Inspection on 21/08/06 for Ridgeway Court

This inspection was carried out on 21st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Ridgeway Court 12/09/07

Ridgeway Court 23/11/05

Ridgeway Court 13/09/04

Ridgeway Court 12/07/04

Ridgeway Court 18/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Hollies & Bloomfield 2 Dudley Road Sedgley Dudley West Midlands DY3 1SX Lead Inspector Mrs Jean Edwards Unannounced Inspection 21st August 2006 08:20 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 The Hollies & Bloomfield DS0000024970.V308261.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. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies & Bloomfield Address 2 Dudley Road Sedgley Dudley West Midlands DY3 1SX 01902 883130 01902 665680 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) Midland Property Investment Fund Ltd Dorothy Fagan Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Voluntary removal of Categories of PD(E) and DE for a period of time to be agreed with CSCI. 23/11/05 Date of last inspection Brief Description of the Service: The Hollies & Bloomfield is a Care Home in two adapted properties, which have been linked via a connecting extension. The home provides 24-hour personal care for up to 39 older people, with general frailty (over the age of 65 years not falling into any other category). Previous registration categories for DE (Dementia) and PD/E (Physical Disabilities over 65 years) were removed following the announced inspection 12 & 13 July 2004. Thirty-six of the beds are provided within the two main buildings with a further three beds located in a flat accessed through a separate ramped entrance at the rear of the building. The stated intention of the management is to work towards running the two interconnected buildings as separate units under the direction of one registered manager. The flat is a semi-independent unit, with any residents accommodated accessing the home in the daytime and having access to staff at night via a call system. The Home is owned and managed by a Property Management Company and has a staff team of 35 people, including 22 care staff and 12 ancillary staff and a Registered Manager. A Director of the Property Company has been approved as the Responsible Individual with support from a Care Management Consultancy. The level of fees for this home is currently between £220.92 and £345.79 per week. This home does not charge top up fees. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first unannounced key inspection visit for 2006 - 7, undertaken by an inspector from the Commission for Social Care Inspection (CSCI), over two days for approximately 14.5 hours. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to make judgements and obtain evidence includes: discussions with the registered proprietor, registered manager, management consultant, acting team leader and staff on duty during the visit. Together with examination of records and documents and discussions with residents, relatives and district nurses. Other information was gathered before this inspection visit from the homes pre inspection questionnaire, reports of visits undertaken by the organisation’s care management consultants, notification of incidents, accidents and events, and an action plan submitted by the home following the unannounced inspection on 23 November 2005. Twenty service user surveys were sent to the home by the CSCI and an analysis of the 13 survey forms returned is contained throughout this report. Comments have been generally positive. There are currently 30 people at the home, including two residents in hospital. During the visit the inspector has spoken to the majority of residents. Longer discussions have taken place with the residents whose care was looked at in depth. Relatives, health professionals and other visitors have been asked for their views. Comments indicate that staff are friendly, helpful and welcoming. There has been a tour of the premises, including the grounds, the semiindependent flat, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and a sample of residents’ bedrooms, with their permission. What the service does well: The registered manager has introduced considerable improvements across all areas of the home, with support from the care management consultants and proprietor. The home provides comprehensive information for prospective residents and their representatives and in answer to the questions on the CSCI service user survey forms eleven responses indicate that they have received satisfactory information to help them make decisions about the home. There is up to date and easy to read information in newsletters about the home, the staff and the way care is provided. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 6 The meals are nutritious, well prepared and appear appetising. Members of care staff ask residents what they prefer for each meal and they take time to offer sensitive help if people need it. The residents are generally complimentary about the food, though further investigation of the mixed results of the CSCI service user survey is needed. The Hollies & Bloomfield is a generally clean, pleasant and comfortable home for residents. There is continuing investment in the decor, fixtures and fittings, with new furniture and equipment. The dining areas are very pleasant, attractive tablecloths, crockery and flower decorations. All 13 respondents to the CSCI service user survey indicate that the home is always fresh and clean. Comments include, very good and the bed is always nice and clean. Residents are very complimentary about the care and support from the manager and staff. In response to the survey question: do you always receive the care and support you need? 7 state - Always, 4 state Usually, 2 state sometimes with the comment: I have always found them helpful. In addition all 13 respondents state that staff always listen and act on what residents say. A new resident states, the staff here are very good and helpful. The manager and proprietor, together with the care management consultants, have introduced quality and monitoring systems across a number of areas of the home, including how care is provided, records and the environment. This inspection was conducted with full co-operation of the Registered Manager, Proprietor, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection? The manager successfully completed the CSCI registration process in February 2006 and her presence and professional development will greatly assist the home to stabilise and continue to achieve improvements. A key worker system has been introduced at the home, with each member of staff responsible for three or four residents, which improves individual care and promotes closer professional relationships. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 7 The way the home plans each persons care continues to improve. The written information is more detailed and specific and provides staff with clearer guidance. Health care assessments also continue to improve, with more detailed records of the measures in place to minimise risks of falls, risks involved in moving and handling people, or risks of people leaving the building unaccompanied. A small number of areas have been identifies as needing further improvement at this visit. The homes considerable efforts to improve the way medication is stored, administered and recorded have been continued with good results. There is a generally good system for the management of residents medicines. A small number of additional areas needing improvement have been identified at this visit. There are small but continuing efforts to provide meaningful activities for the residents and a number of residents have spoken of their enjoyment of a recent event, Kates Party an evening of entertainment purchased by the home from a professional entertainer. As a result the home received a telephone call during the first day of this inspection from a family who were so impressed they wished to donate an evening of entertainment and a buffet for the residents for later in the autumn. Independent advocacy information is now on display in the reception area of the home with contact numbers for Age Concern, Alzheimers Society and Dudley Advocacy. There are continuing improvements to the decor, furnishings and equipment throughout the home. Improvements are now swifter with the recent employment of a new handyman. Though discussions have taken place at this visit with the proprietor with a view to extending the maintenance team for this large property requiring constant and ongoing maintenance due to its age. The proprietor has engaged the services of specialist engineers to rectify the poor TV reception and has now provided large TVs and sound systems in the communal rooms. In addition he is in the process of providing small TV sets in residents bedrooms in accordance with their preference. The semi-independent flat for more mobile residents has been completely redecorated, refurbished and re-equipped to provide very attractive accommodation. The home is now almost fully staffed with a team of better trained, more competent and well motivated carers. The Home has achieved a ratio of 80 of care staff with an NVQ level 2 or above Award. The manager has introduced a formal system of supervision and staff development to provide staff with support and to make sure everyone is aware and is competent in their role. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 8 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 Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 9 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 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 10 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): 2,3,4,5 The overall outcome for this group of standards is judged to be adequate. There is an updated and expanded statement of purpose and service user guide and though there is some progress to update residents contracts / terms and conditions of occupancy a number of do not have contracts. This has the effect that some residents and their advocates may not have sufficient information regarding their rights and entitlements, any agreed restrictions and how care will be provided. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. The home actively encourages introductory and verbal evidence demonstrates that people have been given the opportunity and time to make decisions, which are right for them. This home does not provide intermediate care; therefore Standard 6 is not applicable. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 11 EVIDENCE: The home has a statement of purpose, which clearly sets out the objectives and philosophy of The Hollies & Bloomfield and this is supported with a service user guide, providing good clear information about the home. However there is currently no documentary evidence to demonstrate receipt of documents, which would be good practice. Recent CSCI inspection Reports and information about advocacy services are located in the reception area, together with copies of the homes regular newsletter. The home has people from different cultural and spiritual backgrounds and efforts are made to ensure that staff understand the needs and expectations of those residents, with training and guidance for staff to enable them to be responsive to residents individual needs. For example arrangements have been put in place for residents to attend church services at the home or receive visits from their priest, spiritual advisor or members of their pastoral community. There is evidence from discussions, the CSCI service user surveys and examination of records that a number of residents do not have a contract or statement of terms and conditions. The homes existing contract / terms and conditions needs to be reviewed to demonstrate compliance with published guidance from The Office of Fair Trading and the recently amended Care Homes Regulations (01/07/2006). The document needs to set out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the resident. Evidence from examination of residents records and discussions confirm that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident. The home supported by the care management consultants, uses comprehensive pre-admission assessment documentation, including a personal profile, which is generally well completed. Individual preferences are recorded such as rising, retiring, preferred newspapers, likes and dislikes. These need to be signed by the person or their nearest relative. In addition the profile indicates the persons physical condition, and medical history. Discussions have been held about the need to complete and submit a variation request to the CSCI for conditions of registration for existing residents outside the homes registration category. This requirement has been outstanding for more than 12 months and must be actioned as a priority. