Inspection on 19/01/07 for Stonebridge Nursing Home

This inspection was carried out on 19th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stonebridge Nursing Home 09/07/07

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOMES FOR OLDER PEOPLE Stonebridge Nursing Home 180 Birchfield Road Headless Cross Redditch Worcs B97 4NA Lead Inspector Nick Richards Unannounced Inspection 19th January 2007 08:40 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 Stonebridge Nursing Home DS0000068267.V327910.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. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stonebridge Nursing Home Address 180 Birchfield Road Headless Cross Redditch Worcs B97 4NA 01527 542128 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) Alexandra House Care Services Ltd Julia Marie Foley Care Home 52 Category(ies) of Dementia - over 65 years of age (52), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (52) Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 named service users between the ages of 55 to 65 years. Date of last inspection 19 June 2006 Brief Description of the Service: Stonebridge nursing home is registered to accommodate a maximum of 52 service users with dementia or a mental disorder, who require twenty-four hour nurse care. Alexandra House Care Services Limited, who have one other nursing home in the West Midlands, operates the home. The registered manager is Ms J Foley, who is a first level registered mental nurse. Accommodation is provided in single and double bedrooms, which are located on ground and first floor levels. A passenger lift enables service users with mobility difficulties to access both floors. The home provides a large communal lounge area with combined dining facilities on the ground floor for service users, and a separate conservatory. Communal toilet and bathing facilities are located on both floors, and central kitchen and laundry services are located on the ground floor. The home is situated in a residential area of Redditch, which is convenient for public transport and access to the town centre. There is an enclosed private garden to the rear of the property. The home’s fees range from £427.00 to £580.00 per person per week, and include all costs with the exception of newspapers. Stonebridge Nursing Home DS0000068267.V327910.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 took place over six hours – covering the morning and afternoon period. The inspection represented the first inspection of the service since its purchase by the new owners, Alexandra House Care Services Ltd, who have only owned the home and been registered for a short period of time. The home has a long history of poor performance, and opportunity was taken, during this inspection, to assess the new owners’ management of the service and future intentions for the service. The inspector was notably pleased to see how the new owners have, within a very short period of time, commenced action to improve the home’s performance (and ultimately, improve quality standards for service users). Due to their clinical conditions, many service users were unable to provide an informed opinion about the quality of service provision. Opportunity was, therefore, taken to observe staff interaction with service users, and form an opinion about care provision based on the observation(s) made. Feedback was sought from service users’ relatives – who were very positive about the service. The new owners are taking a responsible approach to improving a service that has, for a considerable period prior to purchase, been a poorly performing service. Appropriate action has been taken to safeguard service users, and an improvement strategy has been formulated to ensure the continued and sustained improvement of the service. What the service does well: Opportunity is taken, when appropriate, to ensure that service users’ private accommodation is personalised. Care staff work hard to ensure that service users’ personal care needs are addressed. This is of particular note given the high dependency of service users, and the complex challenges presented by service users’ behaviour. The quality of service provided by the on-site laundry is commendable. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 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 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. Stonebridge Nursing Home DS0000068267.V327910.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 Stonebridge Nursing Home DS0000068267.V327910.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): 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive all the information and support they need so that they can make a decision regarding their choice of home. The home only offers a service to people whose needs they can meet. EVIDENCE: Five service user files were randomly selected for examination. Service users’ individual needs are comprehensively assessed prior to them moving into the home in order to establish the home’s ability to meet those needs and the appropriate care to be provided. Each care file examined contained a preadmission assessment that had been completed by the home’s registered manager (who is a first level registered mental nurse). The home’s manager assesses each prospective service user in the comfort of their own home, or in Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 9 their place of residence if it is not their own home. It is noted that, due to memory loss problems, most prospective service users are not capable of expressing an informed choice or decision about their (future) residence, so a member of their family usually makes a decision on their behalf. All service users have a contract or statement of terms and conditions of residence that sets out what the individual can expect from the service, and what the service can expect from the individual. As intermediate care is not provided by the home, Standard 6 is not applicable. Stonebridge Nursing Home DS0000068267.V327910.