Inspection on 06/11/07 for The Beeches (Wath)

This inspection was carried out on 6th November 2007.

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

The Beeches (Wath) 17/03/09

The Beeches (Wath) 27/02/08

The Beeches (Wath) 13/09/06

The Beeches (Wath) 02/02/06

The Beeches (Wath) 13/09/05

The Beeches (Wath) 14/12/04

The Beeches (Wath) 18/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Beeches (Wath) The Beeches Residential Care Home Carr Road Wath-Upon-Dearne ROTHERHAM South Yorkshire S63 7AA Lead Inspector Janet McBride Key Unannounced Inspection 6th November 2007 08:45 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 DS0000055216.V349762.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. DS0000055216.V349762.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches (Wath) Address The Beeches Residential Care Home Carr Road Wath-Upon-Dearne ROTHERHAM South Yorkshire S63 7AA 01709 761803 01709 761804 paulhulbert@ntlworld.com www.winniecare.co.uk Winnie Care (Highgrove) Ltd 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) Julie Morgan Care Home 44 Category(ies) of Dementia - over 65 years of age (44) registration, with number of places DS0000055216.V349762.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may admit four persons 60 years of age and over. Date of last inspection 13th September 2006 Brief Description of the Service: The Beeches is registered to provide residential care and accommodation for up to forty-four older people with dementia. The home is purpose built and is located on the main road in the town of Wath Upon Dearne area of Rotherham. There are community amenities close by which includes local shops. The Beeches is owned by Winnie Care (Highgrove Ltd), who also own other homes in the surrounding area. The home is built on two floors with access via a passenger lift or stairs, and Accommodation is provided in two units, each with its own lounge and dining room. Both units have twenty-two single bedrooms, each with en-suite facilities. Two of the single bedrooms have adjoining doors in order to provide two double rooms if they are requested. There are assisted baths and showers on each unit. There is a small, enclosed garden with a patio area for people to use and car parking spaces are provided at the side of the building. Fees are £ 385:00 per week, as at November 2007. Additional charges are made for hairdressing, chiropody and taxis. For further information contact the home. Information about the service was available for people and their families in the Statement of Purpose and the Service User Guide. This information was available in the reception area including the last published inspection report. DS0000055216.V349762.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this Key Unannounced Inspection, which took place on the 6th November 2007 for 8:15 hours. The inspectors manager was also present for a number of hours. The home is registered for forty four places, at the time of inspection twenty seven people were receiving services at the home. Prior to the inspection the manager submitted an Annual Quality Assurance Assessment this gives information regarding the home and services provided. Pre-inspection work was carried out on the information received and other relevant documentation, for example analysis of statutory notifications and complaint records. During the inspection documentation and records were examined, for example medication, complaints, accident records, staff rotas and staff training files. Three care plans were cross-referenced with other relevant documentation relating to those people who use the service, to evaluate how well their care needs were met. A tour of the premises and direct observation of staff interaction with people who use the service was carried out throughout the visit. Information was gathered from as many different individuals as possible that had contact with people within the home, including individual interviews with the manager and five members of staff. Two relatives were spoken to and six people within the home who receive the service. We sent out surveys prior to the inspection, ten were sent to people who use the service, four were received back. Three were sent to relatives, two were received back, three and ere sent to professionals who had contact with the home but none were received back. They were asked to comment on the standard of care, staff skills, attitude, and how the needs of people using the service needs were met. We would like to thank all the staff, relatives and people receiving services within the home for their co-operation in the inspection process. Any issues or concerns that were raised were discussed with the manager at the end of the inspection. What the service does well: We found that people who use the service had information about the home and services provided, they had all been individually assessed prior to admission to the home. Throughout this visit we found the atmosphere and interaction between staff and people living at the home was good, people looked relaxed and comfortable. DS0000055216.V349762.R01.S.doc Version 5.2 Page 6 Staff were seen treating people in a kind manner, they spent time talking to them and referred to them by their first name, this was agreed and documented in the care plans. Feedback from surveys and people on the day said that they were kept informed of matters and issues that affect their relative, and were satisfied with the overall care provided. Relatives confirmed they had access to the complaint procedure and the last inspection report. 