Inspection on 15/12/05 for Grassington House

This inspection was carried out on 15th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grassington House 15/08/06

Grassington House 16/09/05

Grassington House 01/02/05

Grassington House 06/07/04

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

CARE HOMES FOR OLDER PEOPLE Grassington House Grassington House 50 Prince Of Wales Road Dorchester Dorset DT1 1PP Lead Inspector Rosie Brown Unannounced Inspection 12:00 15 December 2005 th 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 DS0000056436.V271728.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. DS0000056436.V271728.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grassington House Address Grassington House 50 Prince Of Wales Road Dorchester Dorset DT1 1PP 01258 837514 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) Mrs Marion Jennifer Franklin Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places DS0000056436.V271728.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Grassington House has one bedroom which may accommodate two service users; this is bedroom 5. 16th September 2005 Date of last inspection Brief Description of the Service: Grassington House is a residential care home, which provides accommodation and personal care for up to 11 residents in the category of old age (OP), not falling within any other category. Mrs Marion Franklin is the registered provider and manager of the service. Her sister, Mrs Sally Drake who jointly owns Grassington House, and her husband, Mr Franklin, support her with management tasks and other general duties. The home is established in a large Victorian semi-detached house situated in a residential area of Dorchester, close to the town centre and local amenities. The residents’ accommodation is available over two floors, and bedrooms situated on the first floor can be accessed by a two-person passenger lift. During 2005 the home was extended and accommodation reorganised, this has ensured that there are 11 single bedrooms, a ground floor laundry and a spacious conservatory. The home also has a front lounge and a separate dining room. An assisted bathroom is available for resident’s use on each floor. The home provides all services for residents including; hairdressing, chiropody, dental care and access to the community nursing service. There is also good social care provision. The rear garden is enclosed by walls and fencing and is also being developed. It currently has a paved terrace with garden furniture and a grassed area with attractive flower borders. To the front of the premises there is a small parking area for visitors’ convenience. DS0000056436.V271728.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Rosie Brown, inspector on The 15th December 2005 between the hours of 12:00 and 2.30pm, undertook this unannounced inspection. This was followed at 3pm by an inspection from the CSCI pharmacy inspector Christine Main who reviewed Standard 9, which is concerned with the medication arrangements in the home. The purpose of the inspection was to assess the progress with requirements and best practice recommendations set out in the previous inspection report and to review 17 of the National Minimum Standards (NMS). It was second of two statutory unannounced inspections planned to take place this year. Information was gathered through discussion with the manager/owner Mrs Franklin, Mr Franklin, two residents and two members of staff on duty at the time. The inspector used observation skills to assess improvements made to the environment and these mainly related to the conservatory extension and certain internal alterations of residents’ rooms and other communal facilities. The communal areas and a selection of residents’ rooms were seen during the visit. In addition, residents’ care records, staff records, maintenance and other records required by the Regulations were examined and the home’s policies manual provided further information. Following the previous inspection two comment cards were received from service users both were complimentary about the care provided and confirmed that their privacy is respected by staff. What the service does well: The home’s statement of purpose has been updated to reflect recent improvements to the environment and facilities now available. Thus ensuring that an informed choice can be made from reading the information supplied by the home. Each prospective resident has a detailed pre admission assessment, which is undertaken by the manager to ensure that the home can meet identified needs. A care plan is drawn up from the information obtained and demonstrates how each resident’s identified needs are to be met. The home maintains good relationships with residents and promotes individuality and actively encourages social activity. Residents are provided with wholesome home baked meals with alternatives and special dietary options. The home is comfortably furnished and attractively decorated and provides a pleasant environment in which to live. DS0000056436.V271728.R01.S.doc Version 5.0 Page 6 Management and carers staff the home each day. What has improved since the last inspection? What they could do better: The care plan for a diabetic resident must include a risk-assessment and information about hypo/hyper-glycaemia and dietary needs. Records of receipt of medicines and monitoring of the records and the audit trail could be improved. A programme of guarding and protecting the central heating radiators that do not have low temperature surface finishes must be implemented using a riskassessment procedure. Each new member of staff should be supplied with training in the recognition of abuse and adult protection procedures as part of the induction programme. DS0000056436.V271728.R01.S.doc Version 5.0 Page 7 The home should continue to promote the NVQ training programme to ensure that at least 50 of staff team are qualified to this standard and provide other training that is directly related to residents needs, eg diabetic care. Staff induction, supervision and training records should be kept in individual files. The Building Control Completion certificate must be supplied to the Commission to confirm that the Building Control Officer and Fire Officer are satisfied with the finished extension work. 