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate systems are in place for care planning and health care screening but, by failing to keep effective care records, registered nurses fail to ensure that the health and social care needs of service users will be effectively met. The principles of respect and dignity were observed being upheld by care staff. There is a good medication management system in place. EVIDENCE: Service users had access to doctors, district nurses, chiropodists, opticians, dentists and other health care professionals. Records were well maintained of all visits and contacts. Regulation 37 notifications made to the Commission for Social Care Inspection demonstrate that appropriate action is taken when people became ill or have Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 11 accidents. The daily records demonstrated that advice is sought and appropriate care is provided. Medication was being appropriately managed and records were well maintained. Staff demonstrated that they knew how to respect service users’ privacy and dignity and it was observed that their relationship with service users was pleasant and courteous. It was observed that privacy and dignity was respected, and bedroom doors, toilets and bathrooms were fitted with locks so that privacy could be obtained when wanted without compromising safety. However, care plans examined failed to demonstrate the care needs of service users and failed to prescribe the care necessary to meet service users’ needs. Some care plans examined were clinically negligent and failed to address care needs that had been identified through assessment. For example, one service user (referred to as “X”) possessed short-term memory problems. The plan of care was as follows; “Ensure X is always called by his name. Explain X before doing each procedure. To maintain contact with family. Talk with X softly and clearly. If any change inform family. To maintain contact with family” (sic). The nurse responsible for writing the care plan was negligent. Of great concern was another care plan for a service user (identified as “Y”) who had challenging behaviour. The care objective was to “maintain physical and psychological stress to harm others” (sic). The plan of care was cited as; “If any changes inform the incharge. Observe Y closely. Keep Y away from the other residents. If condition persist liase G.P. Inform family members. Document the evidence” (sic). The plan of care had been written to address “aggressive” behaviour. The care notes subsequently explained that the service user mistook other service users as his partner and would become protective if he perceived other male service users approaching those individuals whom he believed to be his wife. This had not been incorporated within the plan of care. There was little evidence to suggest that service users (or their representatives) had been actively involved in the care planning process. By failing to include the service user or their representative, nursing staff demonstrate a culture of preclusion. This is not good practice. As care plans evidence the care delivered, the poor/negligent state of the care documentation questions the clinical competence of those nursing staff who have compiled the care plans. Another service user had been diagnosed with Parkinson’s disease. No plan of care had been developed for this clinical need. Given the size of the home, it was reassuring to note that only one person had a superficial pressure ulcer. The new providers had brought new pressure- Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 12 relieving equipment into the home, and this was contributing to the low incidence of pressure damage. One service user who was able to express a viewpoint confirmed that the care provided within the home was good. Observations made at the time of inspection agreed with this viewpoint. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 13 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Facilities and events are currently organised by care staff so that service users have some opportunity to participate in a choice of activities within the home. Service users are able to keep in contact with family and friends. The meals available provide limited choice for the residents. EVIDENCE: The new providers have reviewed the provision of social care within the home, and have moved away from employing an activities co-ordinator – who provided limited social activities in isolation. In an attempt to promote holistic care, they have delegated social care activities to care staff. This effectiveness of this move is being monitored by the providers, and will be subject to review. During the inspection, care staff were seen interacting with, and engaging service users with occupational and recreational activities. Service users Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 14 appeared to be gaining benefit from this. The staff/service user interactions seen were both relaxed and informal. The home continues to access external agencies when required. Religious beliefs are recognised and respected. Clergy representing the Roman Catholic and Protestant faiths regularly visit the home. The registered manager said that, should the home accommodate anybody with differing beliefs or from different cultures, those beliefs and cultures would be respected and met. Opportunity was taken to examine the home’s menu. Although the menu provision was criticised during the last inspection for lack of choice, the current menu still fails to: (a) (b) Demonstrate choice and Clearly demonstrate all the food/meals provided. This was discussed with the registered manager who said that the menus were in the process of being revised, along with their presentation. The manager said that consideration was being given to pictorial representation of the food on the menu to help service users understand the menu choice for the day. Staff were seen providing assistance to service users at mealtimes in a sensitive and supportive manner. Mid-morning drinks and snacks were also seen being provided to service users during the inspection. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure and adult protection procedure in place to fully safeguard service users. The home takes robust steps to safeguard service users. EVIDENCE: The CSCI has not received any complaints about the service since the time of the previous inspection, when the home was subject to Worcestershire’s multiagency adult protection procedure. This has now ceased. Since taking ownership of the home, the present provider has actively taken steps to follow-through concerns expressed. This has included an early morning unannounced visit to the home by the Directors and the home’s management, resulting in two staff being suspended for poor practice (i.e. sleeping on duty and failing to supervise staff effectively). The home has followed its own disciplinary procedures. As part of the new training programme, all staff are to receive training in the recognition and prevention of abuse (which is due to be undertaken in March 2007). This is to be underpinned by “person-centred” dementia training commencing in February and continuing through until May 2007. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The need to develop the home’s physical environment has been noted by the new owners, and action is being planned to improve the home’s environmental standards. EVIDENCE: The home’s physical environment ranges from a period initial building to substantial extensions – one of which was completed in 2005. The home is located on two levels, and access to the first floor is gained by a central passenger lift and two staircases located at opposite ends of the building. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 17 Service users’ accommodation is located on both floors of the home, and includes single and double-occupancy bedrooms. The new owners intend to undertake work to convert all but one double bedroom into single-occupancy bedrooms, and are aiming to make a planning application to undertake the work and add an additional lift shaft. They wish to convert the home into several smaller, living units rather than operate as it is – as one large 57bedded unit. This intention is viewed as very good practice and would help to improve living standards for service users. As part of this improvement plan, the owners are looking to convert the single, large lounge/dining area on the ground floor into several smaller lounges, which would then provide noninstitutional communal living space for each (planned) unit. Some bedrooms had been furnished and personalised by service users’ relatives. However, some service users had no next-of-kin to help them, and their rooms looked somewhat barren in comparison. Some items of furnishing within some bedrooms were damaged, but the new owners intend to refurbish all areas within the home. The improvement plan will aim to totally upgrade the physical environment while maintaining the fabric of the home within its current boundary. At the time of inspection, several areas within the home were odorous. This was, in part, due to the fact that several domestic staff had telephoned in sick at short notice – leaving just one cleaner to deal with the whole home. As an emergency measure, another member of non-care staff had been assigned to provide help. Opportunity should be taken to put into place alternative arrangements to ensure that, when there is an unexpected reduction in domestic staff, other personnel can be drafted in to maintain the (usually) good hygiene standards within the home. Since taking ownership of the home, the new providers have bought new mechanical hoists to help service users with mobility problems, and to promote the health and safety of staff and service users. There were suitable numbers of toilet and bathing facilities within the home. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are within the recommended levels for the number of service users at the home. Staff training has been targeted to ensure that all staff can effectively meet the care needs of people living within the home. EVIDENCE: The staff duty rosters indicated that sufficient staff are available to care for the service users. The home had based these calculations on dependency levels that are regularly reviewed. During the morning period, the home was (generally) staffed by two registered nurses and nine carers (with the manager in a supernumerary capacity). The afternoon period was (generally) staffed by two registered nurses and eight carers, while the night shift comprised of one registered nurse and four carers. Since taking over the home, the new owners have reviewed staffing levels and concluded that the numbers of registered nurses on shift during the daytime period (sometimes as many as four) was excessive and did not necessarily result in better care being provided. They have amended the staffing compliment accordingly. They have also introduced a “lead care assistant” role (qualified to NVQ Level 3). Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 19 In terms of management structure within the home, this has also been reviewed and now operates as (in descending order) the registered manager, a deputy manager, six registered nurses, a lead care assistant, four senior carers and ten care assistants. Staff records were reviewed, and these show that staff had completed application forms, references had been taken up, checks had been undertaken by the Criminal Records Bureau and all applicants had been interviewed. Advertisements have been placed for additional nurses and carers. The home had received 20 application forms from registered nurses of which, eight had been asked to provide a presentation on a given topic. Of the nurses that provided a presentation, two were offered a post. Staff were being formally supervised six times a year, while nursing and care staff were having annual appraisals. Feedback received from relatives overwhelmingly concluded that there were sufficient numbers of staff on duty within the home. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 20 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, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an experienced and trained manager who ensures it is run in the best interests of the people who live and work there. Service users’ rights are effectively protected. EVIDENCE: Historical feedback from relatives confirms that the manager is open and approachable, while current feedback from relatives confirms that staff are friendly and welcoming. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 21 The manager confirmed that she is receiving support from the new owners. Staff were being formally supervised in accordance with the National Minimum Standards. Supervision is important to ensure that staff understand their roles, the homes philosophy of care and how that philosophy is put into practice. It is also necessary to ensure that staff development needs are understood, recognised and actioned accordingly – with a view to improving service delivery. Since taking ownership of the home, the new proprietors have stopped the manager being used as an Appointee, and new terms and conditions clearly stipulate that the home no longer accepts any responsibility for individual’s finances. This is a safeguard to help prevent possible financial abuse. Since taking ownership of the home, the new providers have had the electrical system checked by a competent person and have signed a maintenance contract to ensure that any problems arising are effectively addressed in a safe and competent manner. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 22 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 3 3 3 3 3 2 3 1 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 12 (1) (a) Requirement Care plans must be developed to meet the assessed needs of service users. Care plans must be clinically effective. Care plans must be effectively reviewed and amended by registered nurses (when necessary) at least once a month (or more frequently if there are changes in the service user’s circumstances). Service users or their representative must be included in the care planning process. Timescale for action 01/02/07 Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 24 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 OP15 OP26 Good Practice Recommendations The menu should be reviewed, and should clearly demonstrate the choices available to service users. Arrangements should be made to ensure that when there is an unplanned shortage of cleaning staff, personnel can be drafted in to maintain hygiene standards within the home. Stonebridge Nursing Home DS0000068267.V327910.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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