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Inspection on 04/04/08 for The Grove Residential Home

Also see our care home review for The Grove Residential Home for more information

This inspection was carried out on 4th April 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Steady progress continues to be made in most areas of care provided at this establishment. A district nurse stated that,` the registered manager has given guidance and direction from clients needs to tissue viability issues. In the short time that she has been back she has achieved so much she should get an award`. She further stated, `all areas of care as well as the atmosphere in the home is excellent`. Two people spoken to during lunch confirmed that the food is very good and that they have a choice. Another resident commented that `I was poorly when I came in here the staff looked after me and I am much better now`. Other comments received were; there are no unpleasant smells here and all room have been newly decorated and there are new carpets throughout. We have a bit of banter with the staff and a laugh, they the staff treat me with respect, they are very nice. All residents spoken with confirmed that they had not made a complaint and they felt that they were safe in this home.

What has improved since the last inspection?

The manager stated that since the last inspection there is a full training programme implemented for all staff. The service users guide and statement of purpose has been updated giving information to prospective residents about the home. All residents` files are gradually being updated and efforts to involve residents and relatives in care plans are also ongoing. Decoration of nine bedrooms, bathrooms and corridors has taken place and this is an ongoing process.

CARE HOMES FOR OLDER PEOPLE The Grove Residential Home West Ashby Horncastle Lincolnshire LN9 5PR Lead Inspector Doug Tunmore Unannounced Inspection 14th April 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 Grove Residential Home DS0000057752.V362259.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 Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grove Residential Home Address West Ashby Horncastle Lincolnshire LN9 5PR 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) 01507 522507 Highgrove Care Ltd Ruth Meeds Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd April 2007 Brief Description of the Service: The Grove cares for older people in a non-smoking environment in a large detached property situated in the village of West Ashby, which is two miles from the market town of Horncastle. The home used to be a country house and is set in its own mature grounds and walled gardens with car parking facilities to the front and rear. The house is a listed building and therefore any changes to the facade must involve a planning process. The home has three floors and there is a passenger lift to the bedrooms on the first floor and a stair lift to the second floor. The rooms on the second floor have been created from attic accommodation and all four have traditional sloping ceilings. On the first floor there are four stairs to negotiate to access three of the single bedrooms. Thirteen of the bedrooms are single, two of them have an en-suite toilet. There are two toilets on the ground floor, two bathrooms with toilets and one single toilet on the first floor and a shower room on the second floor. The current fee range is £393:00 - £460 per week. Additional charges are made for hairdressing, chiropody. There is no charge for escorting people to the hospital or the GPs surgery. The Grove Residential Home DS0000057752.V362259.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 one star. This means that people who use this service experience adequate quality outcomes. One inspector undertook this visit to the home. This formed part of an unannounced key inspection. This visit took into account any previous information held by The Commission for Social Care Inspection (commission) including the homes previous inspection reports and the homes Annual Quality Assurance Assessment form, hereafter in this report referred to as AQAA. ‘Have Your Say’ surveys were received by the commission but were not available to the inspector for this visit. The site inspection consisted of case tracking a sample of two residents records and assessing their care. The inspector spoke with two residents and joining two others for lunch. One visiting community nurse was spoken to. The inspector also spent time with the registered manager and two carers. A full tour of the home and a review of a sample of the records were also included. What the service does well: What has improved since the last inspection? The manager stated that since the last inspection there is a full training programme implemented for all staff. The service users guide and statement of purpose has been updated giving information to prospective residents about the home. The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 6 All residents’ files are gradually being updated and efforts to involve residents and relatives in care plans are also ongoing. Decoration of nine bedrooms, bathrooms and corridors has taken place and this is an ongoing process. 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. The Grove Residential Home DS0000057752.V362259.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 The Grove Residential Home DS0000057752.V362259.