third one had no documentary evidence but as a CRB was present the identification documents had been seen but copies not retained in the file. None of the files had a recent photograph of the member of staff. There was evidence of first day induction that covered fire awareness, the environment, confidentiality and the aims and objectives of Forest Home. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 18 A fuller induction programme taking place over the initial weeks is recorded in a ‘Learner portfolio for induction’. There was evidence that all staff, including ancillary staff, had recently had POVA training and care staff had had an update in moving and handling techniques. Certificates for staff attendance for medication administration training and food hygiene were seen and staff spoken with confirmed they had received instruction in those areas of care. The home employs twenty-six care staff, seven of who have achieved an NVQ level 2 or above. This gives a percentage of 30 , which does not meet the national minimum standard of 50 . Forest Home DS0000017820.V306722.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 for this outcome area was good. People who use this service can expect to be consulted about the service and have their personal monies protected but they cannot be assured that all fire prevention recommendations will be enforced. This judgement was made using information available including a visit to the home. EVIDENCE: The manager has many years experience of caring for older people and since the last inspection has commenced the Registered Managers Award (RMA) at a local college. The system for managing personal monies for residents has not changed since the last inspection when it was found to be safe and efficient. The home’s administrator is responsible for the administering of the system. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 20 The home undertakes annual surveys of residents and visitors’ opinions on the level of care being offered. The most recent one was done in February 2006. The questionnaires covered cleanliness, staff attitude, care practice, décor, meals and the choice of food, the response to any complaints and social activities. Responses from both residents and relatives were mainly positive. A comment from one resident was, ‘I cannot think of anything that would make the home better than it already is. I feel safe here’. Staff meetings are held occasionally and from the minutes discussion around handovers, shift patterns and care practice has taken place. Staff said that the manager has an ‘open door’ policy and they feel comfortable raising issues as they arise. Records were seen for routine checks on equipment. The Loler load test had been done on hoists in September ’06, the passenger lift had been inspected in October ’06 and checks run on the water storage tanks had been done in August ’06. The fire logbook showed there were monthly fire drills and monthly checks on emergency lighting. External consultants had checked all fire extinguishers and alarms in August ’06. It was noted that a number of fire doors to residents’ rooms were wedged open during the day. An immediate requirement to address this was left on the day of inspection. Forest Home DS0000017820.V306722.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Forest Home DS0000017820.V306722.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. 2. Standard OP9 OP9 Regulation 13 (2) 13 (2) Requirement Medication stored in a domestic refrigerator must be kept in a locked container. A refrigerator used to store medicines must have the temperature monitored daily to ensure it is functioning at safe levels for medicine storage. The medication administration policy must be expanded to cover additional areas noted in this report, to offer guidance to staff and protection to residents. To prevent cross infection gloves must be changed between residents when administering eye drops. Left over food must be covered, labelled and dated when stored. The home’s POVA policy must be updated to reflect the most recent guidelines issued by the Essex protection of vulnerable adults committee. The manager must continue to work towards ensuring that at least 50 of care staff obtain a NVQ 2. This is a repeat requirement. DS0000017820.V306722.R01.S.doc Timescale for action 31/10/06 31/10/06 3. OP9 13 (2) 30/11/06 4. OP9 13 (2) 13 (5) (c) 13 (3) 13 (4) (c) 13 (6) 13/10/06 5. 6. OP15 OP18 13/10/06 30/11/06 7. OP28 18 31/03/07 Forest Home Version 5.2 Page 23 8. OP29 19 (1) (b) Sch 2 23 (4) (c) 13 (4) (c) 13 (4) (c) 9. 10. OP38 OP38 11. 12. OP38 OP38 13 (3) 23 (2) (b) Staff files must contain evidence that all the required recruitment checks have been undertaken prior to employment. Fire doors that need to be open during the day must be fitted with self-closure devices. Cupboards that contain substances that fall under the COSHH regulations must be kept locked at all times when no staff are present. All hand washing facilities must have supplies of liquid soap and paper towels available. Repairs and refurbishment to the ceiling in the downstairs bathroom, and the toilet where there was a leak, must be undertaken and the décor made good. 30/11/06 31/12/06 13/10/06 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. Refer to Standard OP15 Good Practice Recommendations A review of storage areas should be undertaken to prevent food being stored with non-food items. Forest Home DS0000017820.V306722.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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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