Inspection on 14/03/07 for St Dunstan`s

This inspection was carried out on 14th March 2007.

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

St Dunstan`s 09/03/06

St Dunstan`s 10/08/05

St Dunstan`s 31/01/05

St Dunstan`s 23/07/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Heathfield

Red Oaks

Hothfield Manor Centre

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

CARE HOMES FOR OLDER PEOPLE St Dunstan`s Greenways Ovingdean Brighton East Sussex BN2 7BS Lead Inspector Merle Blakeley Key Unannounced Inspection 14th March 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Dunstan`s DS0000014041.V323872.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. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Dunstan`s Address Greenways Ovingdean Brighton East Sussex BN2 7BS 01273-307811 01273-302704 jacqueline.greer@st-dunstans.org.uk 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) St Dunstan’s Mrs Jacqueline Sandra Greer Care Home 77 Category(ies) of Physical disability (0), Sensory impairment (77) registration, with number of places St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users in receipt of personal care does not exceed 37 within the registered numbers That the maximum number of service users to be accommodated is seventy-seven (77) 9th March 2006 Date of last inspection Brief Description of the Service: St Dunstans is a nursing and care home that provides nursing and social care and accommodation for up to seventy-seven residents with visual or physical impairment. St Dunstans is run by a charitable organisation that provides care to ex-servicemen and women who are visually impaired. The home is situated in its own grounds at Ovingdean, near Brighton. St Dunstans provides its own transport services and drivers to enable residents to go shopping in Brighton, or participate in day trips. The home provides many facilities to enable service users to participate in activities, including a gym, sports hall, swimming pool and crafts workshop. Facilities are also provided to enable service users to accommodate guide dogs. Accommodation is provided in single, en-suite rooms, with a number of shared rooms available if required. St Dunstans has five floors, with service users accommodated on the first, second and third floor. Passenger lifts enable residents to access all areas of the home. A variety of communal space is provided in a large lounge/bar area, dining area and two further lounge areas. There is also a small seating area situated on each floor, and a further small dining area on each unit. There is an enclosed garden that provides a pleasant area for residents to sit, and a gardening club enables residents to participate in landscaping this area. The current fees range from £200.00 to £450.00 per week. Extras charges are made for newspapers, hairdressing, private telephone and some activities. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over a period of seven hours on March 14th 2007. As well as the Lead Inspector a second inspector was also present for three hours to talk to residents and staff. As well as this site visit information was also gained form a returned pre-inspection questionnaire, twenty-three returned service user surveys and Regulation 26 reports. Several staff and residents were spoken to and time was spent with the Manager of Care. Document reading and an environment check were carried out. Staff were also observed interacting with residents. What the service does well: What has improved since the last inspection? During the last inspection three requirements were made. The nursing staff needed to ensure that all medications that were brought into the home by residents were recorded and they also needed to ensure that risk assessments were carried out on all residents who self medicate. These requirements have been carried out. The third requirement was for photo identification to be supplied for each staff members file. This requirement has also been met. Since the last inspection in February 2006 the home has increased the level of support staff and residential staff. The home has also provided a new private lounge area for some of the permanent residents of St Dunstan’s. The decision to provide this lounge was taken after several residents stated that they would like their own private lounge, as opposed to sharing the larger communal areas St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 6 with other temporary users of the service. The continuing work to repair the external brickwork is due to be completed by Easter 2007. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 in not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home carries out a thorough pre-assessment check before a prospective resident moves into the home. EVIDENCE: St Dunstan’s employs a dedicated social worker that is responsible for carrying out pre-assessment interviews with prospective residents. Information about the person’s background, social needs, health, mental health and physical health, finances, family and self-help skills are all taken into account to ascertain whether the home would be able to meet their needs. On completion of this assessment a report is sent to the Admissions Board who would ultimately decide whether or not St Dunstan’s could meet their needs. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home offers residents a very good level of care in regards to health and personal care. EVIDENCE: A number of care plans were viewed during this visit and the information they contained was informative and up-to-date. All aspects of a residents care are included in these plans and they also contain information about doctor’s visits, appointments, weight charts and risk assessments. Care plans are updated and reviewed six monthly and where possible family and friends are involved in this process. During the day three handover periods are carried out where staff are informed about any changes or updates to residents care plans. Care plan records also revealed that residents have access to a wide variety of health care professionals. A general practitioner visits twice weekly and residents are also able to have appointments with the dentist, dietician, CPN, audiologist, physiotherapist, optician, chiropodist, speech therapist and district nurses. Some of these services are provided in-house. The nursing floors St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 10 contain all the required specialist equipment. St Dunstan’s also provides residents with an on site gym with specialist equipment and instructors and an indoor swimming pool. Several of the residents who were spoken to on the day stated that they felt their healthcare needs were well met by the home. All residents at St Dunstan’s have their own personal medication cupboard in their room. During the last inspection nursing staff were required to ensure that all residents