Inspection on 21/06/05 for Rosebery House

This inspection was carried out on 21st June 2005.

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 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

Rosebery House 27/10/08

Rosebery House 01/05/08

Rosebery House 03/05/07

Rosebery House 10/04/06

Rosebery House 20/02/06

Rosebery House 14/12/05

Rosebery House 30/11/04

Rosebery House 18/05/04

Rosebery House 02/12/03

Rosebery House 10/06/03

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

CARE HOMES FOR OLDER PEOPLE Rosebery House Residential Home 2 Rosebery Avenue Eastbourne East Sussex BN22 9QA Lead Inspector Lucy Green Unannounced 21 June 2005 10:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Rosebery House Residential Home Address 2 Rosebery Avenue Eastbourne East Sussex BN22 9QA 01323 501026 01323 511124 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Spemple Limited Mrs Mary Kelly Care Home 26 Category(ies) of Dementia - over 65 years of age (DE(E)) 26 registration, with number of places Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty-six (26). 2. Service users must be aged sixty-five (65) years or over on admission. 3. Service users to be diagnosed with a dementia type illness. 4. One named service user under the age of sixty-five (65) may be accommodated. Date of last inspection 30 November 2004 Brief Description of the Service: Rosebery House is a large, detached property situated in a residential area, adjacent to Hampden Park, Eastbourne. Local shops and amenities are a short, level walk away. The home is registered to accommodate twenty-six older people with dementia. Single bedroom accommodation is provided on two floors. All rooms are equipped with a call bell and a passenger lift provides easy access to the first floor. Assisted bathrooms and toilets are located on both floors of the home. Meals are usually served in the dining room, but can be taken in the residents own room, if preferred. Communal areas consist of a large lounge, dining room and quiet seating area. A large, rear garden provides a safe and pleasant area for residents to walk in and relax. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Rosebery House will be referred to as ‘residents’. This unannounced inspection took place over six and half hours on 21 June 2005. This is the first statutory inspection of this year. The purpose of this inspection was to assess compliance with the requirements of the last inspection and to generally monitor care practices. A tour of the premises took place, rotas and care records were inspected. Eleven of the nineteen residents, one visiting relative, four staff and the Manager were spoken with. Comment cards were left for visitors and five had been returned at the time of writing this report. The Inspector joined the residents in the dining room for their lunchtime meal. What the service does well: Rosebery House is a spacious and attractive home which provides a range of communal areas and a secure garden for residents to wander and relax in. The Manager has been in post for just over a year and has worked hard in this time to create a homely and friendly atmosphere. The feedback received from relatives was positive, people stated that they were made to feel welcome when they visit. One relative stated “ I am always received with a smile”. The home maintains a book for complaints, but since the last inspection only letters of compliment had been received. The home has received four cards from relatives, thanking staff for their ‘care’ and ‘kindness’. Throughout the inspection, positive relationships were observed between staff and residents. Residents moved freely around the home and were not discouraged from going to the office if they wished to speak the Manager of request support. The three care staff interviewed felt that the home worked well as a team. Staff expressed that they were well supported by the Manager, who they described as ‘open and approachable’ and ‘very hands on’. All residents spoken with expressed satisfaction with the meals provided at Rosebery House. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, & 5 Residents would be more assured that the home was able to meet their needs if the home gathered all assessment information prior to admission. Residents benefit from having the opportunity to visit Rosebery House and make choices about their accommodation before they decide to accept a placement. EVIDENCE: The pre-admission assessments for two recently admitted residents were viewed. It was noted that the Social Care Assessment for one of these residents had not been received. It is required that the home gather all assessment information prior to admission to ensure all care needs have been identified and confirmed that they can be met. The home’s own assessing process must also be more robust. The staff member conducting the assessment, must record all information and sign and date the documentation. One of the two assessments inspected, had been carried out many months prior to admission. Through discussion with the Manager, it transpired that this resident had moved to another service following assessment, but had then later decided to move to Rosebery House after all. The home was unable to produce written material to demonstrate Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 9 that a second assessment had been conducted to ensure this person’s needs had not changed. The Manager reported that prospective residents and/or their representatives are encouraged to visit the home prior to admission. For the two most recent admissions, relatives had visited Rosebery House and made choices about which room their relative would like. The Manager stated that unless residents wish to move in very quickly, the home is able to redecorate bedrooms in a colour chosen by the prospective resident. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 Residents would benefit from a more individual and detailed approach to care planning. Residents receive the healthcare support they need. Updating medication procedures will improve the way medication is handled. EVIDENCE: Five care plans were viewed and the contents discussed with the Manager. Whilst care plans were found to contain relevant information about each resident, a need to formalise the care planning system was identified. The home has begun including residents’ relatives in the care planning process and asking them for information about the life history of residents prior to moving into residential care. The Manager has recently revised the process of reviewing care plans and now plans are internally reviewed on a monthly basis, with a three monthly review involving, where possible, the resident and their representative. In order to move care plans forward, the home needs to make care plans more accessible by identifying each specific care need relating to a resident and then providing detailed guidance as to how support should be provided. As care needs change, additional support plans should be devised. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 11 Risk assessments need to be developed. It is required that where risks are identified, they are followed through with an assessment of the controls in place to minimise those risks. Risk assessments should be linked in with the support plans to ensure a member of staff can support residents in the safest and most appropriate way. The Inspector spoke with three care staff and the Manager who all demonstrated a good understanding of residents’ needs, the home now needs to work on transferring this knowledge into the plans of care. Residents are supported with their health care needs and where necessary, external healthcare professionals are accessed for advice and assessment. Care plans contain a record of the input each resident has received from doctors, district nurses, community psychiatric nurses and the like. The storage, recording and disposal of medication were inspected. The storage of medication was found to be satisfactory and the home has a locked trolley for transporting medication around the home. Only senior staff handle medication and the Manager produced attendance certificates to demonstrate that these staff had received relevant training. The Medication Administration Record (known as MAR sheet) revealed that there were some signature gaps, where medication had been dispensed from the blister packs. It was observed during the inspection, that staff do not always sign for medication immediately following administration and this practice is required to be reviewed to prevent mistakes from occurring. It was also identified that the home does not have a uniform system for the disposal of refused medication once it has been dispensed and this needs to be addressed. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 &15 Residents would benefit from a more robust plan of activities. Residents benefit from their visitors being encouraged and welcomed into the home. Residents enjoy varied and wholesome meals. EVIDENCE: The home has an activity programme which identifies activities which are available during the afternoons. The three staff spoken with during the inspection confirmed that where possible, they spend time talking with residents, reading the newspapers to them and arranging quizzes and music sessions. On occasion, residents are supported with a walk out and external entertainers are brought into the home. It was evident throughout the inspection, that the opportunity for social activity within the home, is wholly dependent on staffing levels and the entertainment skills of individuals. The care plans viewed did not identify social needs or how these could be addressed. Two residents informed the Inspector that they get bored and would like to do more with their days. It was also identified that another resident in particular, would benefit from some specialist social support. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 13 It is therefore required that the home review the systems in place for providing activities and opportunities for social interaction. As a recommendation, the home may wish to consider employing an activities co-ordinator with the necessary skills to develop this area. The Manager and staff stated that visitors were welcomed and encouraged to visit their relatives at Rosebery House. This opinion was supported by the feedback obtained from one relative visiting on the day of inspection and the comment cards received from five relatives. One relative informed the Inspector that they visited several times a week and is always made to feel welcome, including being invited to share Christmas lunch at the home. Another relative commented, “I am always received with a smile”. The Inspector joined the residents in the dining room for their lunchtime meal. The meal appeared appetising and wholesome and residents expressed satisfaction with the food they received. All residents spoken with throughout the inspection stated that the food was good and that they looked forward to their meals. Meals are prepared according to a rotating menu. Where a resident wishes to have something different, a range of alternative meals are available. It was noted that the current menu had been devised for the winter months and it is recommended that it is now updated to reflect the current season. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Residents and relatives are encouraged to express their views. Systems are in place to protect residents from abuse. EVIDENCE: The home has a complaints procedure which is available to residents and visitors to the home. No complaints have been received about Rosebery House since the last inspection. On the contrary, the Manager showed the Inspector four ‘thank you’ cards from relatives, complimenting the home on the sensitive way care is provided. The home has policies and procedures in place to promote the protection of vulnerable adults. The ethos of the home encourages poor practice to be challenged and for staff to feel supported to use the whistle blowing policy where necessary. The effectiveness of these systems has recently been tested at the home and shown that Rosebery House will not tolerate abusive practices. The Manager has demonstrated that correct procedures are followed and appropriate action taken. Staff are employed following receipt of satisfactory checks from the Criminal Records Bureau. During the inspection it was identified that not all staff had undertaken training in respect of the prevention of abuse and it is required that this is arranged. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Residents benefit from a spacious and accessible environment. The environment would be more pleasant if maintenance and hygiene issues were addressed, planned and carried out in a more focused way. EVIDENCE: A tour of the home was conducted and the home was generally found to be clean and well maintained. At the time of the inspection, a number of maintenance issues were being attended to and consequently had caused some disruption in the home. The dining room has recently been re-designed and new carpets fitted. The walls have been stripped and are awaiting decoration. Due to a more urgent maintenance issue, completion of the dining room had been put on hold. Whilst the Inspector appreciates why this situation has arisen, a requirement was made that the decoration of the dining room be completed within one week as it did not create a pleasant environment for residents to take their meals and residents commented on the uninviting feel of this room in its current state. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 16 Resident bedrooms were found to be comfortable and personalised to the individual. Residents are able to bring personal furnishings to decorate their rooms. It was noted that three bedrooms were malodorous and this matter needs to be addressed as a matter of priority. As part of the refurbishment, one of the bathrooms has been re-fitted. It was however noted that this room has two doors and consequently unless both are locked – privacy cannot be assured. The home is asked to review this arrangement, consulting with the fire brigade as necessary. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Residents are afforded protection from the home’s recruitment procedures. Residents would further benefit from a more stable team of staff who had accessed the required training courses. EVIDENCE: The last twelve months have represented a period of change at Rosebery House and number of staffing changes have occurred during this period too. At the time of the inspection, the vacancies had almost been filled and the new staff ready to start once the relevant checks had been received. The Manager reported that staffing levels in the interim had been maintained through the use of agency staff. The Manager reported and the rota indicated that staffing levels are generally four staff in the morning, three in the afternoon and two waking night duties. At least one staff member on shift throughout the day, is a senior staff member. The Manager’s hours are supernumerary. At the time of the inspection, there were nineteen residents at Rosebery House and all staff spoken with confirmed that staffing levels were adequate for the number and needs of the people currently accommodated. It should however, be noted that two relatives’ comments cards expressed that there was not always sufficient staff on duty. It has been recommended that staffing levels are reviewed in respect of activities and these comments should be borne in mind. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 18 Separate staff are employed to undertake domestic and cooking tasks each day. The Inspector viewed the recruitment files for two new staff and these were found to be satisfactorily maintained and contain the required level of documentation. The Manager confirmed that staff have received copies of the General Social Care Council code of conduct. The Manager has recently conducted an audit of staff training and had already identified which areas needed to be addressed. She reported that due to the changes in the staff team, training has recently taken a backseat. It is now required that a programme of training is put in place to ensure all new staff complete the required induction and foundation standards and that all staff attend mandatory training courses and regular updates. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35 & 38 Residents benefit from an open, inclusive and safe environment at Rosebery House. EVIDENCE: The three staff interviewed spoke positively about the management of the home, describing the style as ‘open and approachable’. One staff member referred to the Manager as ‘very hands on’ which was respected. During the inspection, it was evident from the interaction observed, that residents felt comfortable approaching the Manager and requesting support. The home does not hold money for any residents, nor do staff provide any support with residents’ financial affairs. The home’s policy on this matter is stated in the Statement of Purpose and alterative arrangements are made on admission. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 20 The home has a number of systems in place to ensure the health and safety of residents, staff and visitors are maintained. It is however, required that all new staff receive fire training by a ‘competent’ person as a matter of priority. Records show that fire drills are now conducted across a twenty-four hour period. During a tour of the building, it was noted that a bed and mattress were being temporarily stored against the wall in one bathroom. It was left as an Immediate Requirement that these be moved to a more appropriate location that day, to protect the safety of people using this room. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 x x 3 x x 2 Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14(1) Requirement All new admissions are assessed in accordance with requirements prior to admission and information available for inspection. All documentaion should be signed an dated. That the homes care planning system to effectively monitor residents health, welfare and social needs. Care plans should provide support guidelines which outline how care should be given. Comprehensive risk assessments are to be carried out in respect of all areas of residents lives and the controls in place evaluated. Medication to be dispensed, administered and where necessary discarded, appropriately. The Registered Person consult with residents, staff and relatives about the home provididng a fulfilling programme of activities. Staff undertake training in the prevention of abuse and protection of vulnerable adults. The dining area to be reecorated. Timescale for action 01 August 2005 2. 7 15 01 September 2005 3. 7 13(4) 01 September 2005 21 June 2005 01 September 2005 01 October 2005 28 June 2005 Page 23 4. 9 13(2) 5. 12 16(2)(m) & (n) 13(6) 23(2)(b)& (d) 6. 7. 18 19 Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 8. 9. 10. 11. 19 26 30 38 23(2)(f) 23(2)(d) 18(1)(c) 13(4) Consideration is given to the bathroom with two entrances, in respect if maintaining privacy. Action is taken to rectify the identified malodorous bedrooms. Staff receive the induction and mandatory training appropriate to the work they perform. The bed and mattress stored in the bathroom be moved to a suitable storage location. 01 August 2005 01 August 2005 01 September 2005 21 June 2005 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. Refer to Standard 12 15 Good Practice Recommendations Tihe home consider employing an activities co-ordinator with the skills to develop an effective programme of activities. The menu be updated to reflect the current season. Rosebery House Residential Home H59-H10 S21246 Rosebery House V218856 210605 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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