Inspection on 06/04/06 for Lyons Gardens

This inspection was carried out on 6th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyons Gardens 12/10/07

Lyons Gardens 07/12/06

Lyons Gardens 19/09/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Lyons Gardens 36 Lincoln Road Glinton Peterborough PE6 7JS Lead Inspector Nicky Hone Key Unannounced Inspection 6th April 2006 13:50 Lyons Gardens DS0000063991.V288110.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 Lyons Gardens DS0000063991.V288110.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. Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lyons Gardens Address 36 Lincoln Road Glinton Peterborough PE6 7JS 01733 254261 01733 254263 mark.hubble@btconnect.com 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) Hereward Care Services Ltd Roslyn Sadie Stone Care Home 11 Category(ies) of Learning disability (11), registration, with number of places Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Service users with a learning disability who also have a physical disability or mental disorder may be admitted. Date of last inspection 19th September 2005 Brief Description of the Service: Lyons Gardens is a purpose built care home on the outskirts of the village of Glinton, about six miles north of the centre of Peterborough. Set back from the main road through the village, the home consists of two bungalows. Each bungalow has a lounge, dining room, kitchen, toilets, bathroom and shower room as well as a laundry, office and staff facilities. One of the bungalows has five single bedrooms with ensuite toilet and washbasin; the other has six. There is parking space at the front of the bungalows and each has its own closed garden area. The bungalows were commissioned by the Greater Peterborough Primary Care Partnership, to replace an outdated home, and the places are all used for respite care. One bungalow offers accommodation to people who have a greater need for support with their physical care needs. The home has its own minibus, but is also on a bus route. Peterborough, with its range of facilities such as restaurants, pubs, shops and leisure facilities is within a short drive. People stay at Lyons Gardens for varying periods of time, from four nights a week to one night a month. Sometimes people stay at Lyons Gardens for several weeks while other accommodation is being found for them. Currently there are about fifty people who receive a service at the home. All eleven places at the home are ‘block-booked’ by Greater Peterborough Primary Care Partnership: one of the directors said that £1326.00 per week is paid for each place (from 01/04/06). Each service user pays a contribution towards this cost, from benefits. There are no other additional charges, except a contribution towards some of the outings. Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days. On the first day of the inspection the manager and deputy manager were both on duty. They were holding a staff meeting. The inspector looked at records and documents, toured the bungalows and spoke to the manager and deputy manager. The inspector also briefly met one service user. The second visit was made on a Sunday. There were 6 people staying at the home: 5 of the service users and 3 staff had gone out for the day in the minibus. The inspector spent an hour talking to the remaining service user and staff member. What the service does well: What has improved since the last inspection? What they could do better: The result of this inspection is that there are concerns about the management of the home. Five of the seven requirements made following the last inspection had not been fully met, and this inspection has resulted in a total of eighteen requirements being made. An immediate requirement notice was Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 6 given to the home because the fire alarm had not been tested every week. Fire doors were still being wedged open. The home does not carry out proper assessments of new service users and there was no evidence that the manager discusses with service users whether the home can meet their needs. Care plans did not contain enough detail for staff to know what level of support each individual has said they need, and there were no risk assessments on the files that were looked at. There was an issue which meant that the confidentiality of two service users had not been upheld. Although the manager said that activities are carried out, there were very few entries in the activities diary, so it looked as though service users have not had opportunities to do very much during the time they stay at Lyons Gardens. There is concern that a doctor might not be available if needed, and some nursing tasks had not been properly delegated to staff by the district nurses. Medicines arriving at and leaving the home were not recorded correctly. Records were not available to show whether staff have received appropriate training. Although a survey has been sent to service users, no report of the results has been sent to the Commission, nor made available to service users. 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. Lyons Gardens DS0000063991.V288110.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 Lyons Gardens DS0000063991.V288110.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): 1, 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Individual needs and aspirations are not assessed so users of the service cannot be sure their needs will be met. EVIDENCE: The home has a statement of purpose and service user guide. The manager said that a copy of this information is sent to new service users before their first stay at the home. The files relating to three service users were looked at. There were some assessments on the files which had been carried out by the person’s social worker/care manager: for one person the assessment had been done in 2001. There were no assessments carried out by the staff from the home and there was nothing to show that the manager had discussed with any of the service users whether the home could meet their needs. There was no written confirmation from the manager to each service user that the home would be suitable for them. Lyons Gardens DS0000063991.V288110.