Inspection on 26/02/08 for The Charlton Centre for Alzheimer`s and Dementia Care

This inspection was carried out on 26th February 2008.

CSCI found this care home to be providing an Poor service.

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 Charlton Centre for... 19/08/09

The Charlton Centre for... 25/02/09

The Charlton Centre for... 28/08/08

The Charlton Centre for... 31/10/07

The Charlton Centre for... 19/10/06

The Charlton Centre for... 29/11/05

The Charlton Centre for... 11/08/05

The Charlton Centre for... 20/12/04

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

CARE HOMES FOR OLDER PEOPLE The Charlton Centre for Alzheimer`s and Dementia Care Carlinghow Hill Batley West Yorkshire WF17 0AE Lead Inspector Nadia Jejna Key Unannounced Inspection 26th February 2008 10:00 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 The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.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. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Charlton Centre for Alzheimer`s and Dementia Care Carlinghow Hill Batley West Yorkshire WF17 0AE Address 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) 01924 473333 01924 444344 ivor@charltoncare.com Charlton Care Homes Ltd Mr Ivor Charles Foster Care Home 67 Category(ies) of Dementia (67) registration, with number of places The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of service users who can be accommodated is: 67 31st October 2007 2. Date of last inspection Brief Description of the Service: The Charlton Centre for Alzheimer’s and Dementia Care (previously known as Carlinghow Nursing Home) is registered to provide a service for up to sixtyseven elderly people with dementia who require nursing care. The home is a large detached stone built property that was converted into a care home from the former Batley General Hospital. The home has three floors connected by a passenger lift. The home is situated on Carlinghow Hill close to Nightingale Cottage Nursing Home, its sister home. Local amenities are within ten minutes’ walking distance. The home is well served by public transport. There is ample parking space at the home. The provider informed the Commission for Social Care Inspection on 31st October 2007 that the fees range from £464.00 to £1,786.35 per week. There are additional charges for hairdressing, newspapers, and magazines. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection consists of a review of information received and held by us since the last inspection and the findings made during a visit to the home. The visit was unannounced and carried out over two days, the 26th and 28th February 2008, by two inspectors. The purpose of this visit was to: • Look at progress made meeting requirements in place from the last inspection in October 2007. • Make sure that the home was being managed for the benefit and well being of the people using the service. Following the poor outcomes of the last inspection the provider was asked to complete and return an improvement plan to us. An outline plan was sent as guidance. At the point of writing this report nothing had been received from the provider. The pharmacy inspector carried out an audit and inspection of the handling, storage and administration of medication on 26th February 2008. The findings of this audit are detailed in the Health and Personal care section of this report. During the visit we talked to people who live there, to visitors who called in during the day and staff on duty. The daily routines of the home, care practice and staff interactions with people were observed. We looked at various records such as staff files, complaints and accidents records and looked round the home. What the service does well: Information about the home is available for people to take away with them and look at. Information about peoples needs is obtained from the healthcare professionals involved with their care. Visitors are welcome in the home at any time to see their relatives. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Action must be taken by the provider to make sure that the home is run and managed in the best interests of the people who live there; so that the experience of living in the home and outcomes for them are improved. Peoples needs should be identified and met in a person centred/individual way rather than the institutional practices that are being followed in the home. This must include making sure that: • Person centred care plans are in place that tell staff about the individuals health, personal, social and psychological care needs including their personal preferences, abilities and wishes and how to meet them. • Where risk assessments identify people as being at risk of falling, developing pressure sores or losing weight, advice is sought from appropriate health care professionals and detailed care plans put in place. This will make sure that peoples healthcare needs are identified and met. • People who are low weight and at risk of losing weight are identified and action taken to prevent further weight loss. This should include contacting appropriate healthcare professionals such as the dietician and making sure that they are given a suitably nourishing diet using good practice guidance that is available. • There are safe systems in place for ordering, storing, administering, recording and disposing of medications. This will make sure that people receive their medications correctly and safely and the treatment of their medical condition is not affected. • Care practices in the home are reviewed to prevent people from being harmed, suffering abuse or being placed at risk of harm or abuse. This must include reviewing the adult protection procedures in line with local authority and government guidance and through staff training. • The home is safe and well maintained; that it meets people’s individual and collective needs in a comfortable and homely way and has been The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 7 • • • designed with reference to relevant guidance for the specialist care needs of people with dementia. There is enough staff on duty at all times to meet the needs and numbers of people living in the home. This must take into account people’s specialist dementia and psychological support needs as well as the size and layout of the building. Pre employment checks including two written references, satisfactory POVA first and enhanced CRB disclosures, full employment history and the reasons for any gaps are in place before staff start at working the home. This is to protect the people living there. Staff receive appropriate training to help them to maintain the health, safety and well being of people living in the home and themselves. This must include training about the specialist needs of people such as dementia and dealing with ‘challenging behaviour’ and appropriate training for qualified nurses to make sure they are qualified and competent for the job they are doing. All new staff should be enrolled on an induction training programme that is to Skills for Care common induction standards when they start work. 