Inspection on 25/10/05 for Grove House

This inspection was carried out on 25th October 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

Grove House 12/07/07

Grove House 15/06/06

Grove House 28/12/05

Grove House 09/02/05

Grove House 24/08/04

Grove House 23/03/04

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

CARE HOMES FOR OLDER PEOPLE Grove House Highfield Road Adlington Chorley Lancashire PR6 9RH Lead Inspector Pauline Randles Announced Inspection 25th October 2005 10:10 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 Grove House DS0000036045.V252014.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. Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grove House Address Highfield Road Adlington Chorley Lancashire PR6 9RH 01257 481442 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) Lancashire County Care Services Care Home 46 Category(ies) of Dementia (24), Old age, not falling within any registration, with number other category (21), Physical disability (10) of places Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 46 service users to include: Up to 21 service users in the category of OP (Old age, not falling within any other category). Up to 24 service users in the category of DE (Dementia). Up to 10 service users in the category PD (Physical Disability aged 55 years and above). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection. All new admissions to the dedicated Dementia care unit must be of the category DE (Dementia). 9th February 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Grove House is a purpose built home located in the village of Adlington between Chorley and Horwich. There are shops and many other local facilities available nearby. Grove House caters for older people and also has a unit for people who have care needs associated with dementia and a rehabilitation unit. The home has two floors accessible via stairs and a passenger lift. The home is set out in four separate units, each with its own combined lounge/dining/kitchen. The private accommodation for service users is all in single rooms. The home has a large garden area, with seating, and a greenhouse and courtyard that are secure. The home has recently been extensively refurbished which has resulted in significant improvements to the environment. Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over a period of six hours. This was the first inspection since the appointment of the new manager. During the course of the inspection four residents were interviewed, two care staff members, the assistant cook, a laundry assistant and an activities organiser. The premises were viewed and records and procedures were examined. Pre-inspection information including completed questionnaires from the manager and comment cards from ten residents, four relatives and a general practitioner helped to inform the findings. What the service does well: What has improved since the last inspection? Extensive refurbishment of the premises had been completed resulting in a more pleasing environment for residents. A new manager had been appointed who expressed a commitment to the continuous improvement of policies and procedures to guide good practice within the home. Staff members had been allocated designated roles, for example laundry assistant and activities organiser to provide additional staff time for these duties. Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 6 Requirements, from the previous inspection, to update the Statement of Purpose, Service User Guide and complaints procedure had been addressed to ensure prospective and current residents had access to accurate and relevant information. What they could do better: To ensure the safety of people living and working at the care home risk assessments must be undertaken in respect of individuals at risk of slips or falls and in the rooms of those residents where the use of moving and handling equipment is difficult due to limitations of space. Additional storage for any resulting excess furniture needs to be identified. To comply with data protection requirements accident reports must be stored on individual files in order to maintain confidentiality. The policy and procedures for medicines management must be reviewed in line with Royal Pharmaceutical Society guidelines to ensure the continuing promotion of good practice. Also, in relation to safe storage of medicines, a record should be maintained of the temperature of all medication storage areas. Improvements are needed to the system for reviewing care plans to ensure a consistency in the information maintained and to guide best practice. In some cases the records were incomplete and the resident hadn’t signed the form. An improved system is needed for the laundry undertaken on the units to ensure residents always have their own clothes returned for them to wear. One resident commented, “ washing sometimes gets a bit lost.” Supervision of all care staff should be undertaken a minimum of six times a year to provide staff with the advice, guidance and support they need. A contingency plan for sickness cover that ensures minimum staffing on all units at all times should be developed. Food temperature records must be fully completed at all times to ensure food safety. Evidence that the premises comply with the Water Services Regulations, and certificates to evidence that the passenger lift and fire extinguishers had been inspected should be available on the premises to confirm that the health and safety of all persons at the care home is protected. Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 7 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. Grove House DS0000036045.V252014.