Inspection on 08/05/07 for St Edmund`s CCSC

This inspection was carried out on 8th May 2007.

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

St Edmund`s CCSC 06/02/08

St Edmund`s CCSC 02/12/05

St Edmund`s CCSC 14/06/05

St Edmund`s CCSC 08/12/04

St Edmund`s CCSC 08/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE St Edmunds CCSC Victoria Park Road Torquay Devon TQ1 3QH Lead Inspector Stella Lindsay Key Inspection (unannounced) 1:30 8th May 2007 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 Edmunds CCSC DS0000037052.V331327.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 Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Edmunds CCSC Address Victoria Park Road Torquay Devon TQ1 3QH 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) 01803 314839 01803 314839 maureen.hussey@torbay.gov.uk Torbay Care Trust Vacancy Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (25) of places St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users may be accommodated from age 40. Since 19th March 2007, categories of registration include DE(E) and MD(E). Date of last inspection 2nd December 2005 Brief Description of the Service: St Edmunds is an intermediate care facility for up to twenty-five service users who have been identified as having the capacity to return home following rehabilitation input. The home provides intensive rehabilitation for a period of up to six weeks. There is no charge to the service user. A multi-disciplinary assessment is carried out, and service users benefit from the attention of physiotherapists and occupational therapists who are based in the home. Visits to clients’ homes are carried out before discharge for assessment of on-going needs for adaptations or support. St.Edmunds has been preparing to launch an intermediate care service for people with Organic or Functional Mental Health needs. The top floor is now dedicated to this service. All bedrooms are currently in single occupancy, though two are large enough to be used as double rooms for married couples. All have a spacious en suite toilet and shower. The home is well equipped for people with reduced mobility, having a shaft passenger lift, assisted baths and disabled toilets. There is a well-equipped gymnasium for use by service users with the therapists. There is level access on each floor and out to the gardens. There is some car parking available on the site. The residential parts of the service are on the first and second floors. Other services including a day centre are located on the ground floor of the building, but are not regulated by the Commission for Social Care Inspection. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days in May 2007. It involved a partial tour of the premises, and meeting with six of the 11 residents, one visiting relative, five staff on duty, as well as the Assistant Manager, Mrs Maureen Hussey, and the Clinical Lead, Mrs Lynne Beckett. Care records and staff files were examined. Surveys were received from staff and former residents. What the service does well: What has improved since the last inspection? A new post of Clinical Lead was established in June 2006, to promote and support the work on health care and assessment within the home and community services. St.Edmunds has been preparing to offer a rehabilitation service for people with organic or functional mental health needs. Much work has gone into preparing the upper floor to house this new service, and to train and prepare staff. This will soon be ready to start work. Staffing levels have increased, following redeployment from elsewhere in the organisation, and there is no longer any use of agency staff. There are now three waking night staff. Some staff are starting training to offer an outreach support service, to enable rehabilitation work to be offered in clients’ own homes, thus enabling even faster discharges. A digital camera has been obtained, which will help in many ways with recording and communicating. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 6 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 Edmunds CCSC DS0000037052.V331327.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 Edmunds CCSC DS0000037052.V331327.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): 1,3,6 Quality in this outcome area is good. Admission is dependent on professional assessments of the person’s likelihood to benefit from the service, and effective help is given to maximise service users’ independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information has been produced for prospective Service Users, including a Statement of Purpose, which will need to be up-dated to include the new developments in this service. Service Users’ Guides were seen in residents’ bedrooms. Care agreements were seen to have been provided, and signed by residents. They are also asked to give consent to information about them to be shared with social and health care professionals. Residents had not had the opportunity to visit before admission, but had confidence in making the move because they had been advised of the benefits offered by St.Edmunds, usually by hospital staff. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 9 Admissions had been made from hospitals, residential homes and peoples’ own homes. After the initial enquiry, an assessment form is sent to a Care Manager. Pre-admission assessments from hospital-based physiotherapists, nurses and Occupational therapists were seen on residents’ files. These are then discussed by the multi-disciplinary team within St.Edmunds. Residents also need to consent to accept and work with a rehabilitation programme. A therapist or Senior Care Officer may visit the potential service user if it is not clear whether they could benefit from the service, but this is not normal practice. The residential part of the service at St.Edmunds is entirely dedicated to intermediate care. The building is designed and equipped for this purpose. Specialist equipment is obtained when necessary. At the time of this inspection an order had been made to hire an electric recliner chair for the duration of one person’s stay. Staff are qualified, trained and appropriately supervised to implement treatment and recovery programmes. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. Care and treatment are individually planned and reviewed daily. Health care is supervised by qualified staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When a new person is admitted to St.Edmunds, one of the Rehabilitation Coordinators interviews them and discusses their programme and care needs, with a checklist to ensure consistent attention to their needs. This includes the person’s goals, as work towards discharge starts immediately. Goals were seen to include improvements in strength, and ‘to go home’. Care needs are assessed in detail. The help that is to be offered is carefully planned, with assessments from therapists leading to daily consideration of what the person can do for themselves. Staff who had recently moved to St.Edmunds said they had to be careful to stand back and keep to the treatment plan, to avoid offering too much help, while residents are regaining their abilities. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 11 Physiotherapists provide people with their own exercise programme, and one confirmed that care staff continue working with these, to assure continued progress. When asked if they get the weekends off, residents said (good humouredly), ‘No – Sundays mean nothing to them!’ Sight and hearing are also checked. The home operates an efficient medication procedure. Records were seen to be accurate, and storage secure. A person’s ability to administer their own medication is part of the initial assessment. Each has a lockable drawer in their bedroom, to keep their medicines safely. There is a payphone in a small room on each floor, assuring private conversations. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. Residents have daily activities directed towards their individual rehabilitation goals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At St.Edmunds, residents’ expectations are concentrated on their stated aims, in particular on using their time there to get strong enough to go home safely. They are expected to come to the dining room for breakfast at 9am. Residents had appointments during the day, including work with therapists in the gym, and home visits to assess needs for adaptations and support following discharge. Residents work with Occupational Therapists on dressing, meal preparation, making hot drinks, and other activities of daily living. An exercise group is held daily, which is mainly designed for building strength to avoid danger of falling. During this inspection eight of the eleven residents attended. It had recently been moved from a morning event to just after lunch, which proved successful. Records showed that residents had been accompanied to walk round the garden as part of their exercise programme. Staff stated that they accompany people to shops to buy ingredients for practice in meal preparation. Residents St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 13 had also been taken to specialist support groups, and to the Exeter Mobility Centre. Family and other carers are included as an essential part of the programme, and also expected to consent to work with the rehabilitation programme. One relative said the staff ‘are brilliant here’. They said that staff are always approachable, and that they find answers for their problems. Cultural and social interests are not normally a priority, but would be considered when they impinge on a person’s care and support needs. Dietary needs are recorded on admission. Dislikes were written on a white board by the servery. Special diets can be supplied; at this time a diabetic diet was provided. Residents were happy with their meals. Their menu requests were taken two days in advance, so they felt they had plenty of choice – but the meal was still a pleasant surprise when it arrived. One was particularly delighted to be offered bacon and egg for breakfast. The main kitchen is away from the residential part of the building. There is a kitchenette where staff can make hot drinks and toast for residents during the night if needed. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. Staff are skilled and understand the importance of actively promoting residents’ rights. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Complaints Procedure is included in the Service Users’ Guide, which is provided to each resident in their room. The Assistant Manager keeps a record of complaints and concerns, and any outcome or action taken. There had been no formal complaints with regard to the residential service. The CSCI had received no complaints. Many of the staff had received training on the protection if vulnerable adults. The Alerters’ guidance was available in the office. It would be helpful to have the contact details for the Torbay Social Services Adult Protection Team readily available. One allegation of rough handling had been made during the previous year. It was not clear who the perpetrator might be, but arrangements were made to ensure better observation and supervision of staff in their caring duties, to prevent any recurrence. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,26 Quality in this outcome area is adequate. The building is well equipped and adapted to meet the residents’ needs, and kept safe and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The layout and facilities in this home are suitable for its purpose. Long corridors are good for walking exercise. Level floors and a shaft lift give residents access to all parts of the building. Most are unable to use the garden without assistance. There are staff available to accompany them when required. There are assisted baths and disabled toilets on both floors, and a specialist gymnasium. Work had just been completed to make the top floor safe for service users with mental health needs. Preparations were still needed to make it homely, and to put in suitable signage to help people find their way around. Unattractive flooring had been laid in the lounge and dining areas. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 16 The lounge and dining room on the first floor, being used by current residents, were bright and attractive. Chairs raisers and pressure cushions were provided according to individual need. One resident who was pleased to show the inspector their bedroom was delighted with the facilities – ‘couldn’t be better.’ Many residents come from hospital, and are pleased to have their own bedroom and en-suite toilet. The soft furnishings were colour co-ordinated, there was a built in wardrobe, and a television had been brought on request. Not all rooms have a television. There was a clock, a thermometer, and a lockable drawer. As residents are expecting to stay for a few weeks at most, they do not bring many personal possessions. There were two unused bedrooms on the top floor which had an unpleasant odour, but otherwise the home was clean and hygienic. Liquid soap and paper towels were provided where personal care might be given, and in communal toilets. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,20 Quality in this outcome area is excellent. The staffing arrangements are commendable, and the staff group is trained and appropriately experienced. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were high at the time of this inspection as staff had been redeployed from other parts of the organisation. The rota showed that there are two or three Physiotherapists and two or three Occupational Therapists on duty Monday to Friday. There are two or three Rehab Co-ordinators on duty seven days per week. There is a Senior Care Officer on duty at all times, six care officers by day, and three waking night staff, including a Night Manager. There were also Support Worker Intermediate Care staff in training, ready for deployment in community support. The Clinical Lead stated that it has been decided to employ a Community Psychiatric Nurse to ensure effective service provision when service users with Mental Health needs are admitted. Domestic and kitchen staff were employed in sufficient numbers to service the whole building and the other services provided within it, including the Day Centre. This is a well-trained staff group, including qualified health care professionals. Also, there is a high proportion of qualified care staff, with approximately 70 having achieved NVQ2 or above at the time of this inspection. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 18 The staff who had recently arrived were being provided with training in rehabilitation. Original St.Edmunds staff were undertaking training in Mental Health Awareness and care of people with Dementia. The Assistant Manager keeps a spreadsheet showing the training undertaken by staff. This shows the wide uptake of training in disability awareness and anti-discrimination as well as the mandatory health and safety training. Recruitment had not taken place recently, but staff files showed that a sound system of recruitment is in place, with CRB clearances, proof of identity, and written references having been obtained, although some had not been returned from the personnel department. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome area is good. This service is responsive and reliable, though improvements in supervision of staff and communication within the home are still needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St.Edmunds needs to register a manager with the CSCI who is able to ensure that the home continues to be run in accordance with the Care Standards Act 2000. The Clinical Lead, Mrs Lynne Beckett, is a highly qualified and experienced Nurse, though unfamiliar with the Care Homes Regulations 2001. The Registered Manager of another home within the organisation has agreed to act as mentor for her. The Assistant Manager, Mrs Maureen Hussey, is line managed by Mrs Beckett. She has achieved NVQ4 in Care and the Registered Managers’ Award. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 20 There are four administrative staff to assist. The management task is very large, as there are day care and community support services as well as residential care, totalling nearly 100 staff. There is not a quality assurance system. Feedback is gathered from each resident as they lead, and completed questionnaires show a high level of satisfaction. There had not been collation or analysis of this information. Lynne Beckett stated that a full audit of the service was due to take place the following month, with academic and professional input, and that a report would be supplied to the CSCI. The Responsible Individual for the Torbay Care Trust had not visited or arranged for a suitable employee of the organisation to visit St.Edmunds since August 2006. This should occur at least monthly, in accordance with Regulation 26, to ensure there is external supervision over the running of the home. Following each of these visits a report on the conduct of the home is to be sent to the Commission for Social Care Inspection and to the home’s manager. The home does not handle finance on behalf of residents, though cash and valuables may be deposited in the home’s safe (for which receipts are issued to service users). Staff had not received supervision. Some staff who returned surveys or spoke to the inspector said they worked well together as a team, sharing knowledge and supporting each other, but did not receive 1;1 sessions with a manager or senior member of staff. In a survey, one staff member said that little information was passed to staff about the changes, which affected morale, and another said that managers were very busy and did not deal effectively with issues. A Senior Care staff meeting took place during this unannounced inspection, which had been attended by two Night Managers, and there had been a recent meeting with the cooks. There had been a Care Officers’ meeting on 15th February, to discuss planned changes. During the many changes that are taking place with the development of the service as well as organisational changes affecting staff, it would be good practice to improve communication with staff, by holding a planned series of staff meetings at different times of day. The Assistant Manager said that staff meetings had in the past been held at 8pm, to make it easier for Night staff to attend, but this had not happened recently. Safe working practices are assured by a thorough training programme, including fire awareness, health and safety, infection control and Moving and Handling including safe use of the hoist. The fire precaution system was professionally serviced on 28/02/07, and the extinguishers checked in December 2006. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 4 3 X X 3 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 2 2 2 X 3 2 X 3 St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 22 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 OP31 Regulation 8 Requirement The Registered Provider, Torbay NHS Care Trust, must apply to register a Manager with the CSCI, to ensure that the home continues to be run in accordance with the Care Standards Act 2000. A report on the conduct of the home following a monthly inspection must be sent to the Commission for Social Care Inspection and to the home’s manager, to ensure external supervision of the running of the home. (Previous timescale of 31/7/05 and 31/12/05 not met). Timescale for action 31/07/07 2. OP33 26 31/07/07 St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 23 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 OP32 OP36 Good Practice Recommendations There should be a planned programme of staff meetings to ensure that all staff have the opportunity to remain well informed during times of change. All care staff should receive formal supervision at least six times a year, to ensure they are up to date in knowledge of the home’s policies and procedures, consider their training needs, and give an opportunity to discuss any issues or anxieties. St Edmunds CCSC DS0000037052.V331327.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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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