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 The overall outcome for this group of standards is judged to be adequate. There is improved care planning and monitoring in place, which provides staff with the information and guidance needed to adequately meet residents needs. There is good evidence of multi disciplinary working taking place on a regular basis, which results in the health needs of residents being appropriately met. The home has made generally very good progress with regard to the arrangements for administration of medication, which means residents are safeguarded. EVIDENCE: Each resident has a care plan, in the new care plan format and there is improved evidence showing good practice of involving residents in the development and review of the plan, though none of the sample of four care plans have signed by the resident or their representative. The plan in most cases includes essential basic information necessary to plan the individuals care and includes a risk assessment element. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 13 From examination of a sample of residents case files, some care plans have small omissions. Examples are missing areas from care plans where a resident is know to wander at night and will attempt to leave the home if not supervised and there is no documented guidance for the management regime for a resident who has a pressure sore and another who has severely inflamed lower limbs and is refusing to comply with treatment. It is stated that the GP has suggested hospital treatment but this is not the familys preferred option. Fuller records of the involvement of all heath and social care professionals are needed, together with further exploration of risks, all options available and agreed decisions. There are also residents with occasional behaviours, which are described as outbursts of anger and aggression and there are not always documented risk assessments or risk management strategies to guide staff as to how to deal with these situations. There is insufficient evidence of updating information and changing actions on care plans, risk assessments and health screening tools. For example following a fall, resulting in a hospital admission, on return to the home a residents entire daily routine has changed from relative independence, spending much of her time in her own bedroom. She is now highly dependent on care staff and she is cared for in a reclining chair the communal area of the home. The plan for this residents care has not been formally reviewed and updated since 28 June 2006. Although district nurses are dressing a sacral pressure sore there is no written plan or guidance for care staff to follow and although a pro pad pressure relieving mattress is in place on her bed, carers are not able to describe any other pressure relieving preventative measures. The majority of residents have good access to health care services to meet their assessed needs both within the home and in the local community. Some residents are able to choose their own GP within the limits of geographical borders and there is documentary evidence that people generally have access to dentists, opticians, and other community services, though access to NHS chiropody services can be problematic. There is evidence from records and discussions that generally each resident’s health is monitored and appropriate action taken. There is evidence in the care plans examined of health care assessments, screening treatment and intervention, and records of general health care information including weight monitoring, nutritional and tissue viability information. The home seeks professional advice on health care issues, acts upon it and generally is able to access the aids and equipment recommended. During the first day of this inspection visit the acting team leader took the opportunity to seek advice from a visiting occupational therapist regarding provision of a replacement shower chair for the fist floor bathroom. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 14 The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. There are currently two residents who wish to administer part of their own medication and there are appropriate, agreed risk assessments in place. Where medication systems are in need of action the registered person is working towards improvements. For example any specialist instructions for the administration of medicines such as Allendronic Acid 70mg and Risedronate Sodium 35mg administered weekly, Promazine administered PRN must be clearly documented as part of the medication regime in each persons care plan. From observations and discussions it is evident that staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms as desired. Discussions with residents indicate that are generally happy with the way that the staff deliver their care and respect their dignity. However a resident comments that whilst the majority of staff are helpful and attentive, some of the younger staff will say, in a minute - which turns into a much longer wait than a minute. The home has policies and procedures, which inform staff how they should handle dying and death. The wishes of residents about terminal care and arrangements after death have yet to be recorded as part of their case file. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The overall outcome for this group of standards is judged to be adequate. There is evidence of some progress to make planned and spontaneous activities available on a regular basis, which gives some residents some opportunities to take advantage of and develop socially stimulating activities. Residents are offered opportunities to exercise choice and control over their personal environment and lifestyle at this home. EVIDENCE: Residents at The Hollies & Bloomfield have the confidence to discuss what makes them happy and comment where improvements can be made. The proprietor and manager take residents feedback seriously and make changes where possible. Evidence from the service user survey forms indicate that staff listen to residents and make efforts to provide a flexible service, for a better quality of life. The manager and staff have growing confidence in the homes quality assurance system to confirm that practice reflects the policies, procedures and guidance. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 16 The home has a key worker system, which enables closer resident staff relationships where likes, dislikes and needs are shared. Key workers could use the information to plan activities, which residents will enjoy. There is a good understanding for the need to increase the level of activities and access to socialisation. There is evidence that some people prefer to spend their time on their own in their own bedrooms, with individual interests. These decisions are well understood, respected and supported by staff at the home. Recent and forthcoming activities are advertised on a notice board in the main corridor. It is evident that staff are enthusiastic about giving support to residents to enable them to participate in organised entertainments and trips. However results of the CSCI service user survey and discussions during this visit indicate that some people do not wish to participate in communal activities and are not entirely satisfied with the level or type of activities on offer. The home needs to continue to develop a system for identifying residents needs and preferences and display information in meaningful formats to bring attention to community events and activities. There is evidence that family and friends of the residents feel welcome and know they can visit the home at any time. It has been indicated that staff always make time to talk to visitors and share information with the agreement of the resident. Residents are able to have personal possessions in their room, but may be not always be able to bring certain items of furniture for example, due to space restrictions or health and safety considerations. There are inventories of residents personal possessions on the sample of files examined, however these are not always signed and dated by the resident or their representative. Residents enjoy the flexibility of meal arrangements and are able to eat in their own room if they wish. Regular drinks are available and staff are willing make drinks at any time. It has been observed that there are plentiful supplies of cool drinks, with easy access for residents, around the communal areas of the home. The food in the home is of good quality, well presented and generally meets the dietary needs of residents. The home has undertaken a documented audit of residents food preferences, and new revised menus are prominently displayed in the home, in suitable formats to the residents capabilities. The results of the CSCI service user survey about meals were variable and seem to indicate that not all residents are entirely satisfied with the meals. However all residents spoken to over the two day visit were complimentary about the food, which appeared appetising and served in an attractive way. Staff have training to help those residents who need help when eating and are sensitive in their approach. It has been recommended that consideration be given to the introduction on a trial basis of fresh fruit or vegetable juices and smoothies to encourage people to have their five portions of fruit or vegetables as part of a healthy diet. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The overall outcome for this group of standards is judged to be good. Residents and relatives generally feel complaints are listened to and action is taken to look into them, though action to make sure all residents are aware of the complaints process needs improvement. There are policies, procedures, guidance and progress in place and there is ongoing staff training to safeguard residents from abuse. Good progress continues to be made to improve arrangements for protecting residents. EVIDENCE: The home has complaints procedure displayed in the reception area and contained in the service user guide. Information supplied as part of the preinspection questionnaire indicates that the home has not received any complaints in the past 12 months. From the results of the service users survey, there are some people indicating that they are unaware of how to raise concerns or use the homes complaints procedure. The results need to be discussed with residents and relatives to make sure they have sufficient awareness and knowledge of procedures. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 18 The home has not received any recent allegations relating to abuse of vulnerable residents. There is a copy of the multi-agency procedures for the protection of vulnerable adults, Safeguard and Protect at the home. The homes policies and procedures regarding protection of residents are generally satisfactory and with the support of the care management consultants they have been reviewed and updated to be generally in line with regulations and other external guidance. The home does not yet have the recommended documentary evidence that all staff have been made aware and have been given time to read and understand the policies, procedures and guidance for the protection of vulnerable adults. Progress is being made to provide all staff with appropriate adult protection training. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26 The overall outcome for this group of standards is judged to be adequate. Significant and positive changes to the décor and furnishings continue to be introduced. The incremental improvements contribute to creating a pleasing and pleasant environment for residents to live in. EVIDENCE: The Hollies & Bloomfield now has a bright and cheerful interior and there have been some improvements to the exterior of the premises, and a complete refurbishment of the semi-independent flat. The grounds to the home require some attention and ongoing maintenance to control the weeds. The tour of the building identified that a number of improvements have been made and the program of redecoration and refurbishment is continuing, with a number of requirements for repairs and redecoration issued at the last inspection acted upon. For example a number of residents bedrooms have been redecorated and refurbished with attractive new furniture and fittings. