Inspection on 10/01/06 for Holly Bank House

This inspection was carried out on 10th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Bank House 13/01/09

Holly Bank House 01/05/07

Holly Bank House 21/08/06

Holly Bank House 12/07/05

Holly Bank House 08/03/05

Holly Bank House 21/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Holly Bank House Coltham Road Short Heath Willenhall West Midlands WV12 5QB Lead Inspector Maggie Bennett Unannounced Inspection 11th January 2006 09:00 Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 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 Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holly Bank House Address Coltham Road Short Heath Willenhall West Midlands WV12 5QB 01922-710524 01922-493250 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) Walsall Metropolitan Borough Council Care Home 21 Category(ies) of Physical disability (21) registration, with number of places Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2005 Brief Description of the Service: Hollybank House is a single storey purpose built residential home located in the Short Heath area of Walsall. The home was commissioned in 1984 and is owned and managed by Walsall Metropolitan Borough Council. It provides accommodation for adults with physical disabilities and is suitably adapted to meet their needs. Hollybank is conveniently situated for the local shops, the health clinic and a public house. Service users are disappointed that the local Post Office has recently closed. The building is divided into three units, one of which is made up of seven self-contained bed-sits with bathroom and kitchen facilities. The remaining two units each have seven bedrooms with a shared sitting room, dining room and kitchen. Both units also have shared toilets, bathroom and shower facilities. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 3.15 p.m. and 8.30 p.m. on a weekday. Full co-operation was received from the Officer in Charge and staff on duty. Several service users were spoken to individually during the course of the inspection. Discussion also took place with two members of staff and the Officer in Charge. The care plans of a random sample of service users were seen and various other documents were inspected. At the last inspection of Hollybank, in July 2005, a total of nine statutory requirements were made. It was found on this occasion that 7 of those requirements had been met or were in the process of being met. A further five statutory requirements were made on this occasion. In October 2005 the Registered Manager of the home for over twenty years, Mr. David Boyes, died suddenly. This loss has been felt by everyone at the home and has understandably created sadness and some anxiety. A new manager is to be appointed within the next few months. What the service does well: What has improved since the last inspection? At the last inspection 3 statutory requirements were made with regard to medication. Since that time, the home have received an advisory visit from the Commission’s Pharmacist Inspector and have made excellent progress in meeting his recommendations. There have been improvements to the décor of the home and more are planned for 2006. Service users spoken to were pleased about the planned refurbishment and re-decoration, particularly those in bed-sit accommodation. Mandatory training in the core health and safety areas has improved, although the home acknowledges that further improvement is needed in order to ensure that all staff receive this training Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 6 and refresher training at the required intervals. The imminent appointment of 4 permanent care staff will be of benefit to the service users. 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. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. It was found at the announced inspection in July 2005 that Hollybank had good assessment procedures in place. EVIDENCE: Standard 2 was not assessed on this occasion as it was met at the announced inspection in July 2005. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Service users are in control of their lives at Hollybank and are assisted, if needed, to make decisions. EVIDENCE: Standard 6 was exceeded at the last inspection and Standard 9 was met. Although Standard 6 was not specifically assessed on this occasion, a sample of care plans was seen in order to assess other standards. It was noted that the care plan for a service user on a respite stay was not in the same format as the long stay service users and did not, therefore, contain as much detail. It is strongly recommended that care plans for all service users are in the same format, particularly bearing in mind that many of the service users who receive respite care visit the home on a regular basis. Service users spoken to during the inspection confirmed that they were encouraged to make decisions about their lives. One service user spoke of how she had been given information about College courses and enabled to make a decision about which to follow. Service users confirmed that they were able to get up and go to bed when they wished. Service users are assisted to take charge of their own finances and advice with budgeting is given when needed. Care plans showed that service users have regular meetings with Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 10 their key-workers when future plans are discussed. Formal six monthly reviews are not taking place at the required intervals. The home state that they are chasing up social workers to arrange these reviews, but their requests are not always responded to. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16 and 17. Service users are assisted to take part in their choice of appropriate activities. Individual rights to privacy, dignity and respect are upheld and service users are encouraged to take responsibility in their daily lives. The quality and presentation of the food provided is not currently to the satisfaction of all service users. EVIDENCE: Service users are able to continue to take part in activities they enjoyed before entering the home. They are also helped to find out about new opportunities and further education. This was confirmed by service users spoken to during the inspection. Staff give advice with regard to benefits and advice is also available from the local Advocacy Service. Service users confirmed during the inspection that their privacy is respected at Hollybank. It was observed during the inspection that staff interact fully with the service users, taking their meals with them, and participating in social events. All service users have a key to their rooms and staff only enter if invited (except in the case of an emergency). Service users’ mail is delivered to their individual “pigeon holes”. There