Inspection on 09/05/05 for Parkside Lodge

This inspection was carried out on 9th May 2005.

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

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

Other inspections for this house

Parkside Lodge 04/08/08

Parkside Lodge 08/08/06

Parkside Lodge 01/11/05

Parkside Lodge 13/09/04

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 Parkside Lodge 28 Wykeham Road Worthing West Sussex Lead Inspector Mrs B Tye Unannounced Monday, 9 May 2005 V226451 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Parkside Lodge Address 28 Wykeham Road, Worthing, West Sussex, BN11 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01903 235393 Mr Salim Nanji & Mrs Zeenat Nanji Mrs Ann J Smith Care Home (CRH) 20 Category(ies) of Old age, not falling in any other category (OP) registration, with number 20 of places Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Parkside Lode is a residential establishment providing accomodation and personal care for older people over the age of 65. The home is a large detached house in the centre of Worthing, close to Victoria Park and approximately one mile from the town centre. The building comprises of three storeys set in its own grounds, with an enclosed garden and car parking spaces for visitors. It has nineteen bedrooms, three of which can be used as doubles, providing the overall number of residents does not exceed twenty. There are two lounges and a dining area for communal use. A passenger lift facilitates access to all floors. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a period of 6 hours. Prior to the inspection the inspector examined information on the current file spanning the last six months. Seven residents and three staff were spoken to by the inspector. Two staff were interviewed and the Quality Assurance Report for the home provided feedback from involved professionals and family members. Care plans for five residents were examined and a tour of the premises was undertaken. The manager of the home was on annual leave and the home was being run by an experienced care worker (Ann Rose) in her absence. All documentation and information required was provided by Mrs Rose on request. The inspector concluded she was experienced and knowledgeable enough to run the home efficiently in the mangers absence. What the service does well: What has improved since the last inspection? The local fire service has completed an inspection that concludes the home meets required standards. The complaints information has been updated to include contact details for the commission. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 6 The lounge carpet has been stretched to make good the puckering, which may have result in residents tripping. A risk assessment has been completed. Proposals for some aspects of maintenance carried out in the home have been risk assessed, highlighting potential hazards and reducing risks to residents. Bedrooms were considered too hot at the last inspection. Each bedroom seen was at an appropriate temperature. Radiators are covered and can be regulated to suit the occupants preference. Residents spoken to all liked their rooms and felt they were 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. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 5 Prospective residents and their families are able to visit the home before moving in, to assess the environment and quality of care provided. A full assessment is carried out prior to admission by the manager or her deputy, to ensure residents needs can be met appropriately by the home. Each resident is provided with a written contract of terms and conditions, which is signed by all involved parties, so residents are clear about their rights within the home. EVIDENCE: All residents spoken to said they had received a copy of their Terms and Conditions for the home, which they had signed following admission. Copies of these were seen on their files. The inspector examined full pre-admission assessments for four residents. These were completed by the manager and identified relevant areas of need including; diet, communication, health, social and cultural needs. Additional information and correspondence by community based professionals is attached to the assessments. This information is kept in residents files in a locked cabinet only accessible by care staff to ensure confidentiality. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 9 Risk assessments were in place for each of the four residents and contained information relating to their specific needs and assessed areas of risk. This promotes independence for residents in all aspects of daily living. Two service users stated they visited the home prior to admission following positive recommendations, both were given a choice of rooms and information about the home including a Service Users guide. This information enabled them to make an informed decision about moving to the home and what to expect. Parkside Lodge has an up to date emergency admission policy in place. The home does not offer intermediate care. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 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 standard(s) 7, 9 and 10 All residents have a comprehensive care plan in place, which means healthcare needs are met appropriately by staff in the home. Medication procedures are in place and staff had received dispensing medication training as part of their induction or by the local pharmacy. This promotes good practice when dealing with medication. Some care plans seen identified specialist healthcare needs such as dementia, depression and diabetes but the home provides no specific training in these areas. Specialist staff training could enhance the quality of care provided to those with high dependency needs. In relation to health and personal care needs, residents are treated with respect by staff and their privacy and dignity is upheld. EVIDENCE: Five care plans were examined and all contained detailed information relating to health and personal care needs of residents. Staff stated this information informed them of individual needs and how to respond to them. Staff handover at each of the three shift changes during the day to ensure each staff member is fully aware of the immediate needs of each resident. In addition the manager and staff meet on a monthly basis as a team to review Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 11 and discuss ‘best practice’ for residents. This information is transferred to careplans. The inspector noted all monthly review information was up to date. Any specialist health needs are referred to community-based professionals via the GP’s. Correspondence held in individual files supported this. Records at the home showed a Chiropodist visits once a month and GP’s are seen as needed. The inspector was able to examine medication charts and storage of medicines within the home. These were seen to be maintained satisfactorily. The home has an up to date policy, procedure and code of practice relating to dispensing medication. Risk assessments for those residents who self medicate homely remedies were held on each file. Five residents spoken to stated they felt the standard of care in respect of health and personal care was ‘excellent’ and that ‘staff knew what each of them needed’ and were ‘very caring in their approach’. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 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 standard(s) 12 and 13 Residents visitors are welcomed to the home and contact with family and friends is encouraged. Residents are supported to actively pursue areas of interests in the wider community. Activities are held in-house on a regular basis offering stimulation to those residents who are less able to explore interests outside the home. The activities provided in house and in the wider community supports residents to satisfy their recreational, cultural and social needs. EVIDENCE: Residents said they were able to exercise choice regarding activities. One said he preferred to remain in the home and enjoyed participating in ‘lounge games’ organised by the staff. These include quizzes, skittles and cards. A library trolley is available (books supplied on a regular basis by Worthing Library) and a resident holds responsibility for collection of books. One resident said her ‘passion in life was music and art’ and that she attended a weekly art class in the community and could ‘listen to music whenever she liked’. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 13 Religious services are held in the home every three weeks to meet varying denominational needs and some residents stated they prefer to attend church in the community. The inspector was unable to view an activities log at the time of the inspection but noted forthcoming activities were displayed on a community pin board in the residents lounge. Staff were observed chatting and joking with some of the residents and the between them was relaxed and friendly. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 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 standard(s) 16 and 18 The home has provided residents with information and staff training in respect of complaints. Although details of timescales for action are not included in the complaints information provided. Residents spoken to were aware of their rights and how to complain within the home, but not of timescales. Staff have received abuse training, but those spoken were unclear of who to contact if they suspected abuse. Lack of confidence by staff in this area could increase risk of residents in the home EVIDENCE: The complaints book for the home was examined. Three complaints in the last year were logged and signed off by the manager. All were resolved satisfactorily. The home has an up to date policy and procedure for complaints and details are outlined in the service user guide. This ensures residents know how to complain and who to. A previous requirement to include details of the commission in the complaints procedure has now been met. Five residents spoken to expressed confidence in being able to complain and each had their own copy of the procedure in their rooms. The inspector noted there was no time scale to deal with complaints in the procedure or residents information. This would inform residents about the timeframe a complaint will be responded to. A requirement has been made to include this in all the homes complaints literature. County procedures for the Protection of Vulnerable Adults and relevant policies and procedures relating to abuse and protection are available in the managers Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 15 office. Staff receive Adult Protection training as part of their induction and also attended ‘Abuse Training’ in February of this year. However two staff spoken to at the time of inspection seemed unsure about appropriate action for reporting abuse within the home. Refresher training in the area of abuse and protection will give all staff clarity about how to act should an incident occur. A recommendation has been made in respect of this so staff can act effectively should an incident occur. Therefore providing better protection of residents living at the home. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 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 standard(s) 19, 21, 22, 24 and 26 The communal areas of the home and residents bedrooms were clean, light, airy and homely providing the residents with a pleasant living environment. Access to a well maintained garden gives residents the option to sit outside in warmer weather. There are sufficient toilets and each bedroom has a basin with washing facilities. There is only one bathroom for a maximum of twenty residents. This may cause difficulties if the majority of residents chose to have more than the one bath a week, that is currently provided. Specialist occupational therapy equipment is been provided to maximise the independence of residents. EVIDENCE: Following a tour of the premises and examination of maintenance records it is evident the home provides a homely, well maintained and safe environment. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 17 The residents have access to a main communal lounge/dining room, which was comfortably furnished, creating a homely environment. A separate lounge on the first floor allows residents to smoke if they wish. Provision of tea and coffee making facilities enable residents to have a space to take visitors other than their bedrooms. There is a passenger lift for residents with limited mobility to access all floors of the house. Radiators throughout the home have been covered to reduce the risk of injury. Provision of a bath-slide, grab rails and raised seating in toilets provide individuals with limited mobility more independence. A call bell is provided in every room so staff are aware and can attend an emergency situation should it arise. Bedrooms were furnished with personal possessions and the option is given to bring furniture from home, giving each resident a sense of ownership in their private space. Each resident has the option to have lockable facilities in their rooms to store money and valuables. Access to one bath is managed by providing a weekly bath to each resident on a rota system. Staff stated anybody requiring an additional bath would be accommodated. Of the residents spoken to none stated a problem in this area and were happy with a weekly bath. All said they were confident they could increase this if they wished, although if the majority requested this the logistics of one bathroom for twenty residents could cause difficulties. A cleaner is employed for 3 hours a day, 5 days a week to ensure the premises is kept clean. All areas of the home were found to be very clean and tidy, providing the residents with a clean environment. Anti bacterial soap is provided at every sink and laundry facilities are provided with correct temperatures, reducing the risk of cross infection within the home. Although policies and procedures were in place for infection control, none of the staff have attended training. Knowledge in this area would promote good practice in the area of hygiene and reduce the risk of infection spreading within the home. A requirement has been made for management to provide this to all staff. The bumpy carpet in the main lounge area has been risk assessed and stretched, in line with requirements from the last report. This will reduce the risk of residents tripping on an uneven floor surface. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 18 The maintenance log showed all maintenance was completed as required on a weekly basis by a handy man who attends the home twice weekly. This means the residents environment is kept safe and well maintained. A maintenance plan for the coming year was not available at the time of inspection, this will be monitored at the next visit. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The staff numbers are adequate to meet the assessed needs of residents. An induction and training programme for staff is provided by the home but does not include all aspects of training needed to ensure the residents specialised needs are met. Recruitment procedures and record keeping are not adequate to ensure that residents would be protected in the home. EVIDENCE: The inspector concluded from examining the duty rotas, speaking to staff and residents and information accessed in individual files that staffing levels are sufficient to meet assessed needs of residents. One resident said ‘staff always make an effort to deal with things quickly’. Staff complete a comprehensive induction prior to working with the residents. The inspector is concerned that areas of training specific to the residents high dependency needs are not provided. The required ratio for 50 of staff to complete NVQ Level 2 or equivalent by 2005 has not been met. A requirement has been made in respect of this. This will mean residents who have specialised needs such as diabeties, depression and forms of mild dementia will have their needs better met within the home. Recruitment policies and procedures are in place to ensure staff employed by the home have the necessary skills and experience to fulfil their roles. CRB checks, terms and conditions and job descriptions were seen on file for staff Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 20 members. However, the absence of references on staff files meant the inspector could not conclude the residents are protected by appropriate recruitment systems. This requirement is still outstanding from a previous inspection. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33,36,37 and 38 Residents and staff said they did benefit from the leadership and management approach within the home. Quality assurance and monitoring systems are in place to measure stated aims and objectives. Use of consulation with residents, staff and their families ensure those providing and receiving care have an input into how the home is run. Although the inspector concluded the residents were priority within the home, this was not always supported by some areas of record keeping. EVIDENCE: The certificate for insurance displayed within the home had expired. An immediate requirement was made in respect of this. Although the manger was on annual leave the day of inspection staff feedback reflected that she provided a clear sense of leadership and direction. Staff Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 22 spoken to stated she was ‘supportive and open’, enabling them to seek guidance as it was needed to ensure residents needs were met appropriately. An annual development plan and quality assurance system is in place, which includes contributions from service users and their families Feedback contained in the homes ‘satisfaction questionnaire’ from residents and their families was highly complimentary and praised the quality of service provided. Regular staff and resident meetings mean participants of the home are kept up to date with changes and able to give their views about how the home is run. The inspector examined record keeping for all aspects of health and safety, risk assessments and policies. Those that were seen, were in good order and up to date. This practice ensures the occupants of the home are safeguarded and protected. Most staff spoken to stated they received regular supervision and contracts were evidenced on staff files. Some supervision records were absent or incomplete in staff records. Better record keeping in this area would reflect the homes monitoring of care practice. A requirement has been made in respect of this. Regular monthly Regulation 26 visits were recorded, though it was not clear if these were unannounced. Copies forwarded to the commission had not been sent on a regular monthly basis. A requirement has been made for the registered manager to ensure written reports on the conduct of the home be sent to the commission on a monthly basis. This will enable the commission to monitor the home over and above the inspections. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 3 x x 2 2 x Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 28 29 30 Regulation 18 29 18 Requirement All minimum of 50 of staff should be trained to NVQ Level 2 by 2005 Two written references be obtained on staff members prior commencing work The registered person shall ensure persons employed to work at the care home recieve training appropriate to the work they perform Records at the home are updated to ensure residents are safeguarded from harm Forward a copy of the homes insurance policy to CSCI Written reports on the conduct of the home are sent to the commision monthly in relation to complaints.The registered person shall inform the person of action taken within 28 days Timescale for action 9th December 2005 9th August 2005 9th December 2005 9th August 2005 Immediate 9th August 2005 9th August 2005 4. 5. 6. 7. 36 34 37 16 18 25 26 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 25 No. 1. Refer to Standard 18 Good Practice Recommendations Refresher training in the area of abuse and protection will give all staff clarity about how to act should an incident occur, therefore ensuring better protection of vulnerable residents. Parkside Lodge H60 H11 S14659 Parkside Lodge V226451 090505 Stage 1.doc Version 1.30 Page 26 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex 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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