Inspection on 13/09/06 for Pennsylvania House

This inspection was carried out on 13th September 2006.

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

Pennsylvania House 18/07/07

Pennsylvania House 16/01/06

Pennsylvania House 07/09/05

Pennsylvania House 09/03/05

Pennsylvania House 27/07/04

Pennsylvania House 30/03/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Pennsylvania House 7-9 Powderham Crescent Exeter Devon EX4 6DA Lead Inspector Sue Dewis Key Unannounced Inspection 13 & 15 September 2006 10:30 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 Pennsylvania House DS0000022007.V307726.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. Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pennsylvania House Address 7-9 Powderham Crescent Exeter Devon EX4 6DA 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) 01392 256346 01392 433224 henry-morgan@tiscali.co.uk Mr Henry Arnold Morgan Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Learning registration, with number disability over 65 years of age (25), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (25), Old age, not falling within any other category (25) Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16th January 2006 Brief Description of the Service: Pennsylvania House is a privately owned home, situated in a residential area of Exeter. It is within a short walk of the city centre. It comprises three adjoining terraced houses with accommodation on the ground, first and second floors. There is a small communal lounge on the ground floor, and a larger one on the first floor. The dining room is on the ground floor. A passenger lift provides access to the upper floors. To the front is a small garden and there is car parking and a small courtyard area to the rear. Mr Morgan is planning a large extension to the rear of the building, which will incorporate a new laundry, dining area and garden. The home provides care and accommodation for a maximum of twenty-five older people with dementia, mental health needs and learning disabilities. Fees range from £297.04 to £450.00 per week. Fees do not include hairdressing, chiropody or outings. The reports from CSCI inspections are displayed on the notice board. Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days in the middle of September 2006, with a total of nine and a quarter hours being spent at the home. The home had been notified that an inspection would take place within three months and had returned a pre-inspection questionnaire, information from which was used to write this report. Part of the inspection process includes questionnaires being sent out to a variety of people who may have an interest in the home, asking for their comments about the service given by the home. Prior to this inspection, questionnaires were sent out to 8 staff, 13 residents, 10 GPs, 6 care managers and 5 relatives. At the time of writing the report, replies had been received from 4 staff, 3 residents, 4 GPs, 1 care manager and 2 relatives. During the inspection 3 residents were case tracked. This involves the inspector looking at the resident’s individual plan of care, and speaking with the resident and the staff who care for them. This enables the Commission to better understand the experience of residents living at the home. Four residents and three staff were spoken with individually and a number of residents were spoken with in a group situation. The inspector sat for some time in both lounges and the dining room observing the interactions between staff and residents. A sample of records were inspected including, the fire log book, residents’ finances, care plans, medication records and some policies and procedures. What the service does well: Pennsylvania House is well managed and provides a comfortable and homely place for residents to live. There was friendly banter between residents and staff and those residents who were spoken with were happy with the care they receive at the home. The home tries to treat residents as individuals with each one receiving the care and support they need and want. There is a good assessment process that assures prospective residents that their needs will be met, and there is good care planning that ensures all aspects of care continue to be monitored and needs met. Staffing levels are sufficient and recruitment and training is robust to ensure residents are protected from harm. All records, including those relating to medication administration, fire precautions, risks and residents’ finances were well Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 6 maintained. There is a simple complaints procedure and any complaints made to the home are thoroughly investigated. Residents felt that meals were very good and there was a good variety of food available. Residents were also satisfied with the level of activities and entertainment available. Positive comment cards were received back from care professionals, staff, visitors and residents. What has improved since the last inspection? 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. Pennsylvania House DS0000022007.V307726.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 Pennsylvania House DS0000022007.V307726.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, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are encouraged to visit the home and an assessment of the support they require ensures that the home can appropriately meet their care needs. The home does not provide intermediate care. EVIDENCE: Three residents’ files were looked at as part of the case tracking process, including the most recent admission, all three contained pre-admission assessment information. These provide good basic information, and are used with information from care managers and a visit from the care manager at the home, to decide whether the home can meet the needs of the prospective resident. Two residents that the inspector spoke with could not remember if they had visited the home before they were admitted but thought their family Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 9 might have. One resident said that they had been unable to visit the home, but that the care manager had visited them in hospital. The service user guide and statement of purpose for the home are given to the resident on admission to the home. Following discussions between the inspector and the care manager, it was decided that the home will send out these documents prior to the resident being admitted, so that they can use these documents to help them decide if they wish to live at the home. The file of the most recently admitted resident contained evidence of consultation with family and care managers. The home was initially unsure as to whether it could fully meet the needs of this resident. It was agreed that they would be admitted for one months trial and the file showed ‘contingency plans’ for the home to follow, should the behaviour of the resident become such that the home was unable to continue to meet their needs. The home does not provide intermediate care. Pennsylvania House DS0000022007.V307726.