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): 6, 7, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans do not contain sufficient detail to ensure service users are needs are met. Risk assessments are not carried out. EVIDENCE: Care plans did not contain sufficient detail for staff to know how to support each person. There was nothing to show that service users or their representatives had been involved in writing the care plan, and some of the care plans seen were not dated or signed by the person who wrote them. The manager said that a new care planning system is going to be introduced. There were no risk assessments on the files seen. The menus and record of food provided indicated that service users are given a choice of meals. One service user had chosen not to go on the outing on the second day of the inspection. Staff are looking at different ways of communicating with service users. Cards with words had been made for one person who has full understanding of what Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 10 is being said but does not use speech to communicate. Staff had also made cards with pictures, for example of different foods and drinks, and symbols, so that service users could make choices. There were two notices on the board in the kitchen referring to matters that should have remained confidential to the individual service users. Lyons Gardens DS0000063991.V288110.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, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Available evidence indicated that service users do not have enough choice in the way they lead their lives while they are living at the home. EVIDENCE: On the first day of the inspection the activity diaries kept in each bungalow had not been completed very well so it looked as though service users do not have very much to do when they stay at the home. On the second day of the inspection all except one of the people staying at the home for the weekend had gone out for the day. The diary in one bungalow showed that the previous day had been very busy: the two service users had gone shopping; had joined in an exercise class with the people from the other bungalow; had joined in a skipping competition in the garden; watched the Grand National; and watched an old movie. A walk to the pub had been cancelled because of torrential rain but everyone had enjoyed the video evening. The manager said both local pubs welcome the service users, and staff are finding out what goes on in the local community so that service users can Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 12 become involved if they want to. Families are encouraged to visit or telephone as much as they wish. One service user was being taken out for lunch by her family. People who stay at Lyons Gardens are encouraged to join in the life of the home, and they are supported to help with the household chores. One person spoken to said she does all her own cleaning and laundry, gets her own breakfast, makes hot drinks and helps with the washing up. A “pizza evening” was held recently when service users made their own pizzas. Menus and the record of food provided showed that a varied and nutritious diet is offered. There is always a choice of two main meals on the menu, or alternatives such as vegetarian meals, jacket potatoes, salad or “something out of the freezer” are always available. Lyons Gardens DS0000063991.V288110.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, 19, 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s procedures for meeting service users’ healthcare needs, and for administering medicines are poor so that service users are not protected. EVIDENCE: There was a care plan on each of the three files checked but there was not enough detail on the care plans for staff to know how much support each individual needs and wants. For the people who stay at the home for short breaks, their families are responsible for arranging appointments for the dentist, optician, chiropodist and so on. The home organises these if people are staying at the home for a longer time. Certificates were on file to show that some staff had been trained to carry out a nursing task, but this task had not been delegated properly by the district nurse for each individual. The manager said that the home’s relationship with the local doctor is poor. The manager was not sure that an adequate GP service was available if one of the people staying at the home becomes too ill during their stay to visit their own doctor. Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 14 On the first day of the inspection, only one of the people staying at the home was taking any medication. This had not been listed correctly on the Medication Administration Record; it was not clear whether the number of tablets in each box had been counted each time the person arrived; and there was no record of the number of tablets sent home with the person after each visit. Lyons Gardens DS0000063991.V288110.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): 22, 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff have not received adequate training in the protection of vulnerable adults to ensure that service users are protected. EVIDENCE: The home’s complaints procedure is clearly detailed in the service user guide. There have been no complaints. A lot of people have sent thank you cards and notes, and complimented the home on the service that is provided. The manager said that staff have not yet had training in protection of vulnerable adults (POVA) since the home was opened. Some staff had training while they were at the previous home. The manager said that two of Hereward Care Services staff are being trained to be trainers, then all staff will be given the training. There are no dates for this yet. The manager and deputy said that two days before the inspection, a service user’s relative reported a concern about possible abuse (not at Lyons Gardens). They were advised to pass this on to the POVA team. Lyons Gardens DS0000063991.V288110.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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The bungalows are equipped to meet the needs of all the service users and are kept clean, well maintained and comfortable. EVIDENCE: Lyons Gardens was built and opened in 2005. The manager said there are still some minor problems but the builders are sorting them out. The home is clean, well decorated and comfortably furnished, and service users’ bedrooms are suitable for them. Equipment needed by people with physical disabilities is available. Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 17 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, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorough checks are carried out on new staff to make sure service users are protected and staff receive regular supervision. EVIDENCE: Before the home opened, all staff had a week’s induction when all mandatory training topics were covered. The manager said that all staff have a first aid certificate and have been trained in moving and handling, basic food hygiene, infection control and fire safety. A training plan, showing dates when staff are booked to go on courses, was seen. Records to show that staff had actually undertaken the training were not available. The manager said that 2 staff have been awarded a National Vocational Qualification in care level II, 3 staff are working towards level III, and 9 staff are doing level II. The manager said she is about one third of the way through her studies for the Registered Manager Award. The files of three staff members were checked. They contained all the documents and information needed to show that the home has a good recruitment procedure. The documents included two written references and evidence that POVA list and Criminal Record Bureau checks had been done before the person started working at the home. The manager said she is now aware that gaps in an applicant’s employment history must be explored. Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 18 A requirement was made at the last inspection that all staff must have one supervision session by 31/12/05, and at least six times a year after that. The manager supplied a list that showed that the majority of staff have had three supervision sessions since September 2005. Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 19 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): 37, 39, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users cannot be confident that the home is managed well enough to meet their needs and keep them safe. There is no evidence that service users’ views are taken into account. EVIDENCE: The number of requirements made following this inspection indicates that the management of the home is poor. ‘Residents’ meetings’ take place: the manager said these are usually held at weekends when there are more people staying at the home. The staff try to arrange the meeting so that it is not always the same service users who are able to attend. This means that some people, for example the person who stays at the home from Monday to Friday each week, are never involved in the residents’ meetings. Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 20 Two surveys have been carried out, one by the company, the other by the GPPCP commissioners. A letter on the notice board in the kitchen explained that 30 of the forms were returned. The letter congratulated the staff that 100 of the returned forms had praised the service provided. The manager had not been told the results of the company’s survey. The home has a health and safety policy (this was not checked). Electrical appliances have been tested, hoists have been serviced, and appropriate tests carried out on the water system. The record of tests of the fire alarm system showed that weekly tests have not been done. In the 26 weeks since October 2005, only 12 tests had been done in one bungalow, and 11 tests in the other. Tests of the emergency lighting had been carried out at least monthly as required. On the second day of the inspection two doors (to the two offices in Bungalow B) were wedged open. Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 21 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 3 2 1 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 1 2 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 1 X 1 X 2 X 2 2 X Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14(1) Requirement A full assessment of needs must be carried out before a service user is offered accommodation at the care home. The registered person must confirm in writing to the service user that the home can meet the service user’s needs. The registered person must ensure that the assessment of the service user’s needs is kept under review and revised when necessary. Each service user must have a written plan of care (Service User Plan) as detailed in Regulation 15. Evidence must be available to show that service users are enabled to make decisions about the care they receive. Timescale for action 31/07/06 2 YA2 14(2) 31/10/06 3 YA6 15 31/07/06 4 YA7 12(2) and 12(3) 31/07/06 5 YA9 13(4) The registered person must 31/07/06 demonstrate that assessments of risk have been carried out and any risks identified have been minimised as far as possible. DS0000063991.V288110.R01.S.doc Version 5.1 Page 23 Lyons Gardens 6 YA10 12(4) Confidentiality must be 06/04/06 maintained at all times to respect service users’ dignity and privacy. Records must be available to show that appropriate and sufficient activities are arranged for service users. This requirement is carried forward: the timescale of 31/12/05 was not met. Evidence must be available to show that service users receive care and support in they way they prefer. The registered person must ensure that appropriate healthcare support (that is, a general practitioner) is available when needed. Any nursing tasks delegated to staff at the home must remain the responsibility of the district nursing service. Appropriate delegation forms must be available to show this is in place for each service user who requires treatment. Arrangements must be made for the recording, handling, safe administration and disposal of medicines received into the care home. The registered person must ensure that staff are fully trained in the protection of vulnerable adults. This requirement is carried forward: the timescale of 31/03/06 was not met. 31/05/06 7 YA12 16(2)(n) 8 YA18 12(1) 31/07/06 9 YA19 13(1) 31/05/06 10 YA19 13(1) 30/05/06 11 YA20 13(2) 06/04/06 12 YA23 13(6) 30/04/06 Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 24 13 YA35 18(1) All staff must receive training appropriate to their work. This requirement is carried forward: the timescale of 31/03/06 was not met. Records must be available to show that staff have received appropriate and sufficient training. The registered manager must have the qualifications, skills and experience necessary for managing the care home in a way that provides a quality service for service users. The registered person must establish a quality assurance system, and ensure that reports of quality reviews are supplied to the Commission and made available to service users. 31/05/06 14 YA35 18(1) 31/05/06 15 YA37 9 31/10/06 16 YA39 24 31/07/06 17 YA41 23(4)(c) & Tests of fire alarm and 17, sch 4 emergency lighting systems must be carried out as required and the record must be available for inspection. This requirement is carried forward: the timescale of 05/12/05 was not met. An immediate requirement notice was sent to the home regarding tests of the fire alarm system. 23(4)(c) Fire doors must not be held in the open position except by a means approved by the fire authority. This requirement is carried forward: the timescale of 19/09/05 was not met. 07/04/06 18 YA42 09/04/06 Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 25 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 YA39 Good Practice Recommendations The manager should consider ways of ensuring that the views of all service users are taken into account in the day-to-day running of the home. Lyons Gardens DS0000063991.V288110.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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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