Inspection on 10/08/06 for Glenarie House Nursing Home

This inspection was carried out on 10th August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glenarie House Nursing Home 04/06/07

Glenarie House Nursing Home 26/10/05

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

CARE HOME ADULTS 18-65 Glenarie House Nursing Home Limited Glenarie House Nursing Home 26 Prescot Drive Newsham Park Liverpool Merseyside L6 8PB Lead Inspector Natalie Charnley Unannounced Inspection 10th August 2006 08:55 Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenarie House Nursing Home Limited Address 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) Glenarie House Nursing Home 26 Prescot Drive Newsham Park Liverpool Merseyside L6 8PB 0151 228 7440 0151 254 1943 Glenarie House Nursing Home Limited Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2005 Brief Description of the Service: Glenarie House is situated in Newsham Park in a busy suburb of Liverpool. The house is a modernised Victorian style house, which over looks parkland. The majority of residents have their own single bedrooms; those residents who share bedrooms have consented to do so. The home has parking to the front of the building and has s set of several stairs up to the front door. The home accommodates smokers and non smokers and has a designated area for smoking in the basement. The home is registered to for 20 people to live there, under the category of ‘mental disorder’. All residents have their own psychiatrist, and Social Worker who maintain contact with the resident and regularly review the resident’s progress. It costs between £399.00 and £551.00 per week to live at the home. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day. The inspector arrived at the home at 08:55 and left at 16:15. The inspector spoke to 5 members of staff, the homeowners, and 6 residents. The inspector completed the inspection by looking at the homes records, a tour of the building, formal and informal interviews and information from previous inspection reports. The inspector followed an inspection plan written before the start of the inspection to ensure that all areas that needed covering were done so. Feedback was given to the homeowner during and at the end of the inspection. Comment cards were left at the home for residents, staff and visitors to complete. A number of residents were ‘case tracked’ as part of the inspection process. This means that their care is examined in detail along with their opinions about the home. The home had not completed pre inspection questionnaire as it had only arrived the day before the inspection. What the service does well: What has improved since the last inspection? The home have begun to implement staff supervision An analysis of training has been completed by an external company, which will allow the home to meet the standard regarding staff training. The home has introduced a specific activities room. A drinks machine has also been installed that provides the home with 10 pence per sold can to go into the residents fund. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service. Residents have a detailed assessment completed before moving into the home to ensure they are kept safe. EVIDENCE: Pre admission assessments were available on files for all residents, including the most recent admission to the home. The assessments are comprehensive and detail what support residents need and what tasks they can do for themselves. Details are also taken on the past medical and psychological health. Some files also contain pre admission information from other sources such as social services, which also help the home build up a picture of a residents needs before they move in. Multi disciplinary assessments are also included which gives opinions on the care needed by other health professionals. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service. Care plans are individual and outline the needs that service users have to ensure they receive appropriate care. Residents are given choice in aspects of their daily life which promotes independence and risks taken by residents are looked in detail and ensure that safety is maintained. EVIDENCE: Residents at the home have individual care plans that detail how they need to be cared for and how they are to maintain their independence. 4 care plans were case tracked as part of this inspection. Care plans are computer generated, but did not have a signature from the member of staff who had written the plan, this is important to show who has made these clinical decisions within the care plan. Regular reviews of these plans take place and are clearly recorded to show any changes that may have taken place. Residents also have a detailed social care plans that shows that the home involve family members on a regular basis, there is also detail regarding the life history of residents, which helps in creating an individual plan. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 10 Risk assessments are available with care files and are specific to individuals. These cover risks such as smoking, aggression and managing finances. Residents stated that they come and go freely from the home, but that wherever possible, they keep staff informed of where they are going and when they will be beck. Residents spoken to during the inspection were asked what types of decisions they make on a daily basis at the home, they commented “I can get up and go out when I want here, its just like home really”, “ I pick what I want to eat from the menu” and “ If I want to stay in my room I can, but I like people here, they are my friends”. All residents spoken to, felt supported to make choices and that Glenarie house felt like ‘home’. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service. Residents participate in appropriate activities and maintain their links with the local community. Meals times do not always offer choices for individuals and their opinions need to be asked to ensure all tastes are catered for. EVIDENCE: The home have recently refurbished an ‘activity room’ in the basement. There is also a smoking lounge with a pool table located in this area. 4 residents go to local day centres, which they stated that they enjoyed. There are currently no residents who are in employment, however 2 are enrolled in educational courses. 