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. DS0000056436.V271728.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection DS0000056436.V271728.R01.S.doc Version 5.0 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 the following standard(s): 1 and 3 The home’s statement of purpose has been updated to reflect recent improvements to the environment and facilities available: an informed choice can therefore be made by a prospective resident or their representative before moving into the home. Each prospective resident has a pre admission assessment, which is undertaken by the manager to ensure that the home can meet identified needs. EVIDENCE: The home has an informative statement of purpose which now includes a description of the new conservatory, the new ground floor bedrooms the relocation of the home’s dining room and the development of the new laundry. Mrs Franklin sent a copy to the Commission on 29/9/05. The care records for one recently accommodated resident demonstrated that a pre-admission assessment was undertaken by the manager before they moved into the home, with an initial care plan drawn up to ensure that identified needs could be met: the assessment had been signed by the service user and manager. DS0000056436.V271728.R01.S.doc Version 5.0 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 and 9 Each resident has a care plan that identifies the care being provided to meet identified needs. Records of residents’ medication kept in the monitored dosage system indicated that these medicines were given as prescribed but records of receipt need improving to provide an audit trail to confirm this is also the case for other prescribed medicines. Standards 8 and 10 were met at the previous inspection. EVIDENCE: Care records and care plans for two residents were examined. These demonstrated that care staff are provided with good written instructions in order to meet identified needs. Discussion with care staff evidenced that the care needs of residents are well known by staff. Care plans also included information about residents’ wishes regarding their care when dying and upon death. The care plan for a diabetic resident did not include a risk-assessment about the identification of hypo/hyperglycaemia and special dietary needs. Generally the care plans are detailed and a good level of detail. DS0000056436.V271728.R01.S.doc Version 5.0 Page 11 The home has a medicines policy but some additions / amendments were recommended. No residents were self-medicating but there is provision for this in the policy. Medicines were stored securely. The full quantity of medicines for 4 weeks, rather than the weekly amount received was recorded. New medicines received were not recorded to provide an audit trail so it was difficult to confirm if they were given as prescribed and recorded. There was no system for monitoring the records and audit trail. The inspector was told that 7 staff administer medicines and most have done additional external training in the safe handling of medication. One carer on duty said that she had not been trained in-house or done a formal course but a second carer was always with her. Staff signed the Medication Administration Record (MAR) chart to record when medicines were given but they did not record the dose when there was a choice (e.g.1 or 2 tablets). There was a record of Senna or Paracetamol on 2 residents MAR charts but no labelled supply or copy of the prescription in the home. If they are not prescribed the record should state that they are a household remedy and they should not given for longer than 48 hours without contacting the doctor. Handwritten directions were not always clear; they should be an accurate copy of the pharmacist’s label and countersigned by a second trained carer to confirm the details are correct. The home records medicines returned for disposal but there were some expired dressings in the cupboard and these should also be returned. DS0000056436.V271728.R01.S.doc Version 5.0 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): 14 and 15 The home provides regular and varied activities for residents in order to meet expectations and personal daily choice. Residents said that the meals and food supplied by the home are very good offering both choice and variety and catering for special dietary need. Standards 12 and 13 were met at the previous inspection. EVIDENCE: The home has a good social care programme that is creatively organised to include individual resident’s preferences, group needs and other interests. Care records evidenced that residents are taken out individually for walks and shopping trips by staff and this opportunity is offered on a daily basis. The menu demonstrated that service users are supplied with a wide variety of healthy food with seasonal variations. The main meal is cooked either by Mrs Franklin or senior staff while carers assist with the preparation of breakfast and tea/supper each day: all staff have been supplied with Basic Food Hygiene training. There is a small but separate dining room, close to the new conservatory, DS0000056436.V271728.R01.S.doc