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 20 Although the home has a new enthusiastic handyman and there is documentary evidence of a reactive maintenance schedule, there has not been a full audit of the home from which a prioritised programme of repairs, redecoration and replacement of equipment has been devised. This previous requirement must be implemented, incorporating the redecoration of residents bedrooms within an identified timescale. The considerable effort and expenditure is acknowledged, however due to the age and size of the premises additional resources / personnel may need to be provided to make the workload of the tasks manageable. Not all residents bedrooms have been provided with lockable space and not all residents have two comfortable chairs in their bedrooms. Discussions and decisions need to be reviewed and documented. There are improvements to the overall cleanliness of the home and bathrooms are now monitored more closely to ensure they are generally free from clutter or items, which may be used communally. Cleaning schedules are in place for bedrooms, bathrooms, and kitchen. It is noted that the laundry and kitchen areas are generally well organised and tidy, though additional monitoring of the cleaning schedules in these areas is needed. During discussion was residents indicate that they are comfortable, the home is clean, warm, generally well ventilated, and well lit. There are a number of spacious communal rooms and residents are able to generally sit where they wish, though some people are protective about their own personal space. There are a number of additional areas needing improvements identified at this visit, some examples are: Explore measures to ensure that the doorbell and nurse calls are appropriately audible to staff in all locations Make safe worn joins in the Hollies first floor corridor carpet as an interim measure and identify a timescale for replacement Undertake an audit of commodes and renovate any metal frames with corrosion to ensure effective infection control measures and replace any commodes in a poor state of repair, for example with torn seats or exposed foam Replace the light cover and investigate and resolve the noisy extractor fan in bathroom 47 and undertake a regular documented audit of extractor fans in bathing and toilet facilities, with remedial action taken In the Hollies first floor shower / hairdressing room 1) replace the shower chair with appropriate appliance, with advice from O/T; replace the loft hatch; remedy large aperture in the ceiling; rectify the defective light and extractor fan and replace tiles by hairdressing sink The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 21 Prioritise the redecoration of bedrooms 23, 24 and the recently vacated bedrooms Provide residents in rooms 11 and 34 with a key for bedroom doors, at an accessible height Rectify the defective double glazed window in the bedroom shared by a married couple The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The overall outcome for this group of standards is judged to be good. Staff morale continues to improve resulting in good attendance, diligence and less reliance on staff working in excess of contracted hours or use of agency staff, which means that residents generally receive a consistent and satisfactory service. Improved recruitment and selection of suitable, competent staff provides good safeguards for vulnerable people living at this home. The home continues to demonstrate a strong commitment to staff training and development. EVIDENCE: There are currently 30 residents accommodated, including 2 people temporarily in hospital. The residents have a variety of dependency levels and some have diverse and complex needs. Assessment of staffing rotas show an improvement in staffing levels, both in terms of numbers and stability. The manager with support from the care management consultants is able to regularly identify residents dependencies and occupancy levels and regularly reviews staffing levels, making appropriate adjustments. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 23 The home is now staffed with a revised staff team, comprising 3 team leaders, 4 senior carers (days), 2 senior carers (nights), 14 care assistants and 11 ancillary staff. Assessment of the staff rota shows a team of 6 / 5 carers, including a competent trained senior / team leader on each wakeful day shift and one senior carer plus 2 carers on night shifts. Assessment of the pre-inspection questionnaire submitted, staff files and staffing rotas during the visit show that 5 staff have left the homes employ, since the last inspection visit in November 2005 and 2 new senior care assistants, 2 new carers and a handyman have appointed. There are considerable improvements to the documentation and management of staff personnel files. Generally robust recruitment processes are in place and there are a small number of improvements needed as a result of this visit. For example there are only 2 verbal references on a new care assistants personnel file. The registered person must obtain 2 satisfactory written references prior to agreeing employment at the home. None of the sample of four new staff files contained a recent photograph. There is evidence of good practice where the manager ensures there are copies of interview questions and answers on each persons file and she signs and dates photocopies of qualifications held on file to evidence that originals have been seen. There is evidence that 19 of the 22 care staff have achieved an NVQ level 2 care award, with new candidates about to be registered. This means that the home is now able to demonstrate that it exceeds the ratio of 50 of care staff with an NVQ 2 (or equivalent) award, with a ratio of 86 , which is commendable. The manager demonstrates a strong commitment to staff training and development, together with support measures such as a system of structured staff supervision. An acting team leader has discussed her experience of supervision, finding it useful and supportive. The homes training plan and individual staff training profiles have not been seen at this visit and the proprietor has agreed to send documentary evidence to the CSCI office, Halesowen. During discussions it is evident that staff are knowledgeable about what residents needs are and how to meet them and there is a warm rapport with both residents and visitors. Staff spoken to generally feel that morale is improving and that they are aware of their responsibilities, what is expected of them. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 24 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): 31,32,33,34,35,36,37,38 The overall outcome for this group of standards is judged to be good. The Registered Manager, supported by the Care Management Consultants and Proprietor, provides good leadership and direction. The communication and monitoring systems are effective and ensure that staff are clear about their roles and responsibilities. The continued improvement in the standards of record keeping and health and safety compliance at this home improves protection for residents from risks of harm. EVIDENCE: Dorothy Fagan, appointed in October 2004, became the Registered Manager, after successfully completing the CSCI registration process on 7 February 2006. She continues to provide leadership and encouragement to implement ongoing improvements, supported by the Care Management Consultancy NRF and Matthew Hughes, a director and the Responsible Individual for the organisation. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 25 There is verbal evidence to demonstrate that residents and their families are actively involved in processes affecting the way they are supported or cared for, such as assessments and care planning. There is evidence that residents meetings take place, and formal systems have recently commenced to regularly seek, collate and evaluate peoples views about the homes performance. The home is making progress to introduce an effective quality assurance system, which includes feedback from residents and relatives, stakeholders in the community, and in which staff feel they have ownership. Staff and residents meetings take place regularly, with minutes available. Progress has been made to produce an up to date annual development plan, which is to be submitted to the CSCI. The care management consultants (RNF) make the required visits to the home and reports of monthly unannounced visits relating to the conduct of the home are made available to the home, registered proprietors and the CSCI office, Halesowen. It is recognised that it is particularly important for the home to receive monitoring, feedback and support for its continued improvement to achieve satisfactory compliance with required standards and for the CSCI to be kept informed between inspection visits. Residents have the opportunity to manage their own money if they wish, and some facilities are provided to help keep it safe. Where the home manages money on residents’ behalf a system is in place to record transactions and accounts for spending. The home holds monies in temporary safekeeping for a number of residents and operates sound financial systems to protect residents monies held in temporary safekeeping. The random assessment of a sample of health and safety and service maintenance records examined shows that they are generally satisfactory. A number of minor improvements are needed and copies of records not available are to be forwarded to the CSCI office, Halesowen. There is evidence that efforts are continuing to improve the standard of record keeping at this home, with positive results. There have been 69 recorded accidents involving residents since January 2006. An analysis and evaluation of accidents involving residents and staff is conducted on a monthly basis. It is recommended that that the format be expanded to record trends and control measures. The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 26 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 X 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 2 X 2 2 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 2 2 3 2 2 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(1-6) Timescale for action 1) To review the contract / terms 01/11/06 and conditions taking account of the revisions to the Care Homes Regulation 5 and the publication from the Office of Fair Trading relating to Contracts and terms & conditions in Care Homes 2) To ensure that there is a copy of an up to date, signed and dated contract / terms and conditions on each residents case file The registered person / manager must carry out an assessment of all service users’ primary need where there is doubt as to whether they are within the homes categories of registration, and if appropriate apply for a variation to the certificate of registration. (Timescale of 17/09/04 and 31/08/05 and 01/02/06 Not Fully Met) This must now be actioned as a priority The registered persons must ensure that any residents accommodated in the flat are fully independently mobile DS0000024970.V308261.R01.S.doc Requirement 2 OP4 Act 2000 S24 14(1) 01/10/06 3 OP4 14(1) 23(2) 01/10/06 The Hollies & Bloomfield Version 5.2 Page 28 4 OP7 15(1) To ensure that service user plans 01/10/06 are developed in consultation with each person and / or their representative, to include aspects such as: 1) Full details of all care provided to meet assessed identified needs (Improved but Timescale of 30/09/04 and 31/08/05 and 01/02/06 Not Fully Met) 2) Specific guidelines for staff regarding care to be provided (Improved but Timescale of 30/09/04 and 31/08/05 and 01/02/06 Not Fully Met) To ensure that the service user plan is (consistently) signed by the service user and / or representative (Timescale of 30/09/04 and 31/08/05 and 01/02/06 Not Fully Met) To ensure that there is a photo on each residents case file To devise and implement a risk assessment re BW wandering and attempting to leave the building 1) To ensure care plans are reviewed at least monthly and more frequently as needs change and dependencies levels increase 2) To review and accurately record changes to daily routines and activities as changes such as deteriorations occur in residents health, for example HB To ensure risk assessments, tissue viability and nutritional screening assessments are reviewed on a regular basis and especially when needs change or increase. 