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. DS0000055216.V349762.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 DS0000055216.V349762.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, 2 and 3. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People that use the service had information about the home and services provided. People were individually assessed prior to admission to ensure their needs could be met. EVIDENCE: The home offers residential and respite care but not intermediate care. All surveys received confirmed that people who use the service were provided with sufficient information before moving into the home, and that they had the opportunity to visit and stay prior to admission. It was also confirmed in surveys that people in the home had been issued with contracts/statement of terms and conditions. The scale of charges was discussed with the manager and any extras that people pay for, are documented on page 5 of this report. Records showed that people who use the service were fully assessed prior to moving into the home, with other professionals involved if required. DS0000055216.V349762.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 and 10. People who use the service experience adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Care plans provided staff with sufficient information that ensured they could meet the care needs of people, however changing needs may not be identified as care plans were not monitored and reviewed on a regular basis. Medication records did not provided an accurate audit trail needed to show that medication was being administered as prescribed. EVIDENCE: Three care plans were checked these set out in detail healthcare, personal and social care needs in an individual plan of care. This ensured that staff deliver the care required and peoples needs were identified and met. Records showed that staff had completed risk assessments, dependent on individual needs. People were nutritional assessed and weighed on a regular basis, and when weight loss had been highlighted they had been referred to dietician. DS0000055216.V349762.R01.S.doc Version 5.2 Page 10 Staff document what care was given on a daily basis, but all care plans seen had not been evaluated monthly, this means changing needs may not be identified. People had access to all health care services and other professionals when required. All surveys confirmed that people received medical care when needed. Medication practice was observed, records, storage and recording of medication was all checked and a number of issues were raised. Medication records did not always indicate that medicine was given as prescribed and no reason was recorded for omission of medicines. The majority of people receiving services had a diagnosis of dementia, therefore a number of people could not make decisions. It was documented in care plans when relatives, advocates and multi disciplinary teams were involved in decisions making. Staff were able to describe care needs of people within the home, and knew which people were able to make independent choices. However they said all people were encouraged to make everyday choices, for example what to eat and what to wear. This promoted the choices and dignity of people living at the home. A number of positive comments were received from relatives for example “On the whole it’s not a bad home, but more attention to detail is needed”. “ My relative has been at the home a number of years and can be very difficult and staff do their up most to care for them, they are always clean and tidy when I visit”. DS0000055216.V349762.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 and 15. People who use the service experience adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People within the home were provided with very little stimulation and interesting activities. They were offered a wholesome and varied selection of food available to meet people’s tastes and choices however further improvements are needed regarding issues raised in these standards. This may affect the quality of care provided for people who use the service. EVIDENCE: An activities coordinator is employed (but also works care hours within the home). All surveys said that activities usually happen, however despite the activities coordinator being on shift that day no activities took place. No programme or any structured hours dedicated to activities was available. Therefore opportunities to join in various activities that will offer some interest and stimulation were not available. Relatives said they could visit at any reasonably time and, that people had the opportunity to maintain some links with the local community by visiting local shops with either their family or members of staff. Menus were discussed with the cook, who confirmed the food budget was sufficient and that food and drinks were available at all times. DS0000055216.V349762.R01.S.doc Version 5.2 Page 12 Lunchtime was observed on both units on one unit it was unhurried and relaxed, dining tables were set with tablecloths, cutlery and plate guards were being used as this assists people to eat their meal independly. People were offered seasoning and choice of drinks. However on the other unit a number of people were sat in wheelchairs, no reason