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): Standards 1, 2,3, 5 and 6 is not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was information available to enable residents to make a choice as to whether or not to enter the home. People received an assessment, which resulted in their needs being met. EVIDENCE: The providers AQAA states that ‘Families and prospective residents are invited to look around, or stay and visit free of change so that they are more aware of the homes facilities. We have also revised out statement of purpose and service users guide to show more clearly what the home can offer’. The home had a statement of purpose and service user’s guide, which was seen to have been updated since the last inspection. Both documents included details about how people could contact the commission. A copy was given to each resident prior to admission. The provider’s action plan received by the The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 9 commission after the last inspection on the 23/04/07 evidenced that the service users guide and statement of purpose had been updated. We looked at two files seen of residents who were being case tracked which showed that there was a detailed admission procedure, which described the needs of residents coming into the home. All residents were assessed before entering the home and written confirmation was sent to them that the home was able to meet their needs. The manager was reminded that she need not wait for the local authority contracts before completing the providers contract and terms of conditions for resident who have been admitted as soon as possible. Two contracts were seen and had been signed by relatives. The home did not provide intermediate care. The Grove Residential Home DS0000057752.V362259.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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Maintaining peoples dignity and ensuring their privacy is not recorded for the information of staff. Resident’s and their representatives are involved in their care plans. The incomplete medication records do not ensure that medication is safely administered. EVIDENCE: The providers AQAA states that ‘We have a good relationship with healthcare staff and continue to access training that is relevant to our residents needs’. We looked at two residents files who were being case tracked they evidenced that daily entries had been made in their care plans by care staff that identified the care given. The homes accident procedures book was seen as well as body maps, which showed that records are kept of falls and any abrasions that residents might have. The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 11 However, issues found in those files of residents who were being case tracked were; no written evidence of residents likes and dislikes relating to food/beverages or any other aspects of her daily living, including current skills or knowledge. There were no records in files, which showed that residents individual intimate care needs are being addressed in their care plans for the information of carers. However, files did evidence that both presidents and their representatives had signed care plans and are fully involved. The provider’s action plan confirmed that all carer plans are being updated and this is an ongoing process. We looked at risk assessments in resident’s files, which showed the level of risk and the required intervention for dealing with these risks e.g. two staff required to move a resident when using a sling or the need for covers for bed rails and accompanying risk assessment. Two people seen commented that the staff were mindful of their privacy and that the staff were very good, also some carers are better than others’. Two carers stated that they are mindful of the dignity of residents and demonstrated that they were aware of their care plans and the needs of people at the home. The home conducts its own surveys and one comment seen from a relative was; ‘we are very pleased with the care our mother receives. She is always very well dressed and looked after’. A visiting community nurse gave good examples of care carried out by the staff at this home. She commented that, ‘there is good communication within the home and between community nurses and the manager. There are now no tissue viability problems and one person admitted with sores was quickly healed. This was due to an amazing diet and liquid intake administered by staff. We looked at two files, which confirmed that health care professionals visit the home when required by the residents. We looked at medication files and found that three medication sheets had not been signed to show that medication had been given. Medication checked against medication sheets showed that one medication (tablet) was still in the blister pack. One resident who self medicates when he visits his family most afternoon does not have a risk assessment, which should be signed and agreed by the provider and the resident. Both the manager and staff confirmed that medication training had been undertaken. The manager said that she would contact the pharmacist to arrange for visits to check medication and offer advise. The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities are available and provide daily stimulation and interest for people living in the home. Visitors were made to feel welcome which enable residents to maintain links and friendships. Meals provided were nutritious and varied, which caters for individual choice. EVIDENCE: The providers AQAA evidences that ‘the home provides a welcoming and homely environment, providing choices as to how residents want to carry out their daily activities based on their care plan’. A previous inspection visits carried out in April 2007, showed that; regular in house church services are held and one resident said she looked forward to communion. The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 13 Residents at this visit confirmed that visitors are always welcomed and they are able to see them privately if desired. The homes survey showed that a relative felt that, ‘we are always greeted by a friendly hello on our arrival’. On the day of the visit a number of residents were having their hair permed. Others were sitting in the lounge or their rooms reading or knitting. The manager