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 Grove House DS0000036045.V252014.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 The Statement of Purpose and Service User Guide provides residents and their representatives with full details of the home’s services and facilities enabling an informed choice to be made about possible residency. EVIDENCE: The Statement of Purpose and Service User Guide had been revised as required following the previous inspection and to reflect the recent changes in service provision. These documents were clearly written and presented and included full information about the provision of services and facilities to enable prospective residents make an informed choice whether to take up residency. Copies of both documents were available at reception for all visitors to the home to access if they wished. Also copies of recent inspection reports were readily available. Grove House DS0000036045.V252014.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, 8,9 and 10 The care plan review system must be consistently applied to ensure relevant and accurate information that is agreed with the resident is recorded to guide best practice. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The policy and practices relating to medicines management must be reviewed to ensure compliance with professional guidelines. Personal support in the home is provided in a manner that supports the privacy and dignity of the residents and promotes their independence. EVIDENCE: Discussion with staff and residents confirmed that residents had become more involved in the review of their individual plan of care and that a history of falls was now sought on admission and reviewed, as previously required. However, information on the four files of residents examined was inconsistently recorded. For example, the weight of the resident had not been recorded on Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 11 two of the files and signatures were omitted. Also the level of information recorded varied between being very sparse and detailed. This weakness in the recording system could result in poor standards of care in practice. Records examined indicated that the health care needs of residents are effectively met. There is good joint working with local health practitioners, a chiropodist visits the home and residents confirmed they are enabled to access optical and dental services as required. The system for recording the receipt, administration and disposal of medicines had improved since the previous inspection, also a signature list of staff designated to administer medication had been developed and a controlled drugs cabinet had been installed thereby resulting in safer practices. To ensure full compliance the policies and procedures for medicines management must be reviewed in line with the Royal Pharmaceutical Society guidelines as previously required and a record should be maintained, on a regular basis, of the temperature of all storage areas Discussion with residents confirmed that the rights of the resident to privacy and dignity is upheld, as defined in a residents’ charter that is clearly displayed in the hallway. Staff members were observed to speak to people in a courteous and respectful manner and to knock on the door before entering a bedroom. One resident said, “we haven’t got a bad carer.” Grove House DS0000036045.V252014.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): 12 and 15 Residents are involved in a wide range of individual and group, social and recreational, activities that aid stimulation. Meals made with good quality ingredients that are balanced and appealing are provided to aid appetite and nutrition. The system for recording the temperature of food had not been accurately and adequately maintained. EVIDENCE: There was good evidence of a range of activities available for residents on an individual and a group basis. Records showed that consultation had taken place and that the activities provided reflected this consultation and the assessed social needs of individuals. In addition records indicated that activity organisers identified personal needs of residents and referred these to a relevant staff member to address. More than one resident talked about a recent trip to the illuminations that had been enjoyed. During the afternoon a number of residents were observed to be enthusiastically joining in singing and dancing activities in one of the lounges. Discussion with the assistant cook and residents and examination of menus confirmed that meals are balanced and nutritious. Special diets including vegetarian, diabetic and soft foods are catered for. One resident commented Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 13 that meals are “ wonderful” whilst another said, “you get plenty to eat” and a further resident said, “ I’m a vegetarian, they take it into consideration for me.” A previous requirement that liquidised and pureed foods should be prepared separately had been noted although no residents are taking liquidised food at present. Temperature check records were not fully completed and signed at the time of inspection. These records must be maintained accurately to evidence consistent safety in the storage of food, its preparation and provision. Grove House DS0000036045.V252014.