Version 5.0 Page 13 which is attractively set out with a selection of dining furniture and a homely ambience has been created. Residents can also take meals in the privacy of their room but the majority choose to eat in the dining room. On the day of the inspection three residents took lunch in the dining room while another had their meal served on a tray in the home’s lounge: remaining residents were served lunch in their rooms. Senior staff explained that the dining arrangements vary from day to day and this is due to residents’ choice and preference. The recommendations set out by the Environmental Health Officer following his visit on 16th September 2005 have been addressed. DS0000056436.V271728.R01.S.doc Version 5.0 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 and 18 A complaints procedure is in place to ensure they are managed properly and residents are confident their concerns are listened to and taken seriously. The home has guidance available on the proper response that should be made to any suspicion or allegation of abuse and staff have been supplied with training in the local guidance to properly ensure that service users are routinely protected. EVIDENCE: The complaints procedure is supplied to service users as part of the admission process. The home keeps a complaints record book but has not received any complaints since the previous inspection. Mr Franklin explained that grumbles are listened to and acted upon thereby keeping ‘everyone happy’. Two residents who spoke with the inspector said they were confident that their concerns would be taken seriously and acted upon. The home keeps a copy of the local ‘No Secrets guidance for reference and also has a ‘Whistle Blowing’ policy. The home’s adult protection policy has been shared with staff. All staff have undertaken the local training concerned with the Protection of Vulnerable Adults and the referral process in the event of an allegation or suspicion of abuse: one new staff member has yet to participate in this training but the inspector was assured by Mrs Franklin that it would be arranged. DS0000056436.V271728.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25 and 26 The recent conservatory extension, internal alterations and outdoor garden improvements ensure that residents are cared for in an attractively decorated and comfortably furnished environment. Not all central heating radiators are guarded or protected and this means vulnerable residents may be at risk to hot surface temperatures. The home now has a new laundry and was clean throughout on the day of the inspection. EVIDENCE: The communal areas and the majority of service users rooms were viewed: all occupied bedrooms were highly personalised. The home has now has 11 bedrooms most of which are available on the ground floor. There is small passenger lift that provides level access to the four bedrooms situated on the first floor. An assisted bathroom is available on the ground floor while a conventional bathroom with portable seat is situated on the first floor: most DS0000056436.V271728.R01.S.doc Version 5.0 Page 16 bedrooms have en-suite facilities and those without have wash basins/vanity units in the room. During the past year the home has been extended and a number of internal improvements made. These include the creation of two ground floor bedrooms with en-suites, a new ground floor laundry, a conservatory and refurbishment of the home’s kitchen. The internal alterations and reorganisation have provided more communal space within the home and a high standard has been achieved with decorating, carpeting and furnishing. Alterations enable level access to the back garden via the home’s new conservatory. The building works are now complete but a certificate confirming satisfactory completion has yet to be received from the Building Control Officer. The newly created rooms have central heating radiators with low temperature finishes: other radiators need to be guarded or protected and in the meantime individual risk-assessments have been drawn up about residents vulnerability to hot surface temperatures. It is recommended that these risk-assessments are kept in resident’s files alongside their care plan and reviewed on a monthly basis. The new laundry although near to bedrooms is soundproofed. It is equipped with a washing machine, which has specific programming ability to meet disinfection standards and the walls and the floor are readily cleanable and impervious to fluids. There is a tumble dryer and sink unit and fitted cupboards that house cleaning products and other cleaning equipment. DS0000056436.V271728.R01.S.doc Version 5.0 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): 28 and 30 Staff who work in the home are subject to proper checks so that residents are protected. The home is providing care staff with induction and NVQ training to ensure that residents are properly cared for by qualified staff. Standards 27 and 28 were met at the previous inspection. EVIDENCE: The home’s staff rota was examined and now details the complete name of each staff member and their designation. It also notes the management arrangements for each day and who is responsible for first aid on each working shift, as recommended in the previous report. The recruitment records for a new member staff demonstrated that all necessary checks and information was obtained before they commenced working in the home. Records showed that the new staff member was subject to induction training that meets NTO specifications. Each new member of staff should be supplied with training in the recognition of abuse and adult protection procedures as part of the induction programme. Staff training