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well formulated and give clear information to enable staff to meet residents’ health and social care needs. Residents are treated with dignity and respect. The health care needs of residents are well met with evidence of good multidisciplinary working taking place where necessary. To ensure the safety of residents, all medicines are stored securely and administered appropriately. EVIDENCE: Following their admission, a detailed assessment of the resident is undertaken. This includes moving and handling, nutrition, pressure areas and any inappropriate behaviour. Detailed risk assessments are then completed for Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 11 moving and handling and nutrition as well as other issues that may have been identified in the assessment. However, this does not include pressure areas. From these assessments a care plan is drawn up, which gives good detailed directions to staff on how to meet the day to day care needs of the resident. Care plans contain information on what, when and where the resident likes to eat and drink, how the resident likes to receive personal care, when they like to get up and go to bed and any other daily routines they may have. Care plans showed evidence of regular monthly reviews and where possible, the involvement of residents was recorded. One resident told the inspector that they had discussed the care they needed with the home. The three staff that the inspector spoke with said that they were very much involved with the care plans and found them useful. They were able to demonstrate that they were aware of the detail of the care plans and described how they are used to ensure the needs of individual residents are met. Health care needs were identified and monitored and it was possible to see where a resident had been unwell and the doctor had visited. One GP commented that they felt the home gave ‘excellent care’. However, another commented that though ‘..is happy and appropriately managed, more difficult patients in past have been less well managed’. The home uses the Boots MDS system (blister packs). All medicines are securely stored in a locked cupboard. Medication is administered and signed for appropriately, with the relevant ‘blister pack’ taken to the resident before the medication is removed, and staff sign to say it has been taken. In line with the home’s policy and procedure all medicines received into and returned from the home are counted and recorded, and all staff who administer medicines have received appropriate training. Staff were seen to offer personal care in a discreet manner and residents told the inspector that staff were always respectful to them and ensured their privacy was maintained. One resident told the inspector that staff always knocked on their door, and called them by the name they had chosen to use. They also commented that staff ‘have the patience of saints with me’. One resident’s hair was very unkempt, though they assured the inspector that it was just the way they liked it. Pennsylvania House DS0000022007.V307726.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Links with visitors and the community are good, giving opportunities to support and enrich residents’ social life. The home offers a suitable range of activities and entertainments to stimulate and occupy residents. Meals were seen to be well presented, providing nutritious variety and choice for residents. EVIDENCE: There is a list of activities for the week displayed on the notice board, which includes reminiscence sessions. On the afternoon of the first day of the inspection a lady visited to provide gentle exercise sessions. Residents said that they generally spend their time as they please, reading, knitting or watching TV. Two residents told the inspector about how they enjoyed the exercise classes, and that someone comes to read the newspapers Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 13 to them. They said that they often go over to the private park and sometimes have tea over there. One resident spoke with the inspector for some time and said that they felt ‘very free, not tied at all’, that they could go to their bedroom whenever they wanted, stay in bed as long as they wanted and that the home would always get the doctor if they needed them. They also said that there was a church service every Sunday afternoon and monthly communion. They told the inspector that birthdays were good and that residents always got a present and a party. Another resident told the inspector that they had lived at the home for over 8 years and was quite happy and found it ‘quite all right living here’. A resident who was fairly new to the home was also very complimentary about everything at the home. Positive comments (via cards) were received from two relatives about the care their relative receives from the home. Residents said that their visitors were always made welcome and encouraged to visit. All residents praised the standard and variety of food and said that there were three choices at lunch and ‘you can pick what you want’. On the afternoon of the first day of inspection a member of staff was observed asking residents what they wanted for tea. The inspector sat with residents while they ate their lunch and noted that the meal looked well balanced and nutritious. One resident told the inspector that the food was really, really good and that they always had several helpings. Staff told the inspector how they ensure one resident’s cultural food needs were met even though they can no longer express their needs themselves. There were detailed instructions for staff on the resident’s care plan, provided by their family. Pennsylvania House DS0000022007.V307726.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately. Residents are protected by staff who are able to recognise abuse and know their duty to report poor practice. EVIDENCE: There is a clear and simple complaints procedure displayed in the main hall and the communal lounges. Residents told the inspector that they felt they could talk to the manager about any concerns they had. They also said that if they needed anything they could talk to their key-worker. Two members of staff have completed the POVA (Protection Of Vulnerable Adults) training for trainers, and are able to ensure all staff are kept up to date with these issues. The three staff members that were spoken with were able to describe differing types of abuse and were clear about the procedures to be followed if they suspected abuse was taking place. All three also confirmed that satisfactory police checks had been obtained for them. The Commission had been contacted by a member of the public expressing concerns about the suitability of a member of night staff to work at the home. The home had not obtained two references for this person, who was later dismissed after more information had been gathered. Also see Standard 29. Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home generally provides residents with a clean, safe, comfortable and homely place to live, however, there are some areas of the home where the standard of décor and cleanliness is poor. EVIDENCE: The inspector did a tour of the communal areas of the home and looked into several residents’ bedrooms. There is only a small courtyard that is not easily accessed at the rear of the home. However, there is small area at the front of the house and a private park opposite the home to which the home has a key, and to which residents are regularly taken. The redevelopment that is planned to the rear of the building will include a garden area. Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 16 Cleanliness of the home has been an issue at previous inspections and while steps have been taken to address the matter, some improvement is still needed. However, the home is generally comfortable and reasonably well maintained and some areas have recently been decorated. Despite this there are still some areas around the home, including corridors and doorways, where the paintwork is scuffed and chipped. Several rooms were looked at and each was very different, reflecting the personality of the occupant and they contained many personal items. One resident told the inspector how her relative had ensured many items had been brought into the home from her previous house. Other residents told the inspector that their rooms were suitable to meet their needs. There is a range of aids and adaptations around the home, including grab rails, raised toilet seats and bath hoists. The home was generally clean and smelled pleasant throughout. However, there were some areas, especially bedrooms, that were very dusty and where the floors needed vacuuming, giving the appearance that the home needed a thorough ‘spring clean’. Also the trolley that teas were being served from was in need of a thorough clean, as were some of the chairs in the communal lounges. Laundry facilities at the home are not suitable, and the floor does not have an impervious covering, which could lead to infection control procedures being compromised. However, a new laundry is to be incorporated into the major extension to the home that is planned for the near future. Staff have received training in infection control procedures and said that disposable gloves and aprons were readily available if needed. Staff wear different coloured tabards when giving personal care or serving food. The care manager and the inspector discussed how the wearing of a new disposable apron for each new task, would improve infection control procedures. Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deployment and numbers of staff available throughout the day and night are sufficient to meet the needs of the current residents. The procedures for the recruitment of staff are now robust and offer full protection to residents. EVIDENCE: Staffing levels are suitable to meet the numbers and needs of current residents. Residents told the inspector that they did not have to wait very long for any help they may need. Discussions with staff indicated that they were very aware of the needs of the residents and said they are able to spend some time with them on a one to one basis. Residents were very complimentary about the staff, saying they ‘are always very good’ and ‘they are always pleasant, can always go to them’. Staff told the inspector and records confirmed that staff have received training in skin care, protection of vulnerable adults, fire practices, dementia and Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 18 medication administration. Staff are also encouraged to take NVQ’s, with five already having achieved this and four working towards them. When these four staff have achieved this, over 50 of the staff at the home will have an NVQ qualification. Two new staff have been appointed since the last inspection and their files were looked at. Both contained all the required information including two references and a satisfactory police check. The Commission had been made aware of concerns over one member of staff working on nights. This staff member had been employed prior to references being obtained from their previous employer. Following investigations by the home the staff member was dismissed. The home now ensures that staff do not start work at the home without all the required checks being undertaken. Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed resulting in practices that generally promote and safeguard the health, safety and welfare of the residents. EVIDENCE: Mr Morgan has owned the home for many years and he is supported by a care manager who has recently completed their RMA (Registered Managers Award). Staff were very complimentary about the care manager, feeling that she provided good support to them and encouraged them to work as a team. Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 20 The home has a variety of quality assurance systems in place, including occasional residents’ meetings, care plan reviews and checks on the quality of food provided. The home manages monies for several residents and uses the ‘Microsoft Money’ system to manage the TSB Residents’ Account. Three residents’ accounts were checked, all were appropriately maintained and had the correct money held in separate wallets. The pre-inspection questionnaire provided evidence that Pennsylvania House complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. So that the risk of burning from hot surfaces is minimised, there is a programme to ensure all radiators within the home are covered. In line with this programme one radiator has recently been covered. All windows above ground floor level are now fitted with restrictors, in order to minimise the risk of any resident falling from these windows. As yet, there is no date when thermostatic valves will be fitted to all taps, in order that the risk of scalding from hot water is minimised. The home is appropriately insured, with the current certificate expiring in November 2006. Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 21 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 X 3 X 3 X 2 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 3 3 3 X 3 X X 2 Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP7 OP19 OP26 OP38 OP38 Good Practice Recommendations You are recommended to ensure risk assessments for pressure areas are completed You are recommended to ensure the building is well maintained You are recommended to ensure all areas of the home and equipment is kept clean at all times You are recommended to ensure all radiators are guarded You are recommended to fit thermostatic mixer valves to all sinks that residents have access to Pennsylvania House DS0000022007.V307726.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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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