5 residents went to Pontins in June for a holiday and were accompanied by 3 staff and further plans are currently being made for another holiday trip. Residents commented “ we can join in with things if we want to but we don’t have to” and “ I like pool, we have competitions which is great”. Staff were observed to be polite and well mannered to residents. Those who were entering residents bedrooms, knocked and asked permission to enter Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 12 before doing so. Resdients stated that they felt well cared for and that staff treated them with respect. The home has a 4 weekly rotating menu. Menus samples showed that no choice is offered at lunchtime and 2 choices offered for tea, to demonstrate choice the home must offer choices for all meals. The chef has no specific catering budget, but stated that he can order what he needs. Residents made positive comments about the food such as “ the food is really nice” and “ I like what we get to eat”, however some commented, “ we get too much mash, sometimes I would like a bit more choice” and “ They never ask us what we would like”. The home must look into how they can offer meals that suit all tastes and ensure that alternate choices are always on offer. Lunch was observed during the inspection, and was noted to be a social and unhurried occasion. Residents were interacting well with each other and members of staff. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality outcomes in this area are poor. This judgement has been made using available evidence including a visit to the service. Residents have their physical and emotional health needs met, however medication practices are poor, which leaves residents at risk. EVIDENCE: As the home employs qualified nurses, residents physical health is also closely monitored and recorded. Residents can access local NHS facilities and are supported to attend outpatient’s appointments by staff. Records of health care are kept in care plans and diaries and are well documented. One resident who had sustained a recent wound to their toe, had this swiftly dealt with and actions were clearly recorded. Resdients confirmed that they can see any visiting professionals such as CPN’s (Community Psychiatric Nurses) and Social Workers in their own rooms. Medication storage areas and medication administration records (MAR charts) were checked during the inspection. Storage areas are within the main home office and residents come to this area when they need their tablets. This was observed during the visit. The medication fridge, within the storeroom, contained 3 creams that were to be stored at room temperature, these were removed immediately. MAR charts Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 14 showed that medications had not been signed in when they had arrived at the home and that some records had correction fluid on them, making them difficult to read. 33 gaps were observed on MAR charts for 11 different residents, which means that staff have not signed to say the medication has been given. 6 medications had not been given as the GP (general practitioner) had prescribed and one residents records showed that their anti psychotic medication dose had been changed half way through the medication cycle. There was no record to show when this had happened and who had changed the record. A number of handwritten entries had not been double signed as a checking process to ensure that the correct medication was being given. There was evidence that the home manager was carrying out regular audits of the MAR charts, which is an example of good practice, however he had identified the balances on 2 medications were incorrect, one medication was short 20 tablets, the other by 20 mls. One medication was checked for a correct balance during the inspection, and found to have 16 doses unaccounted for. Medication practices must be improved as a matter of urgency. Advice was given to the homeowner in this area. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service The home has a good complaints procedure that protects the rights of residents. Staff have a basic knowledge of adult protection procedures, however not all staff have received the necessary training in this area. EVIDENCE: The home has a clear complaints procedure that has recently been updated. Residents knew how to make a complaint if they needed to and were aware that there was a process to follow. No internal complaints have been received at the home, however the home is currently in the middle of a number external complaints, which are being investigated. Some, but not all staff at the home have undergone abuse awareness training. Staff interviewed showed they had some knowledge in this area and felt that the training that they had been given was useful. The staff have access to the local authority adult protection guidelines, which are to be used in the event of an allegation of abuse. All staff working at the home had undergone appropriate character checks and trained nurses had received a PIN (personal identification number) check by the home with the Nursing and Midwifery council. This ensures that they are qualified nurses who are able to practice. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 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 and 30 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service. The home is clean and hygienic providing a safe and protective environment for residents EVIDENCE: A full tour of the home was undertaken. A selection of residents bedrooms were looked at, with their permission and found to be well maintained and homely. A few carpets were noted to be needing replacement in the near future, the homeowner was aware of these needs, and indicated that they would be replaced shortly. Communal areas were also well decorated, bright and airy. Residents spoken to were happy with all aspects of their living areas, stating it was “ nice”, “great to live here” and “clean and nice”. Residents are now only allowed to smoke in the basement pool room, which is a new decision taken by the manager. Residents spoken to stated that they were getting used to this. All areas of the home were clean and tidy. The laundry area was locked at the time of the visit, however the home statement of purpose states that ‘residents are encouraged to attend to their own laundry’. The home must address this area and either remove the statement or keep the laundry open for residents to access. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 17 The home is located opposite Newsham Park, which residents stated they go into on a regular basis. To the rear of the home there is a garden area, to which the residents also have access. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality outcomes in this area are adequate. This judgement has been made using available evidence including a visit to the service. The home has sufficient numbers of staff employed to ensure the safety of residents. Staff training is not up to date, which may leave residents at risk, however staff could show they knew how to look after the residents and were aware of their needs. EVIDENCE: The home staffing rota showed that each shift there is 1 trained nurse and 2 care staff on duty, except for at night when 1 nurse and 1 carer are on duty. Staff, residents and management felt this was a suitable number to support the residents living at the home. Ancillary staff such as cleaners and a chef are also employed in addition to these numbers to keep the home running smoothly. Policies and procedures relating to staffing the home have recently been updated. Policies are available to cover equal opportunities, whistle blowing and sexuality. 4 staff files were sampled which included evidence of training. Staff had all been thoroughly character checked and had terms of employment, evidence of induction training and references in their files. Not all staff were up to date with the mandatory training, which was acknowledged by the homeowner, and must be addressed as a matter of urgency. Care staff are supported by the home to complete their NVQ’s (National Vocational Qualification), and stated that they felt that they had the knowledge Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 19 to provide a good standard of care. Observation of staff showed that they were skilled and confident in dealing with residents living at the home. Residents stated “ staff here are nice” and “ we have a laugh, staff are great”. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality outcomes in this area are adequate. This judgement has been made using available evidence including a visit to the service. Quality assurance checks are not carried out to seek the views of people using the service. Management of the home is effective and risks to residents minimised. EVIDENCE: The manager was not on duty during the inspection. He is a qualified registered mental health nurse who is currently awaiting registration with the Commission for Social Care Inspection, and he has been in post for approximately 2 years. Staff commented favourably about the manager stating he was “supportive” and “helpful”, residents also stated they liked him and that he was approachable. The home policies and procedures were reviewed, a small number had been updated recently, however most are a few years old. The manager must audit Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 21 these policies and update those that need reviewing. Accidents were not being recorded in accordance with the Data Protection Act; advise was given regarding how this is to be achieved. No evidence could be seen that the home has any quality assurance systems in place. The home does not hold residents meetings, as they appeared to have not worked in the past, however some staff meetings are held. The home must decide as to what is the best way to monitor the quality of care given to ensure that residents feel that their views are listened to and acted upon. The home safety certificates were all up to date and in order. The homeowner stated that the gas check was carried out in May 2006, but that a certificate had not yet been issued, but would forward a copy to the inspector when it was received. Fire drills and testing are carried out appropriately and appropriate environmental risk assessments were in place. Following a recent incident at the home, 2 hourly checks of residents were introduced. Residents commented that that they didn’t like being disturbed and so it is reccomended that this be reduced to a headcount at 10pm and 6am. However, before doing so, an appropriate risk assessment must be carried out. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 1 X X 2 X Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 23 No 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 Requirement The registered person must ensure that all care plans are signed by the staff member who develops them The registered person must ensure residents wishes are sought regarding what food is offered at the home and that a choice is offered for every meal The registered person must ensure that: 1. All medications are given as prescribed 2. Medication stored in the fridge is suitable to be stored at that temperature. Other medications must be removed, to ensure that it works correctly 3. Correction fluid is not used on MAR charts 4. Gaps in MAR charts do not occur and where they do appear, this should be followed up by the manager 5. Handwritten entries must be double signed 6. Discrepancies in balance DS0000063674.V307644.R01.S.doc Timescale for action 01/10/06 2 YA17 16(2)(i) 01/11/06 3 YA20 13(2) 01/09/06 Glenarie House Nursing Home Limited Version 5.2 Page 24 4 YA32 18 5 YA39 24(1) 6 YA42 25 checks of homely remedies are comprehensively investigated and dealt with appropriately 7. Medications started mid month are clearly labelled as to when they were changed and by whom they were changed The registered person must ensure all staff receive mandatory training, including on abuse awareness training The registered person must ensure that a formal system is introduced to monitor quality assurance The registered person must ensure all policies and procedures are reviewed on a regular basis and that accident records are put in place that comply with the Data Protection Act 1998 01/11/06 01/11/06 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA24 YA42 Good Practice Recommendations The inspector recommends that the home look into re opening the laundry area to residents to promote independence The inspector recommends that the current 2 hourly checks be reduced to a check at 10pm and at 6am when monitoring who is in the home. Glenarie House Nursing Home Limited DS0000063674.V307644.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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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