Inspection on 30/06/05 for Frank Foster House

This inspection was carried out on 30th June 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 but made no statutory requirements on the home.

Other inspections for this house

Frank Foster House 29/01/09

Frank Foster House 04/01/07

Frank Foster House 05/01/06

Frank Foster House 07/10/04

Frank Foster House 05/05/04

Frank Foster House 22/01/04

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

CARE HOMES FOR OLDER PEOPLE Frank Foster House Loughton Lane Theydon Bois Epping, Essex CM16 7LD Lead Inspector Diana Green Unannounced 30th June 2005 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 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. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Frank Foster House Address Loughton Lane Theydon Bois Epping Essex CM16 7LD 01992 812525 01992 814753 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Runwood Homes Plc Mr Teshwar Seeratun Care Home (CRH) 71 Category(ies) of Old age, not falling within any other category registration, with number (OP), 71 of places Dementia - over 65 years of age (DE(E)), 35 Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who only fall within the category of old age (not to esceed 71 persons). 2. Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 35 persons). 3. The total number of service users accommodated in the home must not exceed 71 persons. 4. The registered person must not admit persons subject to the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995. Date of last inspection 07/10/2004 Brief Description of the Service: Frank Foster House provides personal care with accommodation for up to 71 older people, including 35 older people with dementia. Frank Foster House is owned by a private organisation named Runwood Care Homes Ltd. The home is located in the village of Theydon Bois, Essex. The home was opened in 2002 and was a former local authority home and consists of a twostorey building that has been upgraded and refurbished to a high standard. There are 71 single en-suite bedrooms. There are two passenger lifts. The home has an enclosed courtyard garden that is accessible to wheelchair users. Frank Foster House is accessible by road and parking is available in the car park. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 30/06/05, lasting 6 hours. The inspection process included: discussions with the manager, deputy manager, five staff, five service users and six relatives; a tour of the including a sample of residents’ rooms, bathrooms, communal areas and the laundry; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Feedback was also received from district nurses and social workers. Twenty standards were covered, and nine requirements made including two second repeat requirements. The registered manager and staff were welcoming and helpful throughout the inspection. What the service does well: The home provides a welcoming, homely environment and good standards of personal care: residents and their relatives said that care staff were very respectful and caring. One relative said “the manager is excellent. You can go to him with anything. “ A second relative said that the home is very nice, their relative was happy at Frank Foster and communication was good. Another relative said they were very happy with the home. The manager and staff were helpful and were interested in the welfare of the resident and relative. Residents’ health needs are met appropriately and well monitored and prompt referrals are made to GP’s and relevant health professionals where required. The manager receives regular updated training through the organisations management development programme. Staff are employed in sufficient numbers and are skilled to care for the needs of residents through regular training and supervision by the manager. There are regular internal audits undertaken and prompt action is taken by the manager to address issues provided there are no budgetary constraints. Social and therapeutic activities are provided throughout the day by care staff and designated activities coordinators with relatives encouraged to become involved. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Some concerns were raised by relatives with regard to the quality and variety of food provided, particularly at teatime and lack of a cup of tea provided following lunch. Two residents said that the food was usually satisfactory but the occasional dinner was not good. One relative said that they found the induction to the home poor. They had not seen the manager but another member of staff and had not received the service user guide/statement of purpose prior to admission of their relative. Concerns were also raised that all rooms were the same and they had to ask several times for a beaker with handles to be provided. There have been some delays in providing tables for residents to sit at and bedside lighting. Infection control standards have been compromised though hand-washing facilities not being provided appropriately and unlocked clinical waste bins. Action is not taken promptly to address some maintenance issues; eg peeling wallpaper and radiator covers in need of painting that detracts from the appearance of the home. The gardens are not well maintained and do not provide an attractive environment. There is no plants provided in the courtyard and no sensory planting that could enhance the environment for residents with dementia or a sensory impairment. The laundry facilities are small for the number of residents and need review. There are no adjustable beds and divan beds are not suitable for the safe moving and handling of some residents or the health and safety of staff. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 7 Some privacy /dignity issues were evident e.g. hoisting instructions for individual residents on display but generally feedback from residents indicated that staff were respectful. 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. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 9 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 standard(s) 3 & 4 The admission procedure ensures all residents are assessed on admission ensuring their care needs can be met. Frank Foster provides specialised services for people with dementia that are based on good practice. Further developments in training and staff development will build on good practice and provide assurance that the needs of residents with dementia are met consistently at all times. EVIDENCE: The manager and deputy manager undertake assessment of all prospective residents prior to admission, and information on the person’s needs is recorded. Evidence of pre-admission assessments was present on all four files inspected. The manager and deputy manager showed a good awareness of the needs that the home is able to meet, and this was clearly taken into account when considering prospective admissions. The relative of one service user said they were not provided with a statement of purpose prior to admission to enable them to make an informed choice. Specialised services offered for people with dementia and seen at inspection include a range of social and therapeutic activities provided by all care staff throughout the day. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 10 Signposts in bright colours are provided to assist residents with dementia in orientation of their surroundings. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 11 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 standard(s) 7, 8 & 10 The care planning process provides good information for care staff to satisfactorily meet residents’ needs but is not always agreed with residents’ representatives. Residents health and personal care needs are well met within the home. Staff have a caring approach towards residents, but privacy and dignity are not always upheld. EVIDENCE: Four care files were inspected. These contained care plans that covered the majority of key needs (physical and social) with the exception of foot care, although these needs were evidently being met. All four care plans had been regularly reviewed and agreed with the resident and/or their relative as evidenced by signature. Feedback was received by the relative of one resident, stating they were generally happy with the care at Frank Foster but had not agreed the care plan. Assessments for moving and handling/mobility, risk of falls, pressure areas and continence needs were recorded in all of the files inspected. Residents on the care programme approach had six monthly reviews undertaken. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 12 Residents were enabled a choice of GP with evidence of several GP practices serving the home. Residents were assessed and referred to district nurses for nursing care and provision of pressure relieving equipment. There was one resident with a pressure sore who was receiving treatment from district nurses. The standard of personal care was observed to be good. Staff were observed to encourage residents to walk with their assistance and to take part in physical activities. New weighing scales had been purchased since the previous inspection and the records confirmed that residents were weighed on admission and regularly monitored. Referrals were made to other health professionals ensuring residents health needs were appropriately met. Residents spoken with said that staff were respectful, caring and helpful. Staff spoken with said they were instructed at induction on how to treat residents with respect and this was generally evident from their care practice. However the door of one resident’s room was left ajar when they were receiving personal care, compromising their privacy and dignity. Feedback was also received from a social worker who said that staff were not always aware of the residents’ dementia care needs. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 13 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 standard(s) 12, 13 & 15 Each person is encouraged to take part in activities of their choice. The regular programme of activities provides stimulation and exercise. Individuals are encouraged to take part in local activities. Contacts are encouraged with friends and families. There is a varied diet offered that takes account of individual preferences. The daily routines are flexible and choices are actively promoted. A good range of social and therapeutic activities and interaction takes place in the home. Residents are enabled to maintain contact with the people important to them. The meals in the home are varied and nutritious and cater for special dietary needs. Alternative choices are provided based on residents’ preferences. EVIDENCE: A good range of social and therapeutic activities were on offer at the home and were displayed in large print for residents’ information. Activities were provided by the activities coordinator and care staff and those observed throughout the day comprised card games, bingo, karaoke with music being played during lunch. Comprehensive records were maintained to a high standard that included a life history, social care plan, record of activities undertaken with the outcome for each service user. Service users spoken with Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 14 said they could get up and go to bed when they chose and were enabled a choice of where they took their meals and in taking part with social activities. The statement of purpose detailed the home’s policy on maintaining contact with relatives and friends and those spoken with confirmed there were no restrictions on visits made. One relative spoken with said they attended regularly and activities were provided every afternoon and that staff encourage residents to socialise with each other. Another resident receiving respite said that they were a committed Christian and were pleased to be able to attend the weekly service. The home had a varied menu that was displayed for residents’ information and their choice discussed daily with them. The records were being maintained appropriately and evidenced a balanced, nutritious diet with specialist needs catered for. All residents looked well nourished and three spoken with indicated the food was good and plentiful and plenty of drinks were provided. Two relatives said the food was satisfactory but another said they were concerned at the meals provided at teatime and that only cold drinks were provided following lunch and residents had to wait until 3pm to have a cup of tea. Care staff were observed to assist service users who needed help with eating with sensitivity and respect. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 15 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 standard(s) 16, 17 & 18 Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The manager actively promoted awareness of protection issues through staff training, recruitment practices and respecting individual rights. EVIDENCE: No complaints had been received by the CSCI about the home since the last inspection. Frank Foster has a complaints procedure that includes timescales within which complainants can expect a response and their right to complain directly to the CSCI at any stage. The procedure was included in the statement of purpose and displayed in the home for resident and representative information. Residents spoken to had no complaints about the home, and their representatives said that any issues were dealt with quickly. The legal rights of residents was discussed with the manager who confirmed that postal votes had been facilitated for residents. There were no residents that were able to vote independently. Access to advocacy services was evident at previous inspections and advocacy information was available at the home. The home had a protection of vulnerable adults policy and procedures and a whistle blowing policy. All staff had received copies of the revised local Essex multi-agency guidance. The records provided evidence that staff had received training in POVA, and those spoken with were clear on the procedures to be followed. Records inspected showed that appropriate pre-recruitment checks on new staff were undertaken prior to appointment (see standard 29). There had been no complaints at Frank Foster since November 2004. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 16 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 standard(s) 19, 22, 24 & 26 Frank Foster provides a homely environment for residents. The failure to quickly address maintenance and infection control hazards means that the home does not wholly present as safe for service users or staff. EVIDENCE: A tour of the premises was undertaken. The home was generally clean and well maintained, however some action required from previous inspections had been slow to be addressed (a review of laundry facilities, provision of a table in residents rooms and paper towel and soap dispensers). Wallpaper was peeling off in some areas and radiator covers were in need of painting. The garden shrubs to the front of the building had been roughly trimmed but were unattractive and there were no flowers in the internal courtyard garden. The relative of one service user complained that the gardens were not well maintained. Frank Foster had two lifts that were well maintained and access to communal and individual accommodation was provided through grab rails fitted throughout the home. There were no separate storage facilities and wheelchairs were stored in designated areas throughout the home. Disability Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 17 and aids to daily living were generally well provided, however one relative said that they had to ask several times before a beaker with handles was provided. The home was comfortably furnished and residents were enabled to bring in their own furniture. Those spoken with said they felt it was their home. Divan beds were provided throughout that were not suitable for all residents and posed a health and safety risk for staff when moving and handling residents. The manager advised that a risk assessment was in place. A table for residents to sit at was not available in all rooms. The home was generally clean with no odorous smells. Feedback from relatives indicated they were satisfied with the standard of cleaning and laundry. The laundry is small to accommodate the volume of laundry for the number of residents. Staff hand washing facilities were not available in all en-suite rooms compromising infection control standards and clinical waste bins were unlocked. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staffing levels and skills are appropriate to meet the personal care and physical needs of service users. The recruitment processes are robust to ensure the protection of service users. EVIDENCE: There were 65 residents and 2 were in hospital. The duty rota was inspected and complied with the levels previously agreed. From discussion with the manager, staff and residents there was evidence that staffing levels were sufficient to enable personal care needs to be appropriately met. Residents spoken with said that they were not kept waiting for long when they called staff. In addition to the manager and deputy manager there were two care team managers and eight care staff on duty. Ancillary staff included a secretary, two domestic staff, a laundry person, the cook and a kitchen assistant. The personal files of two new staff were inspected and confirmed the appropriate checks had been undertaken prior to appointment. Two satisfactory written references, proof of identity/recent photograph and passports were available but there was no birth certificate in either file. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 38 Frank Foster is well managed and staff are well supervised but action is needed to ensure health and safety systems and practices are improved and upheld to ensure the safety of residents and staff. EVIDENCE: The manager is a first level registered nurse with current NMC (Nursing and Midwifery Council) registration, had previous experience in managing care homes and had completed the Registered Managers Award. He also held ENB N11’ Caring for People with a Dementia Illness and their Carers’, a Diploma in Nursing Studies and a NEBS Management Certificate for Residential and Nursing Care. Service users and staff said that they found the manager approachable and supportive. Representatives said that the manager was always available and addressed any issues quickly. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 20 There was evidence from observation, inspection of the records and in discussion with staff and residents, that the manager made efforts to ensure the health and safety of staff and residents as far as reasonably practicable. However hand-washing facilities were not available in all residents en-suites posing an infection risk to residents and staff. Residents beds were too low for some residents and posed a health and safety risk for staff when moving and handling some residents. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 4 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x 2 x 2 x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x x x x x x 3 Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 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 7 Regulation 15 Requirement The registered person must ensure that residents care plans are agreed with them or their representative and evidenced by signature The registered person must ensure that residents receiving personal care do not have their privacy/dignity compromised. The registered person must ensure that residents are offered a hot drink following lunch. The registered person must ensure that the gardens are well-maintained and provide a therapeutic environment for residents with dementia. The registered person must ensure that the premises are kept in a good state of repair. The registered person must ensure that residents are provided with suitable utensils to enable their independance. The registered person must ensure that all residents are provided with a table to sit. This is a second repeat requirement The registered person must ensure that a risk assessment is Timescale for action Immediate 2. 10 12(4)(a) Immediate 3. 4. 15 19 16(2)(i) 23(2)(o) Immediate 30/09/05 5. 6. 19 22 23(2)(b 16(2)(g) 30/09/05 Immediate 7. 24 16(2)(c) 30/09/05 8. 24 13(5) 30/11/05 Page 23 Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 9. 26 &38 13(3) & 16(2)(J) 10. 11. 12. 26 & 38 13(3) &16(2)(j) undertaken and an action plan provided to the Commission for the provision of adjustable beds 30/11/05 as indicated by the risk assessment. The registered person must Immediate ensure that handwashing facilities are provided throughout including en-suite rooms. This is a second repeat requirement The registered person must Immediate ensure that clinical waste bins are kept locked. 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 26 Good Practice Recommendations The registered person should ensure that the laundry facilities are reviewed. Frank Foster House I56-I05 S17823 Frank Foster House V236590 300605 - Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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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