who came into the home, whether on a temporary or permanent basis, had their medications recorded, as staff were not previously carrying this out. This lead to inaccuracies when medicines were being audited. The home now ensures that when residents come into the home with their medication, these are recorded in their plans. Random medication checks were carried out for a number of residents and they appeared correct. Some residents choose to self medicate and risk assessments are now being carried out on admission and reviewed on a regular basis to ensure that the person continues to be safe in administering their own medicines. The homes practice development nurse also carries out random checks on medication to identify any possible errors. Staff have received medication training and regular updates are carried out. During this visit residents were seen to be treated with respect and dignity by staff. Residents who were spoken to also said that staff treated them well and that their privacy was respected. Staff always knock on doors before entering and residents are called by their preferred names. The 2007 satisfaction survey also revealed that 100 of the residents felt that they were treated with respect St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. St Dunstan’s provides residents with specialised recreational activities. Residents are supported to maintain family links. Residents receive a well balanced diet. EVIDENCE: St Dunstan’s provides specialised care, accommodation and support for people who are visually impaired. The home has been specifically built for visually impaired people and therefore contains all the necessary aids and equipment needed to support residents to live as independently as possible. Residents have access to a wide variety of activities and recreational interests, which include days out in the homes own mini buses, shopping trips, theatre visits, indoor/outdoor bowls, archery, bingo, acoustic rifle shooting, in house clubs, live music, in house bar, on site swimming pool and gym, transport to local church services and use of the on site craft rooms (pottery, wood work, painting and other crafts). There are also areas for residents to use computers and other specialised visual equipment, as the home also contains a rehabilitation centre. Resident’s families and friends are very welcome in the home and St Dunstan’s tries to ensure that these family links are maintained, particularly as many of St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 12 the residents do not come from the local area but from different areas across the United Kingdom. The home is able to provide accommodation for family members to stay in when necessary. Several visitors were seen on the day and they all stated that they were made welcome by staff. The home also tries to ensure that family and friends are involved were possible in the ongoing residents care. Residents are able to make certain choices and decisions about their lives. They can choose how much they wish to be involved in, when they go out, who they see and where they go. They can also receive assistance with their money and other personal finances. The home has a dedicated finance officer and a wills and trusts co-ordinator. They can also be involved with their care plans and the way in which their personal support is provided. Residents meetings are also held. As this is such a large home an in-house catering company provides all the meals for both residents and staff. The home has its own kitchens where the meals are prepared and transported down to the dining rooms, staff canteen and various other small serveries on the residential and nursing floors. There is a large dining room on the ground floor and in the past there have been some issues regarding noise levels. Some residents have stated that it can become very noisy in there with so many people eating at the same time. The home is aware of this issue and there are plans to possibly cordon off some of the areas to provide some quieter sections. During the day residents were asked about their thoughts on the meals that were provided. The general feedback was very positive with two negative comments. Residents meetings are held whereby residents can voice their opinions about the food. The catering company who provide the meals to the home carry out their own quality assurance and attend residents meetings to gain feedback. A brief visit to the kitchens revealed a modern and well-organised workplace run by a team of chefs and kitchen staff. Weekly menus provide a varied range of meals and also include other diet options such as low fat, diabetic, vegetarian etc. Both inspectors were able to sample the food as they were invited to join the manager for lunch in the staff canteen. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes policies and procedures ensure complaints are acted upon and vulnerable adults are protected from abuse. EVIDENCE: The home has produced a comprehensive complaints policy. The homes complaints log was viewed and four complaints had been made. These were discussed with the manager. Two of the complaints were fairly minor and had been dealt with immediately. One complaint was about the housekeeping department not informing residents that the toilet rolls and soap dispensers in their rooms had changed. The manager stated that this was upheld and residents should have been informed. The fourth complaint was about a staffing issue, which the manager investigated and was noted in the persons file. All complaints had been dealt with satisfactorily and in a timely manner. The results from the homes customer satisfaction questionnaire revealed that all residents are aware of how to make a complaint The home has produced a policy and procedure regarding the protection of vulnerable adults and this policy was recently reviewed in November 2006. All staff have received training in adult protection. The home has not received any adult protection alerts. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a very safe and well-maintained purpose built environment. EVIDENCE: St Dunstan’s has been specifically designed to care for people who have visual impairments and the home contains a large variety of specialised equipment and aids. The home is maintained to a very high standard by a team of maintenance staff. The exterior brickwork of the home is being repaired and it is soon due to be completed. There are also plans to refurbish the nursing wings, which may involve installing ‘overhead tracking systems’ for moving residents more easily. St Dunstan’s are also considering turning some of the en suite bathrooms into ‘wet areas’ which would make these bathrooms more user friendly for people with disabilities. One of the homes many lounges has been turned into a ‘permanent residents’ lounge after some of the residents stated that they would like another communal area for their private use. The St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 15 home is currently trialling this to see how well this area will be utilised. As mentioned previously there are plans to try to redesign the dining area to create a quieter environment at mealtimes. The home is kept very clean and tidy. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home employs an effective and caring staff team. 90 of the staff hold NVQ qualifications. The home carries out suitable recruitment procedures. Staff have access to a very good level of training. EVIDENCE: St Dunstan’s employs a very large staff team of 200 people who are based at Ovingdean. The home has recently increased its staffing levels for the night shifts by employing a further twelve staff. As well as nursing staff being on duty at night there are now also residential staff available. There are nursing and non-nursing staff employed plus ward managers, senior staff, social workers, rehabilitation officers, HR personnel, office staff, domestic staff, drivers, security personnel, maintenance personnel and recreational staff. During the day the second inspector was able to talk to a number of staff about working at St Dunstan’s. All of the staff spoken to said they enjoyed working at the home and they felt well supported in their roles. They also stated that working conditions were good and that they received a good level of supervision and training. Residents who were spoken to during the day were asked about the staff and the feedback was overall very positive with comments such as “couldn’t ask for a better place to live”, “excellent care provided”, “wonderful place”, “you get everything you need in here” and “staff are very good and treat me well”. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 17 St Dunstan’s has achieved an excellent ratio of staff that hold NVQ qualifications. 90 of the care staff team have obtained NVQ Level 2 qualifications and above. The managers are currently undertaking the B’TEC Level 4 qualification in Voluntary Sector Management and Supervisors are receiving Leadership Training. Trained nursing staff hold RGN qualifications. The personnel department maintains all staff recruitment files. During the last inspection the home was required to ensure that all staff had a recent photo attached to their files for proof of identity purposes. This has been carried out. A number of recruitment files were viewed and they contained all the required information, as set out in Schedule 2 of the National Minimum Standards. All new staff receive a thorough induction course before they commence their duties at St Dunstan’s. St Dunstan’s provide staff with a very good level of training. The second inspector was able to interview a number of staff during the morning and the feedback about the training they received was again very positive. Staff said that they had a wide variety of training courses that were offered plus if they felt there was a particular training course they would like to attend, which would enhance their skills at work then they could approach management for support. The home is soon to fully implement the ‘Gold Standards Framework’ – End of Life Care. St Dunstan’s has been part of a pilot scheme to provide a new initiative to care for residents who are dying. As at the end of 2006 approximately sixty-five staff members had received this specialist training. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. An experienced and dedicated Head of Care runs the care side of the home very effectively. The home has a quality assurance programme. Resident’s finances are safeguarded by the home. The home has produced effective health & safety policies and procedures, which protect residents, visitors and staff. EVIDENCE: The Head of Care at St Dunstan’s is a very qualified and experienced RGN who has obtained the Registered Managers Award (RMA) and is currently completing a Masters Degree in Clinical Studies and Management. The home is run in an efficient and caring manner. Staff and residents who were spoken with all felt that the Head of Care was approachable and that they could go to St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 19 her if they had any issues or concerns. The Head of Care has continued to ensure that high standards of care are maintained throughout the home. The home has produced a Quality Assurance Programme, which involves obtaining feedback from residents and their family and friends. A comprehensive questionnaire is sent out annually to residents and family members and asks for their feedback on a range of issues such as care services, accommodation, meals, activities and the environment and where do they think there was room for improvement. The 2007 Customer Satisfaction Questionnaire results were viewed and overall the comments received were very positive. Residents meetings are held monthly and here they are able to voice their opinions and views. They are also able to provide comments about their care at their six monthly review meetings, which family members are also able to attend. The St Dunstan’s charity also conducts their own satisfaction surveys, which cover all services that are offered. Regulation 26 visits are carried out and the records for these visits were viewed. The home has its own finance officer who deals with resident’s monies for safekeeping. The home maintains thorough records of all financial transactions. St Dunstan’s employs a full time Health & Safety Manager who is responsible for all aspects of health & safety for residents and the staff who work there. Health and Safety is of a particular importance in a home which cares for vulnerable people who have visual impairments and total sight loss. An environmental check of the home revealed that it is maintained to a very high standard in all areas and it was evident from viewing a sample of the records that are kept that residents, visitors and staff are well protected. The home also employs a dedicated maintenance team who carry out checks on all systems within the home. St Dunstan’s continues to be very proactive in its approach to health and safety matters. Staff have received core skills training in manual handling, fire safety, infection control, food hygiene awareness and first aid. The home has a fire risk assessment and an evacuation plan. All accidents and ‘near misses’ are recorded and both residents and staff are encouraged to report any matters that need to be brought to the attention of the Health & Safety Manager. St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 20 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 4 St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Dunstan`s DS0000014041.V323872.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Kent ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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