is unrestricted access to the home Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 12 and grounds. There are no service users at present who keep an assistance dog and no one with a pet. Rules on smoking, alcohol and drugs are clearly stated in the Service Users’ Guide. The standard on Meals and Mealtimes was inspected at the last inspection and was not met, service users expressing dissatisfaction and stating that there was a deterioration in the meals. Several thought that this had been caused by a change in the Suppliers. Two of the service users spoken to felt that there had not been a great improvement. It was noted that “economy” size squash bottles were on the table, which service users are unable to pick up. This was noted at the last inspection, service users complaining that they had to rely on staff to serve cold drinks, and were thus being denied their independence in this area. Another service user was unhappy about the amount of processed food being served. She would like more fresh food. It was stated during the inspection that a meeting is to be held with the Suppliers to discuss various concerns. The quality of the food at Hollybank must be discussed with service users and their opinions acted upon. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20. Staff have a good understanding of service users’ personal support needs and this is reflected in care plans which have been produced in a participatory way. There has been good progress on improving the medication systems within the home and when fully in place these systems will ensure that service users’ medication needs are met. EVIDENCE: Discussion with service users and observation of service user plans showed that service users do receive personal support in the way they prefer. Care plans state in the service users’ own words their preferences in respect of how they wish to be assisted. All personal care is provided in private. It is not possible for intimate care to always be provided by a person of the same gender. Similarly, it is not possible at present for service users to be able to choose staff to work with them from the same ethnic, religious or cultural background. Times for getting up and going to bed are very flexible. There is a range of aids/adaptations available in order to maximise independence. Support and advice is available locally from occupational therapists and physiotherapists. The home has close links with the community nursing service. There are designated key-workers, who provide service users with consistency and continuity of care. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 14 At the last inspection 3 statutory requirements were made in respect of medication. Following this the Pharmacist Inspector visited the home on 29th September 2005 and made a number of recommendations. It was pleasing to see that the home has made excellent progress following this visit and in acknowledging this a statutory requirement has not been made on this occasion. Discussions have been held with another Pharmacy company, who will shortly be providing the home with appropriate equipment to enable them to meet the requirements of this Standard. The home are also in the process of producing an up to date policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. The situation with regard to medicines taken whilst away from the home is currently being discussed with the home’s new Pharmacist and the Pharmacist Inspector of the Commission. All staff who administer medication have taken part in accredited medication training. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 There are procedures in place to protect service users. These need to be readily available and familiar to all staff in order that service users are protected from abuse, neglect and self-harm. EVIDENCE: Standard 22 was met at the last inspection. The home has a copy of the Walsall Social Services Adult Protection Procedure. It is recommended that they produce their own local document, which is line with the Social Services procedure and the Department of Health document “No Secrets”. It is further recommended that these procedures are discussed with staff at a staff meeting, so that all are aware of their responsibilities should there be a suspicion or evidence of abuse or neglect. Several staff have taken part in Adult Protection Training and staff spoken to at the inspection were aware of the Whistleblowing Procedure in the home. Policies with regard to any verbal or physical aggression by service users and with regard to service users’ finances are available within the home. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30. There have been improvements to the décor of the home and more are planned for 2006. The recommendations of the Fire Officer must be met in order to protect service users. The home is clean and hygienic, although the policy and procedure for the control of infection needs updating and the provision of a sluicing disinfector would be of benefit. EVIDENCE: Standard 24 was met at the last inspection, with several areas of redecoration having taken place in the home. Further redecoration is planned for 2006. It was noted on this occasion, however, that the recommendations of the Fire Officer, made following his visit of 31st October 2005 have not been met (apart from one item, the provision of appropriate signage). Several fire doors were found to be wedged open during this visit. This practice must cease. Where this is done for the convenience of the service users, automatic closure devices must be fitted to doors. As stated at the last inspection, some bedrooms have been re-decorated. There are plans to redecorate further in 2006. This will include refurbishment of the bed-sits and the kitchenette area will be re-designed to meet the needs of the service users. One person spoken to was very happy that this work was going to be done at last. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 17 The home has a large, separate laundry, with washable walls and floor. There is a policy and procedure in place with regard to the control of infection, but this dates from 1996 and should be updated. The washing machines are capable of temperatures of 95 degrees, but do not have a sluice facility. There is a separate, manual sluice facility. It is strongly recommended that the home purchase an electrical sluicing disinfector for the commode pots. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 34. Staff at Hollybank are committed and competent and generally well respected by the service users. The planned recruitment of new, permanent staff is to be welcomed. Regular requests for mandatory and specialist training are made to the Social Services Training Department and there does seem to be an improvement in this area. Recruitment procedures are robust, although the home must ensure that all required documentation is available on site. EVIDENCE: As on the last inspection of Hollybank, staff were observed to have an excellent rapport with the service users. They were cheerful and enthusiastic. Over 50 of the staff are trained to NVQ Level 2 or equivalent. As at the last inspection, a requirement remains that staff take part in Disability Equality training. The home presented evidence to verify that this specific training is currently being sought. There are also plans to participate in “The Expert Patient” training being organised by the Health Authority. Rotas seen at the inspection showed that there are 5 care staff on morning shifts and 4 during the afternoon/evening. This is in addition to a member of the management team. Overnight there are 2 waking members of staff. Generally service users spoken to felt that sickness levels were not as bad as they were and that there had been an improvement in the numbers on duty. There were, however, occasions when the numbers appearing on the rota did Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 19 not match the reality. One service user said that to have 5 staff on duty in the mornings and 4 in the afternoons was “a luxury”. Another said that “when people go sick we get a raw deal”. Any “one to one” activities, such as going out on social occasions, are curtailed when there are staff shortages. It is hoped these difficulties will soon be resolved as the home intends to recruit new care staff to permanent posts in the near future. Specialist advice is available locally from healthcare professionals. Staff meetings take place regularly, although there has been some slippage of late. The Registered Persons operate robust recruitment procedures and evidence was seen on staff files of satisfactory Criminal Records Bureau and POVA checks. It was concerning to note, however, that evidence of these checks was not available for a member of the Agency staff currently employed at the home. The home must obtain verification of these checks and fax a copy to the Commission before this person carries out any further duties at the home. All new prospective members of staff are to be requested to meet with the service users prior to their interviews. Staff spoken to during the inspection felt that they worked within an excellent staff group and that they had “pulled together from top to bottom” following the untimely death of their Manager. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42. There are systems in place to obtain the views of service users, although service users’ meetings have not been taking place regularly over the past few months, for obvious reasons. The home now needs to develop a comprehensive quality assurance and quality monitoring system. The health, safety and welfare of service users and staff are promoted and protected. The recommendations of the Fire Officer must, however, be met. EVIDENCE: Service users and their representatives are sent questionnaires requesting their views of the home and any improvements they would like to see. Service users’ meetings are also held, although none have been held since September 2005. In addition service users’ views are sought at their regular meetings with their key-workers and these meetings are documented within their care plans. At present the home does not seek the views of visiting professionals, such as social workers and healthcare staff. Although this standard is mostly met, the home must work towards the establishment of a continuous selfmonitoring, verifiable method of quality assurance involving the service users Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 21 and seeking the views of family, friends and involved professionals. An internal audit must take place annually. There is a training plan in place and training is regularly sought for all staff in the mandatory areas of first aid, food hygiene, fire safety, moving and handling and infection control. It appears that the last Fire Awareness training took place in 2004 and therefore further training must be provided in 2006. Staff received training in the use of the hoist in October 2005 and training in infection control in September 2005. Evidence was seen of weekly fire alarm tests and monthly checks of the emergency lights. The last fire drill took place in May 2005. Fire drills must take place at least every six months. As stated in Standard 24 above, the recommendations of the Fire Officer must be met. Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X X X 2 X X 2 X Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 23 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2)(b) Requirement Formal, six monthly reviews must be held for each service user. (It is acknowledged that key-workers carry out monthly reviews with the service users and that the home have requested Social Services to arrange required reviews). Service users must be consulted about the quality and presentation of the food at the home and their views must be acted upon. The home must meet the recommendations of the Fire Officer, made following his visit of 31/10/05. The practice of wedging open fire doors must cease. Service users with kitchenettes must be able to access the sink area. (Previous timescale of 30/06/05 not met). (It is acknowledged that quotes have been sought for this work). The home must receive written verification that any DS0000036419.V277455.R01.S.doc Timescale for action 31/01/06 2. YA17 16(2)(i) 31/01/06 3. YA24 23(4) 11/01/06 28/02/06 4. YA26 23(2)(f) 5. YA34 19 31/01/06 Holly Bank House Version 5.1 Page 24 6. YA42 23(4) 7. YA42 23(4) Agency staff employed have received satisfactory Criminal Records Bureau and POVA checks. Staff must receive regular training in Fire Safety. Fire drills must take place at least every six months. Emergency lights must be tested each month and the testing recorded. (Previous timescale of 12/07/05 not met). 31/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA6 YA23 Good Practice Recommendations It is recommended that reviews of care plans and risk assessments are signed and dated. It is recommended that the care plans of service users on respite stays are in the same detailed format as those who live long-term at the home. It is recommended that Hollybank produce their own Adult Protection Procedure, which is in line with the local Social Services Procedure and the Department of Health document, “No Secrets”. It is recommended that the home’s policy and procedure with regard to the control of infection be updated. It is recommended that the home purchase a sluicing disinfector for the commode pots. 4. 5. YA30 YA30 Holly Bank House DS0000036419.V277455.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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