Inspection on 19/02/08 for Pentlow Nursing Home

This inspection was carried out on 19th February 2008.

CSCI found this care home to be providing an Good service.

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

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 Pentlow Nursing Home 59-63 Summerdown Road Eastbourne East Sussex BN20 8DQ Lead Inspector Elizabeth Dudley Unannounced Inspection 19th February 2008 10:00 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 Pentlow Nursing Home DS0000071386.V358090.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. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pentlow Nursing Home Address 59-63 Summerdown Road Eastbourne East Sussex BN20 8DQ 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) 01323 722245 01323 649518 pentlow@canfordhealthcare.co.uk www.pentlow.co.uk Pentlow Nursing Home Ltd Mrs Lesley Helen Wicks Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with Nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) 2. Physical Disability - (PD) The maximum number of service users to be accommodated is 61. Date of last inspection New service Brief Description of the Service: Pentlow Nursing Home incorporates Summerdown Nursing home, these are separate buildings across the road from each other but have a single registration and work as one nursing home. The home recently changed ownership and is now owned by Pentlow Nursing Home Ltd, which is part of Canford Health Care plc. The Pentlow and Summerdown Nursing Homes are in the Old Town of Eastbourne, and local buses pass the top of the road, there is ample parking in the roads around the nursing homes and limited car parking in the forecourts of both homes. All catering and social activities are shared by both homes, although they have the same manager over both of them, they are staffed separately. Pentlow Nursing home has accommodation for thirty-eight residents and also accepts people for day care; Summerdown Nursing home has accommodation for twenty-three residents. Both homes have a range of double and single rooms, a separate dining room and lounge and large accessible gardens. Fees charged at present range between £500 and £960 per week. Extra services including chiropody, hairdressing, telephone and newspapers are charged separately and this information is available from the home. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key unannounced inspection took place on the 19th February 2008 over a period of eight hours and was facilitated by the appointed manager, Mrs Lesley Wicks. The Summerdown and Pentlow nursing homes are registered as one home and are under the same manager. This inspection report incorporates both homes and unless there is an issue specific to one home, will be referred to as ‘ the home’ or ‘the service’ throughout this report. This also applies to any requirements that may be made. Methods used to collect information about the home included examination of documentation in the home, observation of staff working with residents, the serving of lunches and conversations with residents, staff and visitors to the home. All residents were spoken with during the inspection, and six residents were spoken with in depth and gave their views on life in the home. A visiting relative commented on his satisfaction with the care received by a member of his family resident in the home. During the course of the day a general practitioner was visiting the home, he made positive comments about the care given and the communication from staff regarding the residents. Documentation examined included care plans, personnel files, staff training and supervision records, catering records and health and safety files. Prior to the inspection questionnaires were sent out to relatives, residents and staff. Of these, five were returned from residents. These gave information about the daily life in the home and helped to inform the judgements made in this report. Thanks are extended to those people who responded. The Annual Quality Assurance Assessment, required by the CSCI, which gives an overview of what has been achieved in the home and issues to be addressed, had not yet been received by the home; therefore this was unable to be referred to at this inspection. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 6 Comments from residents included ‘ The care here is very good, I am pleased with it’. ‘ The food is lovely and you get a good choice’. ‘ Staff are very kind but are so busy they don’t have a lot of time to chat to you, but they are always cheerful’. ‘ There is a good range of activities and lots of outings’. What the service does well: What has improved since the last inspection? This is the first inspection since the new provider purchased the home. A programme of redecoration is currently taking place with communal areas and corridors being redecorated. An office for the manager has been completed and some new carpets put in place. There have been six new variable height nursing beds purchased (profiling beds) and there are more being ordered. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 8 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 Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6. People who use the service experience adequate quality outcomes in this area The information given to prospective residents is sufficient to enable them to determine whether the home can meet their needs and expectations, but is not necessarily relevant to the current provider. Residents receive a thorough preadmission assessment to ensure that the home is able to give the care that the resident requires. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide have not yet been completed by the provider, therefore residents in the home and prospective residents are still receiving the information relevant to the past provider. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 10 Residents have not received a new contract or Terms and Conditions relevant to the new provider. A funding agreement is given to the resident prior to their admission to the home and this is in place for two weeks until the trial period is complete Prospective residents are assessed by the manager to ensure that the home can meet their needs. Four of preadmission assessments were seen and were comprehensive. Prospective residents and their representatives can visit the home for tea or to look around the home prior to deciding whether the home is the right one for them. All residents are admitted for an initial trial period. The home does not admit residents for intermediate care. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. People who use the service experience good quality outcomes in this area The delivery of personal and health care to the residents in the home is informed by comprehensive and regularly reviewed care plans. Regular visits from General Practitioners and other health care professionals ensure that the care given is in line with current research. The standard of medication administration generally safeguards the residents in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six care plans were examined, three in each home. The care planning process is computerised but hard copy of these care plans are also in place. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 12 Care plans addressed the care needs of the residents including nutritional, wound care, moving and handling and personal care. These were comprehensive but would benefit the care staff if more instructions in delivery of care were included. The care plans in the Summerdown part of the home were more comprehensive than those of the Pentlow, with staff saying that due to the Pentlow admitting residents with more complex needs and day care residents, that they did not have sufficient time to do the documentation and deliver the care at its present standard. All care plans had been reviewed regularly and there was evidence of consultation with either the residents or their representatives. Risk assessments around some areas of nursing care particularly bedrails require expanding. There was evidence of involvement with other health care professionals including the tissue viability specialist nurses and staff receive updating in tracheotomy care, enteral feeding, and other training relevant to the care specialisations in the home. The home has a retained General Practitioner, which ensures that all residents are visited on a regular basis and problems are dealt with in a speedy manner. Residents appeared well cared for and all of those spoken with were satisfied with the standard of care received. A General Practitioner visiting the home was spoken with and he stated that the standard of the nursing and personal care given by the home was very good and that communication from the nursing staff was good. A recent audit of the beds and chairs by the tissue viability specialist nurse has resulted in the home ordering some more profiling nursing beds. All medication was signed for following administration and medications were administered in a manner that safeguards the residents. Staff must state the reason for why specific medications have not been given and also external medication such as prescribed creams and eye drops, should be signed by the accountable member of staff. Medications are now being audited regularly and the home must be vigilant over this. The storage and recording of controlled drugs meets the regulations. The home cares for residents requiring terminal care and are in the process of implementing the Gold Standards Framework with a view to continuing to the Liverpool care pathway. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 13 All residents being nursed in bed appeared comfortable and there was evidence of the nursing interventions taking place. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. People who use the service experience excellent outcomes in this area. The quality of life offered to residents in the home meets their expectations. The provision of activities is varied, includes outings to places of interest and is tailored to include activities relating to residents specific interests. Residents benefit from a choice of well presented, nutritious and balanced meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Activities within the home are varied with residents benefiting from the employment of an activities coordinator and from entertainers and craft and art providers visiting the home. The home has its own minibus and the programme of activities and outings extends to the weekends. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 15 There is an activities programme in place and a monthly social calendar is given to all residents. There is some time set aside for the activities person and volunteers to spend time with residents who are in their rooms. One resident said that they would like more books to read available and this was discussed with the manager, another resident in the Pentlow said that sometimes they had to miss a specific activity due to there not being sufficient staff to ensure that they got down to the lounge. Visitors are able to visit at any time and are also included in the various functions and meetings held by the home. Ministers of religion visit the home and services are held. These can also be held on a private basis for individuals that prefer this. Residents spoken with said that they could choose their times of rising and retiring and that they were helped to live the life they choose. One resident said ‘ we can do what we like when we like, but have the help to do it if we need it’, another said ‘ there are no rules here. It’s the next best thing to being in your own home’. The standard of catering is good, all meals offer several options on the menu and medical diets are catered for. All residents spoken with said that the food was good and that they had choices. Meals, including liquidised meals were well presented, the size of portions was more than adequate and there was evidence of fresh fruit and vegetables being used. Cooked breakfasts are always available and residents and staff said that snacks and drinks were available during the night. Residents are offered wine with the meals. The home has sufficient catering staff to provide meals for both homes and also for the meals that are provided in the community. All catering staff said that the provision of meals in the community did not impinge on those in the home. Meals are served out by catering staff in the kitchenettes and all catering staff and the majority of care staff have the food hygiene course. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience good quality outcomes in this area Residents and visitors to the home are confident that any complaints they may have would be addressed in a professional and transparent manner. Staff are aware of their responsibilities towards those in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and this is displayed in the corridor and included in the Service User Guide. The home has had no complaints since being registered under the new owner, but has had some minor concerns. It is recommended that details of these are recorded, together with the actions taken to address them. Residents and visitors spoken with were aware of how to make a complaint and were confident that these would be addressed in a professional and transparent manner. The adult safeguarding procedure in the home requires amending to ensure that the reporting protocols are in line with the national ‘multi–agency guidelines’. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 17 All staff receive training about adult safeguarding on an annual basis and staff spoken with were aware of their responsibilities towards those in their care. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22 24,25,26. People who use the service experience good quality outcomes in this area The environment provides an attractive, clean and well-maintained home for those that live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both the Summerdown and Pentlow homes were well maintained and pleasantly decorated with easily accessible gardens. Pentlow is in the process of being redecorated at present. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 19 Both homes have spacious lounges and separate dining rooms, all floors are accessible by shaft lift and both have a range of equipment including ramps, grab rails, assisted baths and variable height beds and pressure relieving mattresses. Resident’s rooms are comfortable and made homely by the addition of residents own possessions. All rooms have a lockable drawer and locks are fitted to the doors if a resident wishes for this and it is supported by a risk assessment. All windows above ground floor have restricted opening but in some cases these were opening above the recommended width. The manager has asked the maintenance person to adjust these. The temperature of the hot water delivered to residents outlets is not being monitored on a regular basis, although all controlled by thermoregulatory valves. Care staff test the temperature of bath and shower water with a thermometer prior to the resident using the water, but no records are kept at present. The manager said that water temperature monitoring and records will commence immediately, therefore no requirement was made, but this will be followed up at the next inspection. The home was very clean and there were no odours apparent. Staff receive training in infection control and the manager liaises with the Health Protection Agency to ensure that policies are up to date and correct procedures are being followed. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. People who use the service experience good quality outcomes in this area. The number of staff on duty is not always sufficient to deliver the care required by the numbers of residents with complex needs that are living in the one home. Staff receive sufficient training to deliver a standard of care that meets residents expectations. Residents are safeguarded by robust recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Summerdown has sufficient staff on duty over a twenty-four hour period to meet the needs of the residents in the home. Care plans and other documentation was well recorded, there was a relaxed and calm atmosphere in the home. However the residents at Pentlow are of a high dependency and some are admitted under the ‘continuing care scheme’. There are also two residents coming in for day care which existing staff care for. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 21 The staff appeared rushed and busy both morning and afternoon, and although residents appeared well cared for, the documentation was not as up to date as Summerdown. In view of the high care needs of the residents in Pentlow, staffing ratios need to be flexible and to be led by the dependency of the residents rather than by numbers of residents alone, and a requirement has been made. Seventeen (51 ) members of staff have the National Vocational Qualification level 2 or 3 in care with more staff being encouraged to participate in this training. Staff are encouraged to participate in other training relevant to the needs of the residents and the training matrix showed that all grades of staff attend a variety of training days, which includes stroke care and sensory loss, Parkinson’s disease and dementia training. All staff undertake supervised practice and an induction training on commencement of work at the home, this includes mandatory training and ongoing training in line with the nationally recognised induction training. Registered nurses undertake the home’s induction course. All staff have mandatory training at the required intervals. Six personnel files were examined and these included all documentation and checks as required by regulation. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37, People who use the service experience good quality outcomes in this area Management systems within the home safeguard the residents and ensure that the home is run in a manner that meets their needs and expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has sufficient qualifications and experience to ensure that the home is run in a manner that meets the expectations of the residents. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 23 Yearly surveys are sent to residents and their relatives to monitor the quality of the services offered by the home, results are collated and used to change practice if required. Residents meetings are held three monthly. Regular staff meetings take place, but formal supervision of staff has not been taken place at regular intervals as directed by the standards and the manager said she would address this. Regulation 26 visits take place on a monthly basis. The audited finances of the home were examined when the home was registered to the new owner six months ago; therefore this was not examined at this inspection. The home does not act as appointee for any residents but keeps small amounts of money for residents, records were seen and were in order. All certificates relating to the servicing of utilities, equipment and fire protection were up to date. Staff have received mandatory training in health and safety matters. It is recommended that keypads be provided on the kitchenettes and the staff and laundry area to protect residents. The manager gave assurances that the other matters relating to residents health and safety, which have been identified in the appropriate sections of the report, would be addressed within the week following the inspection. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 3 2 3 STAFFING Standard No Score 27 2 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 2 3 3 Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 OP2 Regulation Reg 4&5 Requirement The registered provider to produce a Statement of Purpose, Service User Guide, Terms and conditions and contract which correctly reflects the current status of the home. That the registered person ensures staff are employed in sufficient numbers to meet the needs of the service users in the home. Timescale for action 20/04/08 2 OP27 Reg 18(1)(a) 20/03/08 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 OP18 3 OP38 Refer to Standard OP9 Good Practice Recommendations That external medications are signed following administration by the accountable member of staff. That the policy regarding the reporting of abuse and safeguarding adults is reviewed to be in line with the multi agency guidelines. That a means of restricting access to staff rooms and DS0000071386.V358090.R01.S.doc Version 5.2 Page 26 Pentlow Nursing Home laundry is put in place. Pentlow Nursing Home DS0000071386.V358090.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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