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. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 8 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 The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information available about peoples needs from other health and social care professionals is not being used to determine individuals needs or to inform the admission and care planning process. EVIDENCE: The manager said that either he or another nurse visit people before they are admitted to the home to assess their needs. He said he will always get an up to date copy of the local authority or healthcare specialists care needs assessment. Copies of these documents were seen in some of the care plans looked at. We were told that in some cases the information had been filed. In one case the local authority assessment was in the care plan, but not all the information it contained had been used to inform the care planning process. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.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 poor. This judgement has been made using available evidence including a visit to this service. People are at risk of their personal, physical, health and psychological needs not being identified or met because: • The records show that when a risk is identified detailed care plans are not put in place to tell staff what they should do to reduce the risk. • The care plans do not address individuals specific care needs, abilities or wishes. • Staff have not had the training needed to be able to understand or meet peoples specialist care needs. • The medication practices in the home have the potential to place people at risk of harm. EVIDENCE: The area manager had visited 27th, 28th and 31st December 2007 and again 30th and 31st January 2008 to carry out a provider’s audit of the services provided in the home. As part of the audit she looked at six care plans randomly selected from the three units on both visits. Both of these reports said that ‘The standard of the care plans was very good. The information was very individualised to the particular service user.’ The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 11 We looked at care plans on each of the units. In total nine different care plans were seen. We found that the care plans were not always detailed or individual to each person and they were not person centred. The plans contained healthcare assessments but the findings of these were not always followed through into the care plans and actions for staff to follow to meet needs or reduce risk to people. We talked to staff who told us that they had not had training about person centred care, including the manager. One nurse told us they were doing a lot of research in their own time to learn more about dementia and person centred care and had realised that the care plans as they are now do not address all the issues needed to meet individuals needs. Examples of shortfalls found in the care plans were fed back to the manager during and at the end of the visit and to the operations manager on the second morning of the visit. They included: • One person identified as being at high risk of falls had a care plan that said they should wear well fitting footwear and be monitored/supervised. The individual was sitting in a ‘bucket’ style chair but there was no risk assessment around using this equipment. They were not wearing any footwear at all – staff told us they did not like to wear shoes or slippers and would kick them off. There was no information about how often the individual should be monitored or checked or how this would be recorded. Staff told us that when the person was in the lounge they would be there most of the time to ‘keep an eye on them’ but were not sure about how often they would be checked at night. They said that bedrails were used at night to promote safety but there was no risk assessment or consent from relatives about the use of bedrails. The same care plan around falls and mobility also included some basic information about ‘preventing complications from reduced mobility’. The person was at risk of developing pressure sores and had had them in the past. There was no information about what was being done to reduce the risk of developing more sores. Information on the care needs assessment from social services said they had been nursed on a specialist pressure-relieving mattress and sat on pressure relieving cushions. A pressure-relieving cushion was not being used but they did have a foam pressure-relieving mattress on their bed. • The risk assessments used to identify if an individual is at risk of developing pressure sores has a section that asks about an individuals body mass index. Staff had completed those seen. To do this they need to see a body mass index (BMI) chart that tells them what the BMI is after they have got the weight and height of the person and checked it against the graph. We asked staff where this chart was and were told they did not have one. We were concerned because two people had been put down as having a BMI of 25 –29.9 medium and a BMI of 20- 24 average. Both people were clearly frail and underweight. We told the The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 12 • • • • • • manager where to access this information and he had a copy of the BMI chart on the second day of the visit. Using the chart told us that both people had a much lower BMI than had been ‘guessed’ at and should be receiving additional input from their GP and or dietician. The care plans around nutrition/eating and drinking for the two people in the bullet point above were looked at because they looked frail and underweight. Nutritional assessments had been completed for both people. One person was identified as at risk and the other was not. The plan for the person at risk did not mention the outcome of the nutritional risk assessment or say if a referral to the GP or dietician had been made. Neither of the plans told staff what their food likes/dislikes or preferences were and did not say that they needed additions snacks and enriched foods/meals. The night care plans were informative, but they were all similar. The care plans around personal hygiene were the same and did say what the individuals abilities were, how much they could do themselves and how much help or support they needed. For some people where they had identified medical conditions, some of which were quite serious, there were no care plans to address these. For example people who had angina, umbilical hernia, heart disease, sarcoidosis, high blood pressure, epilepsy, oedema (swelling of the legs) and Macular degeneration – a condition that affects eyesight and can result in blindness. Two