5 OP7 15(1) 01/10/06 6 7 OP7 OP7 17(1)(a)2 15(1) 01/10/06 01/10/06 8 OP7 15(1) 17(1) 01/10/06 9 OP8 13(1) 17(1) 01/10/06 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 29 10 OP8 13(1) 17(2) Sch 4 11 OP8 13(1) To ensure records are maintained to provide evidence of an adequate nutritional food intake on a daily basis (Timescale of 14/10/04 and 31/08/05 and 01/02/06 Not Fully Met) 1) To record full details of the district nurses involvement in care plans 2) To include care of pressure sore as part of care plans 01/10/06 01/10/06 12 OP9 13(2) 13 OP9 13(2) 3) To record discussions and decisions with the family of EW relating to ongoing care and acceptable risks, also to be agreed as part of a review with the social worker To ensure the night medication 01/10/06 Temazepam for CP is not administered in the main home, when he has to mobilise to his room in the flat 1) To record individual guidelines 01/10/06 in care plans for the use of any PRN medication, specially used for sedation or calming 2) To ensure that Allendronic Acid 70 mg and Risedronate Sodium 35mg weekly are administered strictly in accordance with written instructions with immediate effect; that is to be taken half an hour before food, drink or other medication with a full glass of water and that the resident remains sitting upright / standing for half an hour following administration 3) To ensure any specialist instructions for the administration of medicines is clearly documented as part of The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 30 the medication regime in each persons care plan 4) To clarify any as directed dosages with the prescriber or the pharmacist 5) To implement records of the administration of Thick & Easy 6) To update the MAR sheets with residents date of birth and any allergies 7) To ensure any homely remedies brought into the home for residents have documented ratification from their GP 8) To ensure any medication, creams etc in residents bedrooms are stored securely To initiate sensitive discussions with residents and / or their representatives about their final wishes and arrangements, to be recorded as part of individual plans The registered person must continue to ensure that the activities made available to service users are flexible, varied and in accordance with service users expectations, preferences and capacities. (Timescale of 31/11/04 and 30/09/05 and 01/02/06 Not Fully Met) 1) To undertake a documented audit of residents preferences, from which a planned programme of group and individual activities must be devised and advertised in appropriate formats to encourage participation 2) To identify designated staff to be responsible for each activity 14 OP11 12(1) 01/11/06 15 OP12 16(2) 01/11/06 16 OP12 16(2)(n) 01/11/06 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 31 17 OP14 13(6) 18 OP14 13(6) 19 OP18 13(6) 18(1)(c) 3) To implement weekly activity planners for each person and record planned and spontaneous activities, with evaluations and refusals recorded To ensure property inventories of 01/10/06 service users property are drawn up on admission and thereafter kept up to date. (Timescale of 31/10/04 and 31/08/05 and 01/02/06 Not Fully Met) To ensure items such as hearing 01/10/06 aids are included on inventories (Timescale of 01/02/06 Not Fully Met) To provide all staff with 01/11/06 awareness / training relating to: Restraint / non-physical intervention from an accredited trainer (Timescale of 31/10/04 and 31/10/05 and 01/02/06 Not Fully Met) 1) To establish a written maintenance and refurbishment programme. To forward a copy to the CSCI. (Timescale of 31/10/04 and 31/10/05 and 01/02/06 Not Fully Met) 1) To renovate / redecorate damaged areas of main corridors, skirting boards, doors, providing measures to protect high maintenance areas though out the home (Timescale of 31/10/05 and 01/02/06 Not Fully Met) 2) To rectify the exposed threshold strips in The Hollies lounge and Bloomfield divided lounge and corridors (Timescale of 31/10/05 and 01/02/06 Not Fully Met) 3) To provide a call point in the Bloomfield lounge (Timescale of 31/10/05 and 01/02/06 20 OP19 23(2(a(b) (c)(e) 01/10/06 21 OP19 23(2(a)b) (c)(e) 01/11/06 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 32 Not Fully Met) 4) To devise a written risk assessment as an interim measure and means of monitoring need for call point in Bloomfield lounge (Timescale of 31/10/05 and 01/02/06 Not Fully Met) 1) To explore measures to ensure that the door bell and nurse calls are appropriately audible to staff in all locations 2) To ensure grounds are maintained to be tidy and well maintained and as far as possible weed free 3) To make safe worn joins in the Hollies first floor corridor carpet as an interim measure and identify a timescale for replacement 1) To undertake an audit of commodes and renovate any metal frames with corrosion to ensure effective infection control measures 2) To replace any commodes in a poor state of repair, for example with torn seats or exposed foam 3) To replace the light cover and investigate and resolve the noisy extractor fan in bathroom 47 4) To undertake a regular documented audit of extractor fans in bathing and toilet facilities, with remedial action taken 5) To ensure all bathing facilities are free from extraneous clutter and available and accessible for residents use The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 33 22 OP19 23(2) 01/10/06 23 OP21 23(2) 01/10/06 24 OP21 23(2) To undertake the following in respect of the bathroom / hairdressers room in The Hollies 1) Replace the shower chair with appropriate appliance, with advice from O/T 2) Replace the loft hatch 3) Remedy large aperture in the ceiling 4) Rectify the defective light and extractor fan 5) Replace tiles by hairdressing sink 1) To prioritise the redecoration of bedrooms 23, 24 and the recently vacated bedrooms 2) To provide residents in rooms 11 and 34 with a keys for bedroom doors, at an accessible height 3) To provide lockable space and keys for all residents bedrooms 4) To accurately identify on bedroom audits where all specified facilities are not provided, with reasons and residents / representatives documented agreement with decisions 5) To renovate the vanity unit in bedroom 4, including replacement of missing door handle 6) To rectify the defective double glazed window in the bedroom shared by a married couple To check the maintain for the Alpha-Excel pressure relieving mattress in room 11 and ensure DS0000024970.V308261.R01.S.doc 01/11/06 25 OP24 23(2) 01/10/06 26 OP24 13(4) 23(2) 01/10/06 The Hollies & Bloomfield Version 5.2 Page 34 27 OP26 13(3) 16(2) 23(2) 13(3)16(2 )23(2) 28 OP26 compatibility with residents bed The laundry walls must present a 01/10/06 readily cleansable surface. (Improved but Timescale of 31/10/04 and 31/10/05 and 01/02/06 Not Fully Met) 1) To devise and implement a 01/10/06 risk assessment and control measures for manual sluicing (where this cannot be avoided) (Timescale of 31/10/04 and 30/09/05 and 01/02/06 Not Met) 2) To devise and implement clinical waste guidelines and a documented risk assessment (Timescale of 31/10/04 and 30/09/05 and 01/02/06 Not Fully Met - needs further