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 The complaints process includes clear information for residents to enable them to raise any concerns with confidence that these will be listened to and acted upon. EVIDENCE: The complaints policy and procedure was clear and concise and had been developed as requested, to include additional information about access to the Commission for Social Care Inspection complaints procedure at any time. Discussion with the manager and examination of procedures that had been produced in an accessible format for residents indicated a positive approach to dealing with complaints. Residents spoken to were satisfied with the service provided. One resident who had been recently admitted to the home said, “I can’t complain, I’ve been worried about fees but this is being looked into.” A letter from the local authority later confirmed that this matter had been dealt with. Staff demonstrated an understanding of the process and their role within it. Grove House DS0000036045.V252014.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, 21 and 26 The refurbishment of Grove House has significantly improved the environment, its ambience and facilities. The premises are clean and hygienically maintained. Systems for assessing individual residents and minimising environmental risks associated with types and quantity of furniture and fabric are inadequate. EVIDENCE: An extensive refurbishment programme including installation of new and modern equipment had been completed that had improved the environment for residents significantly. From discussion with staff and examination of incident records including an incident that occurred at the time of inspection, it was evident that individual risk assessments must be undertaken to safeguard residents who risk slipping from the chair when leaning forward to look at the floral carpet. Individual risk assessments must also be undertaken in relation to those residents needing the use of a hoist in bedrooms where there are space limitations. Alternative Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 16 storage for any excess furniture will need to be identified. It was noted that wheelchairs are safely stored beneath a stair well. Grounds were tidy and provided a pleasant seating area for residents. A railing had been installed to improve security around the inner courtyard as previously requested. Requirements of the fire and environmental health had been addressed. The premises were clean and odour free at the time of inspection. Policies and procedures for control of infection were in place and implemented. There are two separate toilets and one toilet with a shower on each unit and a rise and fall bath has been installed for the greater convenience of residents. A sluice and commode cleaning facility are available in a separate secure sluice room. A laundry room with suitable washing and drying facilities had been established as a part of the refurbishment programme. A designated staff member has responsibility for the daily laundry of all nightwear and bedding plus clothing from one of the residential units. This development had improved the efficiency of the main laundry service. Other items of personal laundry are dealt with on the units in the washing machines installed for that purpose. The system for returning laundry on these units needs to be improved. One resident said, “washing sometimes gets a bit lost” and another comment, from a staff member, made reference to “a blue cardigan ” that had gone missing. To ensure health and safety evidence should be provided that services and facilities comply with the Water Services (Water Fittings) regulations 1999 as previously requested. Grove House DS0000036045.V252014.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): 27, 28 and 29 The skill mix and number of staff on duty was sufficient to competently meet the needs of residents. The recruitment and selection procedures of the home require thorough checks to be carried out to ensure that new staff members have qualities suitable to working in the care sector. EVIDENCE: Staff rotas and examination of training records evidenced that there was a suitable skills mix of staff available. Two members of staff interviewed, described how staff members work together to meet needs of residents. There were adequate numbers of staff on duty at the time of inspection although there had been some recent difficulties in providing sickness cover and there is presently a vacancy for a Residential Care Officer. A General Practitioner on a comment card had reported that, “ there has been a lot of changes at senior level with some lack of continuity, hopefully this will improve.” The manager was aware that the home must be staffed in accordance with regulatory requirements at all times. Over 50 of staff hold qualifications at National Vocational Level 2 and further staff are waiting to commence this training. Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 18 The recruitment policy and procedure is in keeping with requirements and ensures that only people suitable to work in care services are appointed. Two files examined had evidence of references and police checks being accessed prior to appointment. The manager confirmed that applicants are asked about any employment gaps as previously recommended. Terms and conditions of employment had been issued to individual staff by the local authority confirming status and entitlements. Grove House DS0000036045.V252014.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, 36, 37 and 38 The manager has relevant experience, qualities and the qualifications required to provide competent management of the home and be considered for the registered manager position. The culture of openness within the home and the use of formal quality assurance systems enable and encourage feedback as to how well the service is doing in meeting the needs of residents. All staff members are not receiving the level of supervisory support required to advise and guide them in their duties. Improvements need to be made to recording systems in order to meet data protection requirements and maintain confidentiality. Health and safety policies are underpinned by extensive health and safety procedures. Individual assessments of residents in relation to environmental risks associated with the furnishings and fabric of the building must be introduced to ensure safe working practices. Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 20 EVIDENCE: The recently appointed manager holds qualifications in management and care and has related experience of management in a care setting. In discussion, the manager demonstrated an understanding of his role and purpose and a commitment to continuously improve policies, procedures and practices. This was further evidenced through examination of revised procedures, for example an accident reporting monitoring database and a new system that was being introduced for the storing and indexing of files. Staff members confirmed the manager to be “approachable.” An application had been made for manager registration to the Commission for Social Care Inspection as required. The care home holds the Investor in People Award and undertakes quality assurance surveys of the residents and other stakeholders on behalf of the local authority. Results of a recent survey were published on the relevant notice board and were available for inspection. It was recommended that comments from these surveys be included in the Service User Guide, as previously suggested. The manager advised, and supervision schedules confirmed, that due to a vacancy for a Residential Care Office supervision of staff had not occurred with the required frequency. This became apparent from speaking with one staff member who displayed, and agreed, a need to discuss her responsibilities more fully with a direct line manager. Supervision should take place a minimum of six times a year and cover elements as outlined in the standard to ensure continuing support and guidance for staff and a development of competence. Examination of records indicated that information was not always stored and maintained in accordance with data protection requirements. To improve record keeping and confidentiality, accident report forms must be stored on individual files and food temperature records must be accurate and up to date. Extensive health and safety procedures were available and there was evidence of staff undertaking training in safe working practices as elements of induction and foundation training. Electric, gas and water test certificates were readily available. The certificates relating to inspection of the passenger lift and fire extinguishers were not available for examination on this occasion. The fire extinguishers clearly indicated a recent date of inspection. A fire risk assessment had been undertaken and new procedures initiated to improve evacuation procedures. As noted in relation to standard 19 individual risk Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 21 assessments must be introduced in relating to the risk of a resident slipping from a chair and the safe use of moving equipment in rooms of limited space. Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 22 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 N/A N/A N/A N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 N/A 14 N/A 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/A 18 N/A 2 N/A 3 N/A N/A N/A N/A 3 STAFFING Standard No Score 27 3 28 3 29 3 30 N/A MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 N/A 3 N/A N/A 2 2 2 Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13 (4) (b) (c) Timescale for action The care plan review process 15/11/05 must be fully and consistently completed and where practicable the review document be signed by the resident concerned. Policies and procedures for 31/01/06 medicines management must be reviewed in line with the guidelines of the Royal Pharmaceutical Society. (previous timescale of 30/04/05 not met.) Individual risk assessments must 31/01/06 be undertaken where residents are deemed to be at risk due to environmental factors that involve the furnishings and fabric of the premises or limitations in space for use of specialist equipment in bedrooms. Records must be accurately 01/12/05 maintained, available on the premises and stored in accordance with data protection requirements. Requirement 2 OP9 13 (2) 3 OP38OP19 13 (4) (b) (c) 4 OP37 17 (3) (a) (b) Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 24 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 3 4 5 7 8 Refer to Standard OP9 OP19 OP26 OP26 OP27 OP31 OP36 Good Practice Recommendations A record should be maintained on a regular basis of the temperature of all medication storage areas. Consideration should be given to suitable storage of furniture should a risk assessment indicate a potential hazard when moving and handling a resident. Service users should receive only their own clothing from washing and ensure that clothes are not mislaid. Evidence should be available to confirm that services and facilities comply with the requirements of the Water Fittings (Water Regulations) 1999. The manager should develop a contingency plan to ensure minimum staffing in the event of staff sickness. The provider should ensure that the manager completes their registration with the Commission for Social Care Inspection. Formal supervision of care staff should be provided a minimum of six times a year. Grove House DS0000036045.V252014.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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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