records demonstrated that of the 11 staff employed one has an NVQ level 3 qualification and three are currently training to this standard, while another is commencing training in the New Year. In addition, Mrs Drake works as part of the care team and is a qualified nurse: she is also undertaking NVQ DS0000056436.V271728.R01.S.doc Version 5.0 Page 18 management training. The home should continue to promote the NVQ training programme to ensure that at least 50 of staff team are qualified to this standard and provide other training that is directly related to residents needs, eg diabetic care. Mr Franklin provided a record of staff mandatory training and this included the topics of fire safety, health and safety, basic food hygiene, first aid and moving and handling. It is recommended that staff induction, supervision and training records be kept in individual files. DS0000056436.V271728.R01.S.doc Version 5.0 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, 37 and 38 The home is well managed by the registered provider/manager, Mrs Franklin who is suitably experienced: she has yet to achieve an NVQ 4 management qualification. A quality assurance system is being developed so that service users contribute to future developments in the home. The home keeps all records required by the Regulations to demonstrate that residents are well cared for. Arrangements are in place to ensure that the health, safety and welfare of residents and staff are promoted and protected. DS0000056436.V271728.R01.S.doc Version 5.0 Page 20 EVIDENCE: Mrs Franklin has relevant experience in residential care. She has run and managed the home in a positive manner since becoming registered in 2004 and has initiated a number of improvements in the home: these include improvements to the environment and a proper staff recruitment, employment and training programme. Mrs Franklin is currently undertaking NVQ management training. Mrs Franklin is assisted in the management and running the home by her husband and her sister, Mrs Sally Drake who is co-owner of the home. Mr Franklin is developing a quality assurance system that takes into account the views of residents and their representatives. The home does not manage residents’ money or personal allowances and this is clearly stated in the home’s statement of purpose. Mr Franklin is reorganising the storage of records and is developing a system to ensure that all records required by the regulations are kept appropriately by the home. The home’s equipment and house maintenance records are kept in a file and this contained certificates, which indicated regular servicing of the passenger lift, central heating system and electrical system take place. The bath hoist is also serviced annually. A programme of covering or guarding unprotected central heating radiators should be implemented using a risk-assessment process. The home’s fire records demonstrated that in house checks of the fire safety system and fire fighting equipment are undertaken and a regular servicing contract is in place with an external contractor. The home’s last fire drill took place on 14th September 2005 and included both residents and staff. The fire training record for staff detailed that in-house training was supplied on 4th July 2005: this record was signed by staff to acknowledge their involvement. The home’s fire risk-assessment has been updated since the previous inspection to detail where extractor fans are fitted in the home. DS0000056436.V271728.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X 3 2 DS0000056436.V271728.R01.S.doc Version 5.0 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. Standard Regulation Requirement The care plan for a diabetic resident must include a riskassessment and information about hypo/hyper-glycaemia and dietary needs. The home must record the receipt of all medicines accurately, and the dose given if a choice is prescribed, so that there is a clear audit trail. There must be evidence of regular monitoring of this and the medicine records to ensure that medicines are given as prescribed. A Building Control Completion certificate must be obtained and supplied to the Commission. Confirmation that all works are satisfactory must also be received from the Fire Safety Officer. An action plan detailing how a programme of guarding or protecting central heating radiators according to individual risk-assessments will be progressed must be supplied to the Commission. (Previous timescale of 31/10/05 not met). DS0000056436.V271728.R01.S.doc Timescale for action 31/01/06 1. OP7 14 & 15 & 13(4)(c) 2. OP9 13(2) 31/01/06 3. OP19 23 28/02/06 4. OP25 13(4)(c) 28/02/06 Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The home should follow guidance from the Royal Pharmaceutical society: The medicines policy should be updated with the recommended additions. When medicines are handwritten on the MAR chart a second competent person should check the details are clear and accurate and countersign; household remedies should be clearly marked as such. All carers who give medicines should be trained in the home’s policies for medicines handling and record keeping and have an assessment of competence. They should also have external training on how medicines are used and how to recognise and deal with problems in use. The home’s induction programme for new staff should include the recognition of abuse and local ‘No Secrets’ training. Staff induction, supervision and training records should be kept in individual files. 1. OP9 2. 3. OP18 OP30 DS0000056436.V271728.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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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