was given for not transferring to dining chairs. Wheelchairs were dirty and encrusted with food debris. No tables were set until people sat down, knives and folks were offered but no spoons or plate guards fitted until well into the meal. The cook served lunch and care staff were involved in serving and assisting. Two people said, “they missed salt”, this was not offered until prompted by the inspector, both said, “it was lovely with salt”. People on both units made very positive comments about the food, and all surveys received back from people said they liked the food. It was noticed that a lot of food was left at lunchtime, but a number of people were still having breakfast at 09:45 and lunch was served at 12:30 and the portions were very generous. The lunchtime meal sampled was tasty, hot and well presented. DS0000055216.V349762.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 and 18. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The complaints procedure was accessible and displayed within the home. Policies and procedures were in place on adult protection, this promoted and protected people who use the service. EVIDENCE: There was a comprehensive complaints procedure, which was on display. Complaint records showed that any complaint had been recorded, responded and investigated in an efficient and thorough manner. All surveys confirmed that people were aware of the complaint procedure and knew how to make a complaint. One relative said, “The home always responds appropriately when concerns had been raised”. Policies and procedures were in place regarding the protection of vulnerable adults. Staff confirmed they were aware of abuse polices and procedures, and staff were able to describe the action they would take on receiving any allegations. Management had been proactive in referring any allegations or incidents to adult protection, these are investigated and responded to in a satisfactory manner. DS0000055216.V349762.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, 21, 24 and 26. People who use the service experience adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Some areas of the home were clean and tidy, but an unpleasant odour in various areas and some furniture was not clean. However comments from people who use the service and relatives thought the home was a comfortable environment. EVIDENCE: The entrance and reception area to the home is very pleasant and welcoming, there is a smoking room for people who use the service. Communal space is available on each of the units, which includes various lounge and dining areas. A tour of the premises found the general appearance of the home satisfactory with new furniture in dining rooms. Bedrooms were seen on both units, people could bring personal furnishings with them on admission, however very few were found to be homely or personalised. There was an unpleasant odour in a number of bedrooms, and DS0000055216.V349762.R01.S.doc Version 5.2 Page 15 two carpets were in need of cleaning. One mattress was found to be very stained, and two chairs and a table were in need of cleaning. The home had a call system in each bedroom, but some call cords were missing, therefore people could not summon help when required. Bedding was very worn and thin and pillows were misshaped and lumpy. Toiletries, Sterident and prescribed creams were found in bedrooms and not in locked cupboards. Laundry facilities at the home are satisfactory, but the clean laundry cupboard was found to contain towels that were very worn no face clothes, sheets were thin and pillows were similar to the ones found in the bedrooms. Staff did go out and purchase new pillows, towels and face clothes before the end of our visit. There are assisted baths and showers on each unit. A tour of these areas found that they contained surplus mattress or wheelchairs. All cupboards for keeping toiletries and prescribed ointments were all found to be unlocked in all ensuites and bathrooms with exception of one shower room. This creates an unnecessary risk to people living at the home. Cleaning and domestic hours were discussed with the manager, as they had no domestic cover most days after either two or three pm. From the issues found the homes cleaning regime needs re-structuring to bring improvements, to ensure that the home is clean at all times of the day. DS0000055216.V349762.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 and 30. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staff had the skills and knowledge to fulfil their roles within the home; a stable staff group ensures continuity of care by staff that know the people who use the service. Recruitment policies are followed ensuring the safety and protection of people who live at the home. EVIDENCE: Staffing was discussed with the manager and the duty rota examined, this clearly identified staff within the home and their role, gave a clear line of accountability of management and ancillary staff. The home had a very stable male and female staff group. Observation on the day and checking of duty rotas confirmed there were sufficient staff to meet the needs of people who use the service. Domestic hours need to be reassessed due to the issue of odours and items that required cleaning highlighted by this visit. Comments received from relatives on surveys and those spoken to during the visit confirmed that they were happy with staff saying “The staff always seem to care for the