expansion) To expand staff rotas to include: 1) Service user dependencies and occupancy levels (or provide alternative means for this information) 2) Total hours worked by each person 3) Total care hours provided each week 4) Managerial hours 5) Catering hours 6) Domestic hours 7) Laundry hours (Timescale of 30/09/04 and 31/08/05 and 01/02/06 Not Fully Met) 29 OP27 18(1)(a) 01/10/06 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 35 30 OP29 17(2) Sch 2&4 19(1) 17(2) Sch 2&4 19(1) 31 OP29 To provide recent photographs of 01/10/06 newly employed staff on their personnel files (Timescale of 01/02/06 Not Fully Met) 1) To ensure job application 01/11/06 forms and health declarations are dated 2) To ensure that two written references are received and on file before any member of staff commences employment at the home 3) To ensure that there is a copy of the hairdressers POVA/CRB clearance on file 4) To ensure that there are copies of the private Chiropodists qualifications, public liability insurance and POVA/CRB clearances All staff (continue to) receive training appropriate to the work they are to perform, this to include: - Restraint (Physical / nonphysical intervention (Timescale of 31/10/04 and 31/10/05 and 01/02/06 Not Fully Met) The registered person must ensure that the policy relating to Clinical Procedures (12) is amended so that it does not indicate the home undertakes clinical procedures To forward copies the following to the CSCI office, Halesowen 1) The annual development plan for the home 2) The collated results of the homes service user surveys 32 OP30 18(1)(c) 23(4) 01/11/06 33 OP33 17(2) 01/10/06 34 OP33 24 01/11/06 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 36 3) The collated results of the homes relatives surveys 4) The collated results of the homes stakeholder surveys To ensure that an up to date 01/10/06 copy of the homes public liability insurance is displayed at all times 1) To confirm with the homes 01/11/06 insurers the maximum amounts of residents monies, which may be held in the homes safe (Timescale of 01/02/06 Not Fully Met) 2) To encourage residents / or their representatives to place any large amounts of money in appropriate bank accounts (01/02/06 Not Fully Met) * To send documentary evidence of compliance to CSCI office, Halesowen To remove any written information containing personal / sensitive information from public view and ensure all information is handled and stored in compliance with the Data Protection Act 1998 To provide documentary evidence that approved risk assessment awareness training has been arranged for all staff to be delivered within an identified timescale. (Timescale of 31/10/04 and 27/07/05 and 01/02/06 Not Fully Met) To improve food safety in the following areas 1) To ensure the microwave oven is thoroughly cleaned after every use, especially roof interior 2) To monitor thorough cleaning The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 37 35 OP34 17(1) 25 24 36 OP35 37 OP37 17(1) 01/10/06 38 OP38 13(4) 18(1)(c) 01/11/06 39 OP38 13(4) 23(2) 01/10/06 of all areas of kitchen is carried out in accordance with kitchen cleaning schedule 3) To ensure all mop-heads are laundered daily at thermal disinfection temperatures (95c) 1) To undertake a regular documented audit of fire doors, ensuring their integrity and ability to close properly into their rebates, as a priority 2) To rectify the fire doors with deficits identified during this inspection, especially bedrooms 23 and 24, as a matter of priority 3) To provide magnetic door closers linked to the fire alarm system and approved by West Midland Fire Service for residents wishing to prop open their bedroom doors 4) To replace cracked window pane in fire door on first floor of The Hollies 1) To make appropriate arrangements for electrical items brought into the home by residents / relatives to be PAT tested in a timely manner 2) To ensure the overdue service of the nurse call systems is undertaken, with a copy of the service certificate forwarded to the CSCI office, Halesowen 3) To undertake regular documented visual checks of - Hoists & slings - Wheelchairs 40 OP38 13(4) 23(4) 28/08/06 41 OP38 13(4) 01/10/06 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 38 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that residents or representatives signatures are obtained for receipt of their copies of the homes statement and purpose, service user guide and complaints procedure That a summary sheet be devised and implemented to record required personal care has been provided or refused It is recommended that consideration be given to the introduction on a trial basis of fresh fruit or vegetable juices and smoothies to encourage people to have their five portions of fruit or vegetables as part of a healthy diet. That staff signatures are obtained to demonstrate their awareness of the local authorities multi-agency procedures for the protection of vulnerable adults Any incidents involving violence against staff should be documented on separate violence at work forms as well as the accident records. It is recommended that staff signatures be obtained to demonstrate their awareness of the homes policy. That strategies are used to explore the comments made by some residents on the CSCI service user survey forms, indicating not everyone is satisfied with aspects of the service such as staff availability, activities, meals and awareness of complaints procedure Residents or their representatives should sign the printed statements to acknowledge their awareness of their rights to access their records. 2 OP7 3 OP15 4 OP18 5 OP18 6 OP33 7 OP37 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 39 8 OP38 That consideration be given to the issue of security of the clinical waste receptacle, which should be locked be held in a secure area. That the accident analysis is expanded to show any trends and record any identified control measures. That copies of the infection control guidance issued June 2006 by the DoH be obtained and used to expand the laundry procedures and infection control guidance for staff That information be obtained from Environmental Services regarding new legislation (Jan 2006) relating to food safety 9 10 OP38 OP38 11 OP38 The Hollies & Bloomfield DS0000024970.V308261.R01.S.doc Version 5.2 Page 40 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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