Inspection on 06/02/07 for Keele House

This inspection was carried out on 6th February 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Keele House 23/01/09

Keele House 13/02/06

Keele House 04/10/05

Keele House 02/02/05

Keele House 24/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Keele House Keele House 176 High Street Ramsgate Kent CT11 9TS Lead Inspector Christine Grafton Key Unannounced Inspection 6th February 2007 09:40 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 Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keele House Address Keele House 176 High Street Ramsgate Kent CT11 9TS 01843 591735 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) Soory & Co Ltd Dr Thangarajah Soory Ms Joan Elizibeth Smith Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To admit one (1) Service User whose date of birth is 02.05.1946. At any time no more than four (4) persons under the age of 65 years but over the age of 55 years to be accommodated for respite care. At no time can more than one (1) person be admitted for emergency respite care. 13th February 2006 Date of last inspection Brief Description of the Service: Keele House is a detached three-storey building with two shaft lifts, providing access to all floors. There are 27 single bedrooms and 2 doubles, the majority with ensuite toilet facilities. Bedrooms are provided with call bells and most have television points. There are 2 main lounges, a dining room, a very small room where smoking is permitted and an additional visitors’ room in the basement. There is an enclosed garden with patio and seating area for residents use, weather permitting. The home is located within easy reach of local shops and all public amenities. Parking is on street in the adjacent road. The current owners took over Keele House on 7th June 2004. The manager has worked at the home for over 25 years. There is a staff team of full and part-time workers, including carers who work a rota that includes 2 staff on waking duty at night. There are designated staff members responsible for the cooking and cleaning. The home provides care to suit residents’ individual needs and is careful not to admit people with high needs that it is not equipped to meet. The home currently has a local authority contract to provide respite care for up to 4 people at any one time. Information provided by the manager in December 2006 indicates that the fees for the home range from £303.00 per week to £349.00 per week. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report takes account of information obtained from various sources since the last inspection, including a visit to the home, telephone contacts with various different people about the home, including the registered provider and manager. Written information was provided by the manager in a pre-inspection questionnaire. An unannounced visit took place on 6th February 2007 between 09.40 hours and 16.30 hours. The visit included talking to the manager, deputy manager, staff, residents and observing the interactions between residents and staff. A tour of the building was carried out and various records were checked. The care of three residents was case tracked. At the time of the visit there were 29 residents. What the service does well: What has improved since the last inspection? Staff have worked hard to improve the care plans, which are being clearly cross-referenced, with detailed monthly review records. This makes sure that any important changes are followed up promptly and residents’ healthcare needs are being met. On-going improvements to the environment demonstrate the registered provider’s commitment to ensuring that residents live in pleasant, comfortable Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 6 surroundings. Since the last inspection, alterations have been made to a corridor to remove two steps, creating better access to four bedrooms. New carpets have been fitted in four bedrooms and in the front lounge. These are attractive additions, which residents confirmed they like and add to the homeliness of the environment. The dining room has been redecorated, with the addition of two large mirrors in alcoves, which has created a very congenial eating environment. New ensuite toilets have been added in two bedrooms and new bedroom furnishings provided in one bedroom. New lounge armchairs are being purchased on a monthly basis as part of a rolling programme. A resident confirmed that their armchair is very comfortable 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. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Keele House DS0000060970.V306299.R01.S.doc Version 5.2 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 the following standard(s): 1, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s statement of purpose and service users’ guide contain the information that residents and prospective residents need to make an informed decision about moving into the home. Residents can move into the home knowing that their needs have been assessed and the home endeavours to meet their needs. The home does not admit people for intermediate care, so standard 6 was judged as not applicable. EVIDENCE: The statement of purpose and service users’ guide have been reviewed and updated to take account of staff changes and improvements to the environment. Both documents contain all the required information. Following Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 9 discussion, the manager agreed to make some small amendments to the statement of purpose to clarify some statements. The service users’ guide is written in plain language, which is easy to follow. The manager confirmed that all residents are given their own copy of the service users’ guide, which includes a sample agreement and the complaints procedure. The information provided to residents makes it clear what services are included in the fees and those services that they have to pay extra for. The manager carries out pre-admission assessments of prospective residents, either at their own home, or at hospital. Evidence was seen of a thorough preadmission assessment that had been used to inform the home’s assessment and care plan, documented following admission. Copies of care management assessments are obtained and evidence was seen in files examined as part of the case tracking. Although the home does not provide intermediate care, it has a contract with the local authority and currently provides respite care for up to three residents at any one time. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system is clear and consistent, providing staff with the information they need to meet residents’ needs and residents’ health care needs are being appropriately met. The systems for medication administration are on the whole well managed, with clear and comprehensive arrangements in place to ensure residents’ medication needs are met. Residents’ privacy and dignity is respected. EVIDENCE: Three residents’ care pathways were case tracked. This included discussion with two of those residents, the manager and deputy manager. A thorough care planning system has been established. Care plans contain details including: personal profiles, background histories, comprehensive Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 11 assessments, dependency assessments, action plans and monthly weight records. Key workers complete monthly review records and where necessary update the care plans. Daily records are used to inform the care plans and cross-referencing has improved. Risk assessments are being completed and updated with guidance recorded for staff to follow. However, it was discussed in two cases, where a high risk of falls had been identified, that although there were strategies in place to reduce risk, the written documentation could be improved by expanding the final part of the risk assessment. One case was seen where a risk assessment had been completed well and the new deputy manager clearly understood the need for this in the other two cases. The manager and deputy manager both made an undertaking to complete the two risk assessments discussed to a similar standard. The quality of the care plans overall has improved significantly since the last inspection. Medication procedures were checked in discussion with the deputy manager. A small medication room has been created. A medication trolley is used and two staff give out the medications, with both signing the medication administration records. A monitored dosage system is used and blister packs were checked in relation to those residents case tracked. The numbers of tablets left were seen to correspond with the signed administration records. The manager and deputy manager were spoken to individually and both demonstrated a good understanding of the residents’ needs. Five residents made comments that they feel their health care needs are being met at the home. One resident commented that staff know what to do if someone is taken ill or has a ‘black out’. Residents commented that staff treat them with respect. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 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, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being given opportunities to take part in a variety of leisure activities in the home. Residents are provided with an appealing, varied and balanced diet. EVIDENCE: Several residents spoke about their enjoyment from participating in activities, such as bingo, exercises to music, quizzes and singing along with the ‘music man’. Others spoke of individual interests, such as knitting, reading newspapers and library books, or watching television. Residents confirmed that their daily routines are flexible and a resident spoke of liking their own company at times and enjoying just being alone in their room sometimes. During the morning of the visit, a group of residents were joining in with an exercise session being lead by two staff members. There was much laughter and even those not joining in seemed to enjoy watching and listening to the music. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 13 The day’s menu is displayed on a wipe clean board in the dining room. Menus are planned four weeks in advance from a selection of eight weeks’ menus covering a wide variety. Home cooked meals and fresh vegetables are provided. The meal served consisted of seasoned chicken, mashed potatoes, carrots and peas, followed by a homemade fruit flan and cream. The meal was attractively served and looked appetising. All of the residents spoken to said that the food is nice, some saying it is good, and the lowest comment was that it is ‘alright’. The dining room has been redecorated and the addition of two large mirrors in alcoves has made for a very congenial setting. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know that their complaints will be listened to and acted upon. Policies and procedures are in place to safeguard residents from abuse. EVIDENCE: Residents spoken to said that they had no complaints and would speak to the manager, or staff, if they had any worries. They praised the home, saying that the staff are good and listen to them. A complaints notice is prominently displayed in the entrance hall and the manager confirmed that each resident is given a copy. There is a system in place to record any complaints together with information about the action taken by the home to resolve any issues. A concern was raised since the last inspection that the commission was made aware of. The registered provider investigated this and sent an investigation report to the commission. This indicated that the provider had acted appropriately. Minutes of a staff meeting held after this indicated that staff had been reminded about the home’s ‘whistle blowing’ policy. A staff member spoken to was very clear about their responsibilities with regard to this and measures to protect residents from abuse. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 15 The home has a detailed policy and clear written procedures on abuse and adult protection. The manager said that these policies are covered in the staff induction programme and are regularly discussed within the staff formal supervision meetings. Following the investigation referred to above, the registered provider has stated that any suspicions of abuse would be reported to care management and to the commission. The manager stated that a qualified external trainer did adult protection training with ten staff in November 2006 and this training has been arranged for ten more staff in April 2007. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with an attractive, comfortable and homely place in which to live. Recent investment and the on-going improvement programme have enhanced the quality of life for a number of residents. EVIDENCE: The home was seen to be well decorated and well maintained. The manager confirmed that a regular programme for the renewal of fabrics, furniture and fittings is in place. Improvements since the last inspection include: building alterations to a ground floor area to improve access to four bedrooms. Two steps have been removed in a corridor and sloped access created, with new carpets fitted in the four bedrooms that this access route serves. The dining Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 17 room has been redecorated and new carpet fitted in the front lounge - both look very attractive. New ensuite toilets have been added in two bedrooms and new bedroom furnishings provided in one bedroom. These were seen to be good quality and add to the homeliness of the bedroom. The manager said that the renewal programme currently includes the purchase of three new armchairs each month for the lounges and some new ones were seen. A resident confirmed that their armchair is very comfortable. Other future plans discussed include extending a small single bedroom to provide more space. This work is due to commence in summer months. On the tour of the building various mobility aids were seen, such as grab rails, raised toilet seats and frames, individual aids such as walking frames and wheelchairs. The home has a mobile hoist, which the manager stated is used mainly in emergency, as currently there are no residents who need this facility. Several residents commented that they like their bedrooms and from the tour of the building it was clear that bedrooms have been personalised and arranged to suit residents’ individual needs. Good standards of cleanliness and hygiene were observed. All areas seen were clean and where there are problems with odour, effective systems are in place to keep the home fresh smelling. There is a well-equipped laundry in the basement and there is a small sluicing facility adjacent to the staff toilet. Safe infection control practices were observed and an up to date Clinical Waste Certificate was seen. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 18 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, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are appropriate to meet the assessed needs of residents in this home. Residents are protected by the home’s recruitment procedures and commitment to staff training. EVIDENCE: The registered provider uses the Residential Forum Guidance recommend by the Department of Health to calculate the numbers of staff required. Evidence was seen that the manager works to these figures when arranging staff rotas. The manager said she aims to provide four carers on duty in the mornings, with three carers in the afternoons and evenings and rotas indicated that this was being achieved. However, as four staff have left since December 2006, the home is currently recruiting for more care staff and existing staff are covering the vacant shifts. Staff on duty at the time of this visit consisted of: three carers, the deputy manager (working as the fourth carer on shift), the manager, a cook and a cleaner. The manager confirmed that the home is registered with a staff agency who can be called upon to provide additional cover if needed. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 19 Residents spoken to felt there were enough staff and commented that staff are always available to help them when needed. Two staff files were checked and seen to contain all relevant paperwork in relation to the requirements of legislation, for example application forms, proof of identity, references, job descriptions and statements of the terms and conditions of employment. Evidence of criminal records bureau (CRB) and protection of vulnerable adults register (POVA) checks was seen. It was discussed with the manager that staff files could be improved by the addition of a checklist detailing the dates of interview, dates references are requested and returned, dates the CRB and POVA checks are received and the full start date. Evidence was seen of a thorough induction programme that is linked to the National Vocational Qualification (NVQ) in care units. The manager stated that this is usually completed over a six-week period. This is followed with a more comprehensive training package provided by an external trainer that takes 1216 weeks to complete and evidence was seen that it is linked to the Skills for Care training programme. Information provided by the manager in the pre-inspection questionnaire indicates that ten staff have achieved their NVQ level 2 or above. The stafftraining matrix indicates that staff attend a wide range of courses. Examples of training undertaken during the past year include: moving and handling, infection control, first aid and fire training. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 20 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, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the home is being run in a manner that protects their best interests and that their health, safety and welfare are promoted and protected. EVIDENCE: The manager has many years experience working at this home, but she has not undertaken any formal management and care qualifications. She has, however, attended a wide range of short courses to update her knowledge, skills and competence. The manager stated that it is the registered provider’s intention that the new deputy manager undertakes an NVQ level 4 in Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 21 management and care and it is hoped that this will be commenced within the next year. Satisfaction surveys were sent out to residents and/or their relatives in October 2006. A selection of those returned were seen to contain mainly positive comments with some suggestions for improvement, which the manager said had been taken seriously and acted upon. The manager stated that the registered provider visits the home regularly and does the monthly regulation 26 visits. However, copies of the monthly visit reports were not available at the home and the manager said she had not seen them. Residents’ views are also sought at residents’ meetings and staff views are encouraged at staff meetings and at their two-monthly formal supervision meetings. Copies of the last staff meeting minutes were seen, indicating that twelve staff attended plus the registered provider. Feedback from residents and staff spoken to at this visit indicates that they feel the home is well managed. Several residents confirmed that the registered provider speaks to them on his visits to the home and they appreciated this. Records of residents’ monies were checked and seen to be appropriately kept. The fire safety logbook contained records of weekly fire bell tests, regular staff fire instruction and fire drills. The pre-inspection questionnaire indicates that staff training during the past 12 months has included: health and safety training and food hygiene. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 3 x 3 Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP33 Regulation 26(5) Timescale for action That a copy of each monthly visit 31/03/07 report is supplied to the registered manager and a copy kept available at the home for inspection by the commission if requested. Requirement 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 OP8 Good Practice Recommendations That risk assessments are expanded where a high risk has been identified in a resident’s care plan to provide more guidance for staff on what they should do to reduce the risk. That a check list is added to the front of staff files indicating the date of interview, dates references applied for and received, dates POVA First checks received and the dates the CRB check is sent for and received, plus the full start date. DS0000060970.V306299.R01.S.doc Version 5.2 Page 24 2 OP29 Keele House 3 OP31 That the manager and/or deputy manager undertakes their NVQ level 4 in management and care. Keele House DS0000060970.V306299.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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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