people were identified as having macular degeneration and staff had written muscular degeneration for one person on more than one occasion, this shows a lack of knowledge and understanding of this condition and could cause confusion in the future. All people living in the home have a diagnosis of some form of dementia. Many of the care plans we saw did not tell us what type of dementia the person had. Two care plans on the challenging behaviour unit told us something about how dementia had affected these individuals in relation to how their behaviour could change. The care plans from other units did not tell us how the person had been affected by the dementia or how staff could help them. One daily progress report reported on 21/01/08 that the persons GP had advised they might have borderline diabetes. The care plan documentation did not say what action had been taken as a result of receiving this information. From talking to staff it was clear they had a basic understanding of peoples needs but not all of them understood what ‘person centred care’ was. Care staff said they write in the daily progress notes if they have time. Entries made by them were informative but often had not been countersigned by the nurse in charge. They said they did not have time to read the full care plans. Information from people we spoke to was mixed: • Some people were satisfied with the care and support their relative received and said that most of the staff were nice and kind. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 13 • • • • Some people said they were not kept up to date with changes in their relative’s condition. One person had not been told when their relative had a fall. One person said they had had to ask a few times and wait a long time for a chiropodist to attend to their relative’s feet. One person said staff had not treated a mouth condition affecting their relative. There is a medicines policy in the home that has been produced by the company. The date of the policy is January 2006 and should be reviewed to make sure practice is in line with current legislation and guidance. The findings of the pharmacy inspection told us that the systems for dealing with medications in the home are not robust. Examples were given to the manager and include: • There were some medicines in the trolleys that were not recorded on the MAR (Medication Administration Record) chart. This is not safe and means that people might be given medication that is not prescribed for them. All medications for people in the home must be prescribed by a GP, dispensed by a pharmacist and listed on a MAR. This is a safeguard that makes sure people are being given the correct medication as prescribed by their GP. • The manager told us that five nurses have been disciplined because problems had been identified with MAR charts not being signed and medication doses being missed. He told us he had talked to them about the Nursing and Midwifery Council codes of conduct. We asked if they had been given medication training updates; the response was no. • That one person had not been given their medication for two days because there was no stock available. This included a tablet prescribed to treat the symptoms of Parkinson’s disease, which must be given at regular intervals to keep symptoms at bay. Another person prescribed a once weekly medication was given it two days late; this means it was not given as prescribed and may have an effect on the treatment of their medical condition. • On returning from a hospital stay one person had two of their medications stopped but these tablets had been left in the trolley. One of the medications had been removed from the stock in the trolley on two days but there was no record to say if it had been given to the person or disposed of. • Medication for a person that had been reduced from 5 to 4 tablets had remained packed as 5. The MAR charts and packaging stated that 4 should be given and to dispose of the fifth tablet but there were no records made to show that this had happened. This means it is difficult to know that the correct amount has been given and that remaining tablets have been disposed of safely. At the end of the pharmacy inspection the manager put a recording system in place. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 14 • • An audit of current stock and records showed that some medication had been signed for but not given. For example one person had been prescribed 20 ml twice a day of an antibiotic syrup, 200 ml had been supplied. The MAR chart had showed 14 records/signatures, which adds up to 280 mls, more than the quantity supplied. The date of opening of medicines with limited use once opened is not always recorded. This means there is a risk that the medication may be used beyond the date recommended by the manufacturer and may not be safe to administer. Good records are kept on the Birch unit of medication that has been changed by the prescriber/GP. This means that staff have up to date information on a person’s medical treatment. The lockable medicines trolleys are kept in lockable rooms on Cedar and Willow units. The trolley on Birch unit is chained to a wall in an area that is accessed by a small door. The room behind this area should be used, as this is lockable and would provide greater security for medication. The person in charge of ordering the monthly medication must have sight of the prescriptions before a supply is made. This provides an opportunity to check if any new medicines or dose changes are included. Any problems with prescriptions can be addressed at this point rather than after the supply has been made. The checking of prescriptions is an important part of the management of medication. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 15 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 poor. This judgement has been made using available evidence including a visit to this service. People’s social, cultural and leisure needs are not being met because the staff team lack training and time. People’s individual wishes, needs and aspirations are not being recognised or taken into account because the home is run in an institutional way with certain things being done ay certain times. People are at risk of becoming malnourished because their dietary needs are not being properly met. EVIDENCE: During the registration process the provider indicated that a second activity organiser would be employed. We found that one person is employed to plan social and leisure activities for all three units. They have not had any training to help them do this. We were told they were leaving at the end of the week and the manager was in the process of recruiting a replacement. Most of the care plans we looked at contained a life/social history but this information was not being used to plan activities or social stimulation for the individuals. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 16 There were no planned, regular activities. The organiser completed activity records in the care plans, which were often one to one sessions or small group activities such as afternoon tea or baking. Some staff spent time with people chatting and in one case playing a game of chess but others did not interact or mingle and were in the rooms watching people. Some of the staff had a very good way of talking to and involving people, making them feel valued, when they did something with them. But the majority of staff interactions were task based, giving a drink or a meal or taking somebody, who had asked, to the bathroom. Some people were constantly walking around the corridors and were ignored by staff. The communal areas were bare and did not have a homely feel to them. One lounge had a TV on a high shelf in the corner of the room that was difficult for people to watch. Radios were playing in many of the communal areas but were on ‘pop’ stations and raised the question who was listening to the music? Staff told us that people can choose when to get up and go to bed. This is good for those who can communicate easily. Information should be added to the care plans about the preferred daily routines for people who cannot communicate easily. This could come from their relatives. There is a small lounge on Birch unit that has been designated as a ‘faith room’. It is used as the place for people to have communion. Apart from some bibles on a bookshelf there is nothing else to show how and why people should be able to recognise it as a faith room. People’s religion and chosen faith is recorded in the care plans but again the information is not used to provide meaningful activities. The care plan for individual who used to be a Sunday School teacher did not say how this could be made a meaningful part of their care and support on a day-to-day basis. The menus are planned on a four weekly rotation. The master copy is on display in the kitchen. The cook said that kitchen staff put it together after talking to nurses and carers. We were told that they catered for diabetic diets and that they used full fat milk, added cream to custard and porridge and butter to the vegetables. Some staff attended a training session about fortified foods and liquid diets. We were told that fruit and biscuits were always available for people. Staff gave out tea and biscuits at mealtimes, mid morning and mid afternoon. We did not see people sitting with drinks in between these times, even though there are kitchenettes on each unit. We were told that people can have extra drinks and snacks on request and that everybody gets a supper drink and snack at 6.30 pm. For people who can communicate their wishes easily this is satisfactory but the majority of people we saw had some form of communication problems and would not be able to ask. Breakfast is served from 8 am which means that many people could go over thirteen hours without food or drink. The food/fluid wastage charts used we saw were a poor way of recording what somebody had had to eat or drink – they asked if the The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 17 person had eaten a quarter, a half, three quarters or all of the meal, but there was nothing to indicate what portion size had been offered. This is a serious issue as some of the people we saw were frail and at high risk of being underweight for their age and height. We talked to the manager about this and during the visit he downloaded information from the internet as we had advised him to. This included CSCI ‘nutritional triggers and information including a body mass index calculator’. There were no menus to be seen on any of the units. Staff told us that people were asked the day before what meal choice they wanted the next day. This is not good practice for people with dementia and poor short-term memory. The care plans seen did not tell us what peoples dietary preferences, likes and dislikes were. A visitor told us that the lunch their relative had been given was not something they would have at home, they were given lasagne when they would have preferred the other choice of corned beef pie. Meals are prepared in the kitchen on the ground floor and taken to the units on hot trolleys. The dining rooms are canteen style rather than homely. There were cloths on the tables in two units but the tables were not set. Staff gave people cutlery and utensils as they served the meal. The crockery used was a mixture of different styles and colours, some of which were chipped and some people were given plastic mugs. Meals were served to people as a process/job to be done rather than making it a sociable mealtime event/experience. Some staff helped people to eat in a respectful and nice way but others were seen ‘spooning’ food into somebody’s mouth while holding a conversation with another member of staff on the other side of the room. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Institutionalised care practices throughout the home means that people are not being protected from abuse. EVIDENCE: A copy of the complaints procedure is displayed in the reception area. Following the quality assurance survey in December 2007 it was identified people were not sure of how to raise concerns. The manager said that he posted a copy of the complaints procedure to people’s next of kin or representative. Since the last inspection in October 2007 the manager has recorded three complaints. One was about another resident being found in somebody’s bedroom, another was from a visitor who wanted to visit their relative without interference from other residents. These said that they had been resolved on the day. The third complaint had been referred by the local authority on behalf of a relative who was unhappy about the care their relative had received in the home. The records said a case conference was to be held early in November 2007 but there was no information if this had happened or what the outcome was. The manager told us that he and another manager had attended ‘train the trainer’ courses about adult protection and abuse run by the local authority. He said that he has made sure all staff have received this training. The provider’s The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 19 induction information pack contains a copy of the homes policies and procedures around abuse and adult protection. We looked at this. It gave staff information about abuse but did not tell them what to do if they see or suspect that abuse is taking place. Staff told us that they had received training titled POVA – protection of vulnerable adults - and if they saw or suspected abuse they would report it to the person in charge or somebody senior in the organisation. When some were asked how they would view a person being refused a drink, they did recognise it as a form of abuse and said they would go and get the person a drink. It is a concern that we did not see people being offered drinks or snacks except at designated times and that we saw one person who did not want what was offered at mealtime go without because staff did not offer them anything else. We saw a carer make somebody sit back down in their chair without speaking to them to wait for the meal to be served, this information was given to the manager by telephone call on 3rd March 2008. Evidence found from looking at peoples care plans shows that their personal, physical, health, psychological and social care needs are not being fully met and there is a risk that they will be neglected. At the time of this visit the care provided to four people is being looked at under the local authority safeguarding procedures. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 20 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 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Work must be done to make the home safe, clean, odour free, comfortable and suitable for people with dementia. EVIDENCE: Information from the provider to support the application for the change in registration in April 2007 said that one wing of the building had been redesigned in line with good practice advice from the dementia research unit at Stirling University. This research advises about making environments more suitable and ‘enabling’ for people with dementia. The application said that ‘bedrooms have been fitted with front doors painted in primary colours, letter boxes, memory boxes by the door.’ We saw that Birch unit has been expensively refurbished and redecorated. It is clean, fresh and smart but it is ‘hotel’ style and not easy to find your way around as all corridors looked the same. There was poor use of signposting to tell people where they are and where communal facilities are. The manager looked at this and on the second The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 21 day of the visit pictures and signs had been put in place to show more clearly where toilets, bathrooms and communal areas were. We talked to the area manager and the manager about research and guidance that is available to improve environments for people with dementia and where they could get it. The other parts of the home compare very poorly to Birch unit. Visitors said that coming through the new section to the other parts of the home was like ‘ going from first class to the third class.’ The other areas of the home are in need of cleaning, redecoration, refurbishment and the lighting improving. The lighting in the communal dining/lounge area on the first floor was not very bright later in the afternoon. The home looked generally clean but there were strong odours of urine in some areas, especially some of the armchairs in the top floor lounge. The manager and domestic staff said that a new product is being used to reduce/eliminate odours. Steps should be taken to make sure that chairs are cleaned/treated regularly as necessary. Requirements have been made in the last three reports about the condition of the external window frames and guttering. This has been partly addressed with most of the front of the home having had the external window frames painted and some of the guttering replaced. The manager said that bad weather has delayed this work from being completed. Some internal work has been done in response to requirements made at the last inspection. The dining area on the top floor has been redecorated, but the use of this space should be reconsidered because it is in the centre of the building and part of the main access route to other rooms on this floor; this means that mealtimes are disturbed by people walking through. The bathroom has been refurbished and some of the corridors have been painted. There is still a lot of work that must be done to make sure the home is safe and suitable for people with dementia. Some areas of the home have been ‘flooded’ when people have left taps running, flooding the rooms below or from water damage in bad weather because there are some leaking flat roofs. A bedroom, one of the lounge areas and the laundry has been affected. The manager said he had talked to senior management about providing pressure taps that will stop running after a short time to reduce the problem of people leaving taps running. The manager said that the night staff have been asked to clean the wheelchairs at night and sign a monitoring form to say it has been done. The buzzer/nurse call system needs to be checked to make sure it is working properly. On the first day of the visit the emergency bell for a bedroom had been activated but staff in the dining room were not responding because they could not hear it. On the top floor of the building a call system panel was lit for The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 22 a room but nobody knew which room it was or which part of the building it was. All bedroom doors have locks that can be locked and opened from the inside by turning a small handle/knob but they can also be locked from the outside using a master key. On some doors the locks were quite high and would be difficult to open. We found that most bedroom doors were locked because some people walk in and out of other people’s bedrooms. We were told that at night many doors are locked. The manager said that he was putting together a consent/risk assessment document to record the wishes of the individual or their relatives about the use of door locks. The laundry has two washing machines but neither of them will do a 60 degrees wash. They do have a sluice cycle that washes at a higher temperature. One washing machine has been removed as it was faulty and a replacement will be ordered. The laundry floor is tiled but a section of this has been lifted to identify and repair a water leak. The home has sink style sluice facilities on each floor. We were told that commode pans and urinals are rinsed in these sinks and treated with disinfectant. There are mechanical sluice disinfectors but they are broken and cannot be used. Some of the commode pots were very stained and scratched. This should be reviewed as it increases the risk of cross infection. Not all staff have done infection control training. The manager has got a copy of the Department of Health resource kit about infection control – Essential Steps – but he has not used it. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 23 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, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People are placed at risk because: • There are not enough staff on duty to meet peoples needs. • Staff have not had the training needed to equip them to understand or meet peoples specialist needs. • The homes recruitment procedures are not robust and some people have been employed before required checks have been completed. EVIDENCE: The manager said that staff numbers are set by company policy. On Birch unit there were nine people with four staff through the day and three at night, including one nurse on all shifts. The other two units work on a ratio of one member of staff to five people through the day and one to ten at night, including a nurse. This system of staffing does not take into accounts people’s personal, social, psychological and specialist healthcare needs. The numbers of staff on duty should be reviewed to make sure that people’s needs are met. On the first day of the visit the people living in the unit on the top floor of the home were still being given their morning medications at 11:00 am. Information from people we talked to told us that: • Sometimes they had to wait for staff • That were not enough staff on duty to look after ‘the type of people who lived in the home’. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 24 • People were not adequately supervised because there were not enough staff. Staff files were looked at for eight people who had been employed since the last inspection. We found that: • Four people had been employed with only one written reference in place at the time they started to work. In one case the second reference was dated a month after they had started working. The manager said verbal references had been taken up for some of them but there was no record of this and they must always be followed with a written reference to be kept on file. • Interview records and notes were not kept in the files. • One person had not included an employment history. Another person had gaps in their employment history but there were no records to show if this had been discussed. • Not all of the files contained a photograph of the person to help with checking their identity. • Three people had been employed before their POVA first check had been returned. • Five files had no information of training given to or planned for the individuals. Information given to us as part of the registration process for the home to provide dementia care tells us that: ‘Staff at the home have had training in person centred care and are supported in their learning from materials from Bradford and Stirling Universities. The home will be providing another activity organiser. Staffing levels in the new challenging behaviour unit will be 3:1 plus a qualified nurse.’ Information taken from the two regulation 26 visit reports by the providers representative states that: ‘The manager is commencing dementia care training sessions with ten staff starting 7th February 2008. This training will incorporate the Alzheimer’s Society ‘Today, yesterday and tomorrow’ course. A training matrix has been formulated for all staff; this ensures that all mandatory training updates are easily identifiable when they are due.’ When asked about training the manager told us: • Moving and handling training has been provided to all staff since the last inspection. A member of staff is going to do a moving and handling train the trainer course in June 2008 so that this training will always be kept up to date. • Fire safety training updates have been provided to nearly all staff in November and December 2007. Some new staff still need to do it, the manager was advised that this should be an essential part of the induction training for staff to do in the first week of employment. Again a member of staff is going to attend a fire safety train the trainer course. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 25 • • Eight staff have attended a training session from a dietician about fortified foods and liquid diets. An induction pack has been produced to use for induction training. Information in it has been taken from the Skills for Care common induction standards. From records seen and talking to staff we saw that: • The training matrix does not list all the topics staff need to cover as part of their induction training and to make sure they have the knowledge and skills needed to maintain the health, safety and well being of people living in the home and themselves. The copy provided lists moving and handling, fire safety, abuse and dementia. Records were not seen about training around health and safety, food hygiene, first aid and infection control. Talking to staff confirmed that they have not had this training. • New staff are not being enrolled on the induction training programme. Staff files did not show whether or not they had done any training at all. Three care staff told us they had done an ‘induction’ week working with another carer and did not recall being given any workbooks. • Not all staff have had training that will help them to understand person centred care, dementia and how to care for and support people who have it. We spoke to twelve staff during the visits. Seven said that they had done some dementia training with the manager but not all of them had completed it. Some of them did have a basic understanding of dementia and how it affected people and some had a basic understanding person centred care. This home provides care to people with dementia and it should be part of the training programme that is given to all new staff. • Not all of the staff working on the challenging behaviour unit have had any specialist training around challenging behaviour. It should be a priority for the staff on this unit but all staff should get this training. • Training and updates for the qualified nurses has not been provided where shortfalls in their practice questions their competence. For example the nurses who were disciplined about medication problems but no training updates were arranged for them and the inappropriate ‘guess work’ of peoples body mass index seen in the pressure sore risk assessments. There is an expectation from the provider that the manager will provide the dementia training to staff using a training pack bought from the Alzheimer’s Society. This is because he has completed a course about ‘Dementia care Mapping’. Sessions are planned but can be difficult to deliver if other things require his attention. Staff told us that sessions had been arranged and cancelled. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 26 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 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not being managed or run in the best interests of the people who live there. There are areas of serious concern detailed throughout the report that indicate people are at risk because of the institutional practices in the home and because staff have not received appropriate training. EVIDENCE: In April 2007 the home was registered to provide care to people with dementia and changed its name to the Charlton Centre for Alzheimer’s and Dementia Care. This means that the home now specialises in providing care and support to people with dementia. During this inspection we found that the specialist needs of people with dementia are not being met properly because: • The work on making sure the environment and facilities are suitable and ‘enabling’ for people with dementia has not continued beyond the unit that had been prepared for the registration process. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 27 • • Not all of the staff have received training around dementia, what the different types are, how people can be affected by it and what to do to help them. The care and support plans are not individual or person centred and do not give staff the guidance and information they need to meet that individuals needs. Following the last inspection the provider was told to forward an improvement plan telling us how they intended improve outcomes for people living in the home and meet the requirements made in the given timescales. The deadline for this being returned to us has passed. The manager said he had sent something to head office but on checking back through e-mails sent they were responses stating that action had been taken to meet the immediate requirements made after the last inspection. These were: The main bathroom on Willow unit not to be used until all the shortfalls are remedied. The shortfalls are: the bath is dirty, part of the floor covering is missing and is a tripping and hygiene hazard, dirty razor blades were left in the bathroom cabinet, soiled continence pads in the clinical waste bin and were not put in bags, pipes were exposed, the finish on the bath was cracked and is a potential infection control hazard, the sink is cracked, the commode chair has rusting legs. The dining room on Willow unit must be cleaned by 12.00 hours on 1.11.07. Wheelchairs to be cleaned and stored appropriately by 12.00 hours on 1.11.07. Medication fridge on Cedar unit to be cleaned and defrosted by 12.00 hours on 1.11.07. Detailed care plans are in place for people by 30.11.07. The example given was for a person who did not have a care plan about eating and drinking, even though a nutritional risk assessment stated that they were at risk, and that a speech therapist had advised a soft diet. Accurate records must be kept of all medication and medication must be stored safely, by 30.11.07. Not all the medication checked tallied with the records held. Loose tablets were found in the bottom of the medication trolley and a loose tablet had been pushed back into a blister pack, which contained tablets which were not the same as the loose one. All staff must receive fire training by 30.11.07. Records indicated that no staff have had fire training since 29.8.06. You must ensure all staff are familiar with the systems for fire prevention and detection and are competent to act appropriately in case of fire. A monthly management visit must be carried out and a report relating to this visit must be forwarded to the Commission. The responses from the provider told us that the work on the bathroom had been completed, wheelchairs were being cleaned and the medication fridge had been dealt with. We were told that all staff had received fire safety training and reports for two monthly management visits were kept in the home, the Commission has received one. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 28 Our findings from this visit clearly show that effective action has not been taken to make sure that there are safe systems for dealing with medications or to make sure detailed care plans are in place. Quality monitoring systems have been put back in place but the validity of the outcomes of these is questionable. The two reports produced by the provider’s representative indicated that there were no serious concerns around care planning, medications and training. We have found that are serious shortfalls in all of these areas that cause concern and indicate that peoples needs are not being properly met. More detailed information has been recorded in the relevant sections of this report. The manager works full time hours, usually Monday to Friday. These are meant to be supernumerary hours but said he sometimes works as part of the care team if there is a staff shortage. He is qualified nurse with a number of years experience working with the elderly and in mental health. He has not yet completed a management qualification equivalent to NVQ level 4. One of the visitors we spoke to said they were not sure who the manager was as they had not been introduced. This was an issue identified in the quality assurance carried out in December 2007 and part of the action plan was for the manager to work some weekends and meet relatives. This has not happened yet. The accident record books used in the home are not compliant with Data Protection because staff are not using them properly. Information about two different people was recorded on an accident from, one on the front page and another on the back page. There was not enough detail about the accident/incident and there was no follow up information about the outcome of the accident. The accident records were not being audited to see if there were any trends for particular individuals, to assess if somebody might need medical advice/support to look at why they might be falling so often, or if any action or preventative measures could be put in place to reduce the risks. The home does not act as appointee or agent for anybody living in the home. Small amounts of personal money are held in safekeeping for thirty-four people. We looked at the records kept. The amounts held tallied with the records kept. But there was not always a clear audit trail of where the money had come from or receipts for monies received, spent or returned. The systems for looking after people’s money would be more robust if the records included this information. The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X X 1 STAFFING Standard No Score 27 1 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X X 1 The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 30 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 Requirement The registered provider must make sure that the care plans provide staff with detailed, individual guidance about how to meet a person’s health, personal, social and psychological care needs including their personal preferences, abilities and wishes. Wherever possible the person at the centre of the plan and or their relatives should be involved in the care planning process. Timescale for action 16/04/08 2. OP8 16/04/08 12, 13, 14 The manager must make sure that where risk assessments identify people as being at risk of falling, developing pressure sores or losing weight, advice is sought from appropriate health care professionals and detailed care plans put in place. This will make sure that peoples healthcare needs are identified and met. 13 The manager must make sure that if a safety risk assessment identifies the need to use bed rails that clear and detailed DS0000059693.V360147.R01.S.doc 3. OP8 16/04/08 The Charlton Centre for Alzheimer`s and Dementia Care Version 5.2 Page 31 records are kept which include the following information: • Why they were being used. • Who is responsible for checking that they are the correct type for the bed, that they are fitted correctly, in good working order. • How often they should be checked and where the results are to be recorded. • That the person or their relatives had been consulted about using bedrails. This risk assessment must be kept under review. 