Inspection on 28/09/05 for Grassmere Residential Care Home

This inspection was carried out on 28th September 2005.

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

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

Other inspections for this house

Grassmere Residential Care Home 17/06/09

Grassmere Residential Care Home 02/07/08

Grassmere Residential Care Home 12/07/07

Grassmere Residential Care Home 07/12/06

Grassmere Residential Care Home 24/05/05

Grassmere Residential Care Home 26/01/05

Grassmere Residential Care Home 21/07/04

Grassmere Residential Care Home 20/01/04

Grassmere Residential Care Home 25/09/03

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

CARE HOMES FOR OLDER PEOPLE Grassmere Residential Home 675-677 Washwood Heath Road Ward End Birmingham B8 2JL Lead Inspector Amanda Lyndon Announced 28 September 2005 th 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. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Grassmere Residential Care Home Address 675-677 Washwood Heath Road Ward End Birmingham B8 2JL 0121 327 3140 0121 327 3949 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) United Care Limited Rosanna OMara Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to accommodate 26 adults over the age of 65 who are in need of care for reasons of old age and may include mild dementia. Registration category will be 26(OP) Date of last inspection 24th May 2005 Brief Description of the Service: Grassmere Residential Care Home is situated on Washwood Heath Road, close to shops, pubs, churches and Ward End Park. It is well served by public transport. The Home provides residential care for up to 26 older people and this may include people in need of care for reasons of mild dementia and memory loss. All rooms are for single occupancy and seventeen of these have en suite facilities. There are three linked sitting areas for residents, together with a dining room. The home also has two passenger lifts for access to the upstairs and a newer annex. Nurse call facilities are available in the Home. There is a small garden for use by residents to the rear and car parking facilities. The home has a hair dressing salon. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was undertaken over one visit when there were twenty residents living there. Information was gathered by speaking with residents and staff, observing staff perform their duties and examining care, medication and health and safety records. A tour of the Home was undertaken. This is the second inspection of this service in the 2005/2006 inspection year and linked to the Commission’s focus on outcomes for residents and proportionate inspection, we would recommend that you read this report in conjunction with the last inspection of this service on 24 May 2005 What the service does well: The Commission received six completed comment cards in respect of the service provided at Grassmere and these were all positive in nature. Residents’ general health and personal care needs are well met by the care staff working at the Home. Residents’ health care needs are closely monitored and medical advice is sought as deemed necessary. One resident said “ The staff promptly get the Doctor for me if I am ill” Residents are supported in a respectful manner by staff working at the Home and this ensures that their self-esteem and dignity are maintained. Residents can exercise their choice over their daily lives and routines. One resident said “ I prefer to have a bath rather than a shower and the staff ensure that this is what I have” Another resident said “ I go to bed at whatever time I want to” Residents are supported by the staff to maintain contact with their families and friends and social interactions are encouraged between residents. One resident said “ I spend most of my time in the lounge with the staff and residents, we are all friends here, that’s how I feel”. Grassmere provides a homely, comfortable and clean environment for residents to live in. One resident said “ The staff always keep my room nice and clean” Residents can bring their personal items into the Home and this ensures that they feel comfortable in their surroundings. There is a stable workforce and agency staff are not used which promotes continuity of care. One resident said “ I have lived here for quite a while now and the staff are great” Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 & 4 Prior to living at Grassmere prospective residents are aware that their individual care needs can be met at the Home and their care needs are continually monitored throughout their stay to ensure that their needs were being best met. EVIDENCE: A comprehensive service user guide and accompanying resident information booklet had been produced and this required development to include the information that people with mild dementia can now be accommodated at Grassmere. Residents are issued with a comprehensive contract of terms and conditions of residency and this included all relevant information. Comprehensive assessments are undertaken by senior staff for all prospective residents using a comprehensive pre admission assessment document and residents are reassessed prior to discharge back to the Home following a stay in hospital or in the event that their care needs change, in order to ensure that their care needs could continue to be met at Grassmere. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 9 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, 9 & 10 Residents’ health and personal care needs are well met by the care staff who use generally comprehensive care plans to ensure residents’ continuity of care. Medication is administered in a generally safe manner, with the exception that refrigerated prescription items are not always stored safely which may put residents at risk. Residents are supported in a respectful manner by staff working at the Home and this ensures that their self-esteem and dignity are respected. EVIDENCE: Comprehensive assessments of residents’ needs are undertaken on admission to Grassmere and these included good detail of residents’ abilities, personal preferences and who they would like to be involved in their care. Care plans were derived from this information and are reviewed at least monthly, and also in the event that residents’ care needs change, however residents and/or their representatives were not involved in this process. Although mental health assessments had been undertaken, individual dementia needs care plans had not been written and it was, therefore unclear what specific support was required from the staff in this area. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 10 In addition to this, there were inconsistencies in the care plans in respect of the amount of detail about the specific care to be afforded to individual residents. Other comprehensive residents’ personal risk assessments had been undertaken and these included detail of the support required from the staff in these areas. Daily reports were recorded in good detail and included detail of the activities that residents engaged in during that day and any contact that they had with their families. Residents have the option of retaining their own General Practitioner on admission to the Home (if the GP is in agreement). In addition, residents have access to other Social and Health Care Professionals including Social Workers, Dentists, Opticians and District Nurses and there was a comprehensive record of these visits available. Residents are weighed regularly. One resident said “ The staff promptly get the Doctor for me if I am ill” Residents appeared to be well supported by care staff to meet their personal care needs and were wearing clothing appropriate for the time of year. The system for the management of medication, including Controlled Drugs was good and the policies and procedures in respect of these were both comprehensive and up to date. One resident chose to self administer their own medication and regular compliance audits were undertaken regarding this. Quantities of medications received were recorded and any reasons for non administration of medicines were documented. Hand written entries on medication administration charts (MAR) had not been countersigned and it was not always clear from reading the MAR chart whether a medication had been discontinued. Refrigerated prescription items were not stored securely in the fridge, eye drops and liquid medications were not dated when opened and the actual dose administered in respect of variable dose prescriptions were not recorded on the MAR charts. Staff were assisting and interacting appropriately and respectfully with residents throughout the inspection. Residents have access to a pay phone which is located in the reception area of the Home and have the option of a private telephone line in their bedroom. Consent had been obtained for residents to have appropriate privacy locks on their bedroom doors, depending on their abilities. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 11 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) 13 & 14 Residents are supported by the staff working at the Home to maintain contact with their families and friends and residents are able to exercise their choice over their daily lives and routines and this ensures that their individuality and independence are maintained. EVIDENCE: All of the above standards were met at the last inspection. There was an open visiting policy and residents can go outside of the Home with their families as they choose. One resident said “ I spend most of my time in the lounge with the staff and residents, we are all friends here, that’s how I feel”. Residents met during the inspection stated that they could choose the time that they rise out of bed in the morning and the time that they go to bed at night and could make decisions regarding their daily lives. One resident said “ I go to bed at whatever time I want to” Another resident said “ I prefer to have a bath rather than a shower and the staff ensure that this is what I have”. Residents’ preferred term of address was recorded in their care plans and staff were greeting residents using their preferred names. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 12 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 The complaints procedure is comprehensive and is accessible to residents and their visitors. EVIDENCE: Standards 16 and 18 were met at last inspection There had been no new complaints recorded in the complaints log for the last year, and The Commission had not directly received any complaints in respect of the service provided at Grassmere. A number of compliments had been received. One resident said “ I would talk to one of the senior staff if I wasn’t happy about anything, but I have never had any problems here”. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 13 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, 21, 22, 24, 25 & 26 Grassmere provides a homely, comfortable and clean environment for residents to live in and residents are encouraged to bring personal items in to the Home to ensure that they feel comfortable in their surroundings. EVIDENCE: The internal environment of the Home was comfortable and homely in style and there was a rolling programme of redecoration in place. Furniture and floor coverings were generally of a good quality, however the carpet on a back staircase was found to be worn. There were three domestic style baths and one shower in addition to the assisted bathing facilities and a new walk in shower facility was nearing completion. Remedial action must be taken to address the building work outstanding in one of the first floor assisted bathrooms. A full audit of the premises had been undertaken by a qualified Occupational Therapist and appropriate aids and adaptations were available. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 14 Residents’ bedrooms contained many personal items that reflected their individual tastes and a nurse call facility and lockable storage facility was available in each bedroom. The temperature within the Home was comfortable on the day of the inspection and new windows had been fitted throughout the premises. It was noted that some of the windows would allow residents to exit the building or intruders to enter the building via these. The Home was found to be clean and fresh on the day of the inspection and hygienic hand washing and sluicing facilities were appropriately located. One resident said “ The staff always keep my room nice and clean” A contract is in place for the safe and hygienic disposal of clinical waste. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 15 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, 28, 29, 30 Adequate staffing levels are maintained to meet the needs of residents. The recruitment practice is generally robust, however a lapse in respect of this on one occasion did not afford full protection for residents. Staff induction and training ensures that residents are supported by competent staff. EVIDENCE: The staffing rotas identified that the Home were working within approved staffing levels and a cleaner, cook, laundress and maintenance person provide ancillary support each day. The Home had not used agency or temporary staff and staff did not work an excessive number of hours each week. Senior staff provide on call support for the person in charge of the shift and detail of this is identified on the staffing rota. One resident said “ I have lived here for quite a while now and the staff are great”. Another resident said “The staff do their best for us, they are kind and helpful”. Staff files sampled contained all information as required by Regulations, with the exception of a new staff member and relevant references and satisfactory criminal records clearance had not been obtained in respect of this person prior to commencing employment at the Home. Staff are issued with a contract of terms and conditions of employment and job description. Interview notes are kept, in keeping with good practice, however information omitted from prospective staff members job application forms was not always explored prior to the person commencing employment at the Home. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 16 New staff undertake a comprehensive induction and this includes basic health and safety issues. Staff had undertaken training relevant to the role that they perform including dementia care, accredited training in the safe management of medication, infection control, supervisory management and nutritional screening. 70 of staff have achieved NVQ Level 2 in Care qualification or above. Staff training in respect of the protection of vulnerable adults had not been provided. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 17 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, 32, 33, 36 & 38 This is a well managed Home run for the benefit of the residents and it is regularly monitored for quality. The health, safety and welfare of residents is protected through regular maintenance checks of equipment with the exception of portable electrical appliances. Staff had not received health and safety training and remedial action was required in respect of the premises regarding some health and safety issues, which fails to afford full protection for residents. EVIDENCE: The Registered Manager has completed the Registered Managers’ Award qualification and has had much experience of caring for older people. The service provided at Grassmere is monitored regularly by external Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 18 Managers and reports of these visits are sent to CSCI. Internal audits are undertaken regularly in respect of health and safety, staff performance, care planning and medication systems. In addition to this the Registered Provider uses the services of an external quality assurance system and this was in date. A system for formal staff supervision and appraisal had been implemented and was up to date with the exception of the Deputy Manager. Health and safety checks of equipment used had been undertaken including the fire alarm system, emergency lighting, hot water outlets, hoisting equipment, gas appliances and the passenger lift. Portable electrical appliances had not been checked for safety recently. Recommendations made during the last Environmental Health Inspection were being actioned Staff had received training in health and safety issues including resident moving and handling, however not all staff had received training in health and safety or fire safety recently. A number of staff had an emergency first aid certificate Accident records were well maintained and included information about any action taken following an accident in order to minimise the risk of a further accident of a similar nature and these were audited regularly. There was evidence that prompt medical advice is sought following an accident involving a resident as necessary. Remedial action must be taken to ensure that staff do not have to negotiate the step on the first floor landing in order to transport wheelchair users into the passenger lift and individual risk assessments must be undertaken in respect of the risk of each resident falling down the staircase leading to the front entrance of the Home and any remedial action deemed necessary must be undertaken. Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 19 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 2 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x 2 3 x 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 3 x x 2 x 2 Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 20 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. 2. Standard OP1 OP7 Regulation 5 15 Requirement Timescale for action 30/11/05 3. 4. OP7 OP9 12(1) 15 13(2) The service user guide must be updated to reflect the current service provided at Grassmere Care plans must be written and 15/11/05 reviewed with the involvement of residents and/or their representatives and must detail the actual care to be afforded Care plans must be written in 15/11/05 respect of any dementia care needs of residents The system for the management 01/11/05 of medication must be further developed to include: Refrigerated prescription items must be stored securely at all times The actual dosages administered in respect of variable doses must be recorded on the MAR charts 5. 6. OP19 OP21 16(2)( c) 23(2)(b) 7. OP25 13(4) Carpets in the Home must be of a good standard Remedial action must be taken to address the building work outstanding in one of the first floor assisted bathrooms. An audit must be undertaken 30/11/05 01/12/05 05/10/05 Page 21 Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 and remedial action taken to prevent residents exiting the Home and intruders entering the premises via the windows The Registered Manager received this in the form of an immediate requirement Staff must not commence 28/09/05 employment at the Home prior to satisfactory criminal records clearance being obtained The Registered Manager received this in the form of an immediate requirement (previous immediate requirement timescale of 24 May 2005 not met) Staff must not commence employment at the Home without two satisfactory references being obtained in respect of that person 8. OP29 13(6) 19(1) 9. OP29 13(6) 19(1) 28/09/05 10. OP29 13(6) 19(1) The Registered Manager received this in the form of an immediate requirement Information omitted from 05/10/05 prospective staff members job application forms must be explored prior to the person commencing employment at the Home The Registered Manager received this in the form of an immediate requirement Staff training in respect of the 01/12/05 protection of vulnerable adults must be provided. The system for formal staff 01/12/05 supervision and appraisal must be up to date Staff must receive statutory 31/10/05 training including: Version 1.40 Page 22 11. 12. 13. OP30 OP36 OP38 13(6) 18(1) 18(2) 18(1) 23(4) Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Fire safety Health and Safety The Registered Manager received this in the form of an immediate requirement All portable electrical appliances 28/10/05 must be checked for safety The Registered Manager received this in the form of an immediate requirement Remedial action must be taken 31/10/05 to ensure that staff do not have to negotiate the step on the first floor landing in order to transport wheelchair users into the passenger lift The Registered Manager received this in the form of an immediate requirement Individual risk assessments must 31/10/05 be undertaken in respect of the risk of each resident falling down the staircase leading to the front entrance of the Home and any remedial action deemed necessary must be undertaken. 14. OP38 13(4) 15. OP38 13(4) 16. OP38 13(4) 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 OP9 Good Practice Recommendations Eye drops and liquid prescription items should be dated on opening Grassmere Residential Home E54 S16769 Grassmere V244401 280905 AI Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45 - 46 Stephenson Street Birmingham B2 4UZ 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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