residents and are very helpful from the manager to the care staff”. “The staff always responds to any questions I have regarding my relative”. “I am well satisfied with the home”. DS0000055216.V349762.R01.S.doc Version 5.2 Page 17 There were robust recruitment and selection procedures including an equal opportunities policy. A number of staff recruitment files were examined, which confirmed that all the required employment checks have been undertaken prior to staff being employed, including Criminal Record Bureau (CRB) Protection Of Vulnerable Adults (POVA) checks. This ensured people who use the service were safe and protected. Training and development of staff was discussed with the manager and staff, who confirmed training had been completed. Training records indicated that a number of the staff team had accessed various courses since the last inspection, for example dementia, abuse, moving and handling and basic first aid course. Development of staff was evident by 50 of staff achieving National Vocational Qualification (NVQ) level 2 or 3 in care with other members of staff continuing to work towards attaining this qualification. DS0000055216.V349762.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, 36 and 38. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The financial interests of people were safeguarded, good health and safety procedures ensured they were protected. However the manager needs to ensure a more structured approach in her leadership. EVIDENCE: Management structure at the home consisted of a registered manager, deputy manager and an administrator. The manager had completed the registered managers award, and intends to start a dementia course next year. Although the manager has the experience to run the home she needs a more structured approach to monitor the day to day running of the home. Quality assurance systems were in place and the manager could evidence they monitor the quality of care and services within the home. DS0000055216.V349762.R01.S.doc Version 5.2 Page 19 However areas referred to earlier in this report had not been picked up by the quality assurance system Surveys were sent out six monthly to gain the views of relatives about the care and services provided. The company’s operations manager continues to carry out monitoring visits, and completes regulation 26 reports, which state what she found during her visit and who she spoke to, these were available to examine. Staff meetings, resident and relative were held three to six monthly with minutes taken. Staff said they received supervision on a regular basis either from the deputy managers or the manager. Finances and financial recording were discussed with the homes administrator, with some random records and balances checked. All were found correct they were stored separately with accurate recording of transactions and receipts kept. Maintenance and service records were examined, these were up to date with current certificates. The required Health and Safety policies and procedures and the relevant notices were displayed throughout the home. Fire safety procedures were in place, records examined showed they were current and up to date. This keeps people living and working at the home safe. DS0000055216.V349762.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 DS0000055216.V349762.R01.S.doc Version 5.2 Page 21 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 15(2)(b) Timescale for action Care plans must be reviewed and 19/11/07 monitored on a regular basis. (Timescale of 30/11/06 not met) Medication 1) Staff must record why they omit medication. (Timescale of 01/10.06 not met) 2) Staff must sign all medication records when prescribed medicines as been given. 3) Medication must be given at the time stated on the prescription. 4) Prescribed creams and lotions must kept secure. Locks on cupboard doors that contain toiletries must be operable, to ensure vulnerable people are kept safe. Cords must be left within reach of people’s beds. Sufficient bed linen, towels and face clothes must be available to meet the needs of people. 06/11/07 Requirement 2 OP9 13(2) 3 OP24 23(2)(c) 01/12/07 4 5 OP24 23(2)(c) 23(2) 01/12/07 OP24 01/12/07 DS0000055216.V349762.R01.S.doc Version 5.2 Page 22 6 OP26 23(2)(d) The home must be kept clean, hygienic and free from offensive odours throughout the home. Cleaning regime must ensure that the home is clean at all times of the day. 01/12/07 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 OP9 OP12 Good Practice Recommendations Recording of Temazepam should be documented in a bound book with numbered pages, signed and dated by two staff. A programme of recreational activities should be available to meet people’s needs. The activities coordinator should be encouraged to develop her skills and ensure people living at the home are offered a range of stimulating activities. Care duties should not encroach on dedicated activity time. Mealtime’s seasoning, choice of drinks and aids and the right equipment should be available to support people to retain their independence. Bathrooms should not be used as storage for equipment. The manager should monitor the day to day running of the home to ensure the stated purpose, aims and objectives are met. 3 4 5 OP15 OP21 OP31 DS0000055216.V349762.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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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