4. OP9 13 (2) All medication must be administered as prescribed and be available to administer from. Accurate records must be kept for all medicines including disposed medicines. This will make sure that people receive their medications correctly and safely and the treatment of their medical condition is not affected. A system should be in place to make sure that only medicines currently prescribed and in date are used. This reduces the risk of incorrect and unsafe administration of medication. The timescale of 01/11/07 made in the last report has not been met. 5. OP15 16(2)(i) The provider must make sure that people living in the home are given adequate quantities of suitable, wholesome and nutritious food and drink in order DS0000059693.V360147.R01.S.doc 16/04/08 16/04/08 The Charlton Centre for Alzheimer`s and Dementia Care Version 5.2 Page 32 to make sure that they are not at risk of losing weight or becoming dehydrated. Support and guidance should be requested from healthcare professionals. 6. OP16 22 The provider must make sure 30/04/08 that all complaints/concerns are investigated using the complaints procedure, responding to them within 28 days and that records are kept of investigations made and the outcomes. The provider must review care 30/04/08 practices in the home to make sure that action is taken to prevent people from being harmed, suffering abuse or being placed at risk of harm or abuse. This must include reviewing the adult protection procedures in line with local authority and government guidance and through staff training. The building must be kept in good state of repair. Attention should be given to the windows, guttering and down pipes. Timescales of 31/12/05, 12/02/07 and 31/01/08 not met. 9. OP19 23 The provider must make sure that the home is safe and well maintained; that it meets people’s individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance for the specialist care needs of people with dementia. This must include making sure that: • The call bell system is DS0000059693.V360147.R01.S.doc 7. OP18 12(1) (4)(a) 13(6) 8. OP19 23 (2) b 30/05/08 30/06/08 The Charlton Centre for Alzheimer`s and Dementia Care Version 5.2 Page 33 maintained. • Water damage to rooms is repaired. 10. OP26 16(2)(j) The provider must make sure that the home is kept clean, hygienic and that systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. Timescale of 30/11/07 not met. The provider must make sure that there are enough staff on duty at all times to meet the needs and numbers of people living in the home. This must take into account people’s specialist dementia and psychological support needs as well as the size and layout of the building. The provider must make sure that pre employment checks including two written references, satisfactory POVA first and enhanced CRB disclosures, full employment history and the reasons for any gaps are in place before staff start at working the home. This is to protect the people living there. Timescale of 30/11/07 not met. The provider must make sure that staff receive appropriate training to help them to maintain the health, safety and well being of people living in the home and themselves. This must include training about the specialist needs of people such as dementia and dealing with ‘challenging behaviour’ and appropriate training for qualified nurses to make sure they are DS0000059693.V360147.R01.S.doc 16/04/08 11. OP27 18 16/04/08 12. OP29 19 16/04/08 13. OP30 18(1)(c) 16/04/08 The Charlton Centre for Alzheimer`s and Dementia Care Version 5.2 Page 34 qualified and competent for the job they are doing. The provider must make sure that all new staff are enrolled on an induction training programme that is to Skills for Care common induction standards when they start work. Timescale of 31/12/07 not met. 14. OP33 24 The provider must make sure that the home is being run and managed for the benefit of the people living in the home. This must include taking the views of people who live in the home and their representatives into account. 15. OP33 26 30/04/08 The provider must make sure that a monthly visit is made to the home and a report regarding this visit is completed regarding the conduct of the home. Guidance available from CSCI on conducting these visits should be used and the provider must be satisfied that the visits are a true and accurate reflection of what is happening in the home. If shortfalls are identified the provider must show what action is being taken to remedy them and improve outcomes for people living in the home. This report must be forwarded to the Commission until further notice. 30/04/08 The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 35 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. Refer to Standard OP3 Good Practice Recommendations Steps should be taken to make sure that the information from care needs assessments by healthcare professionals is used to inform the pre admission assessments and to assess if the facilities and services provided by the home will meet their needs. Regular, monthly prescriptions should be seen before sending to the pharmacy. This makes sure a check can be made that all the medicines required have been listed and prevents people from being without. The provider should make sure that people living in the home are offered a range of suitable social and leisure activities that are appropriate to their needs, expectations and abilities. The provider should make sure that people who provide training are qualified and competent to do so. All staff should have personal training and development plans that are reviewed at regular intervals. 5. 6. OP31 OP35 The manager should complete the Registered managers award. Confirmation should be sent to the Commission in writing that the residents’ bank account is non- interest bearing. The provider should look at making the systems for looking after people’s money more robust by keeping a record of where the money came from along with receipts for monies received, spent or returned. 7. OP38 The provider should make sure that the accident records are used in the correct manner in order to comply with the requirements of the Data Protection Act as well as to provide all the information needed after somebody has had an accident. DS0000059693.V360147.R01.S.doc Version 5.2 Page 36 2. OP9 3. OP12 4. OP30 The Charlton Centre for Alzheimer`s and Dementia Care The Charlton Centre for Alzheimer`s and Dementia Care DS0000059693.V360147.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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