confirmed that there is an activities worker on a Wednesday. The activities book was seen and showed that religious holidays are celebrated and relatives are invited to attend. Entertainers also attend the home and two residents stated that a magician came and a singer who was very good. One resident commented that it was very difficult to get a group to play cards or board games. They also felt that there were not much activities. This comment was passed onto the manager who commented that now summers coming more outdoor activities would be available and trips to the local markets. The visiting community nurse commented that, a number of people knit for charity and this gives them a purpose. The inspector joined two residents for lunch and spoke to two others about the food on offer. Comments were complimentary about the food on offer and that choices were available. The community nurse made comments about the good dietary intake at this home and the positive effect this has on maintaining skin tissue. The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints received are treated properly and residents and visitors knew that any complaints they had to make would be addressed and taken seriously. EVIDENCE: The providers AQAA confirms that ‘ we ensure that residents, visitors and staff are aware of the complaints policy in the service users guide and statement of purpose. There is a copy of the complaints procedure on the notice board and staff training is arranged for the protection of vulnerable adults’. There was a complaints procedure available in the entrance hall and all residents receive a copy of the complaints procedure in the service user’s guide. The home and the commission had not received any complaints since the last inspection. The two residents seen had no complaints about the home during the inspection. Both residents felt they could approach staff if they had any concerns. The providers training profile showed that protecting vulnerable adults training has been arranged for the 31/07/08 with an outside training The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 15 agency. Two carers confirmed the positive action that they would take if they became aware of abusive practices at this home. They were also aware of the forthcoming adult protection training. The provider’s action plan evidenced that information has been given to staff regarding protecting vulnerable adults and also staff are attending National Vocational Qualifications training in caring for the elderly which addresses this issue. We saw throughout the visit staff being polite and respectful when talking to or undertaking care duties with residents. The providers AQAA evidenced that their had been no complaints or vulnerable adults protection issues since the last inspection. The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in clean, well-decorated, homely and safe accommodation. through maintenance being promptly addressed. EVIDENCE: The providers AQAA states that, ‘ we recognise the need to continue to update décor and furnishings’. A full inspection of the premises was undertaken and it was found that the home was clean, tidy, well decorated and odour free throughout. The manager pointed out the nine bedrooms, bathrooms/toilets, which had been decorated and the new carpets. On the day of the visit a carpenter was working on realigning doors where carpets had been fitted. The manager The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 17 confirmed that an ongoing redecoration programme is to be carried out to ensure that the home is comfortable for residents. One resident stated, ‘its noted for being clean and when you come in there is no smells. All rooms newly decorated and new carpets fitted’. Two other residents confirmed that they like their rooms, which had been personalised with photographs and other memorabilia. The manager confirmed that any blocked sink flows have been addressed, also exterior work is to commence with windows being replaced or painted and a roofer is to undertake extensive work in September 08 on the main roof. The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was adequately staffed with employees who were experienced, competent and trained to care for older people. Residents are protected by robust recruitment practices. EVIDENCE: The providers AQAA evidences confirmed, ‘we integrate all overseas staff into the staff team efficiently and reward loyalty, training and achievement’. All staff spoke of working as a team. Staff and residents felt there were sufficient staff in the home. One resident stated that when she presses her emergency buzzer carers come to her assistance quickly. The manager is to employ another cleaner and a full time cook in the near future. Two members of staff seen confirmed that they have undertaken training including; first aid, administration of medication, food hygiene and hoist training. They also stated that there is an extensive training programme for The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 19 2008. The providers training programme was seen and showed that dementia training, moving and handling, health and safety awareness, equality and diversity, mental capacity act and death and dying is to be undertaken by an outside agency. Information in the providers AQAA showed that six staff have an NVQ level 2 and two have an NVQ level 3 (National Vocational Qualification), which is a recognised training award in care. A previous visit on the 23/04/07 found that those staff that had been recruited from overseas through an agency had relevant documents in their personnel file. This inspection found and the procedure for recruiting staff is robust with all documentation present as required. The manager was reminded about registering all staff with the General Social Care Council (GSCC). The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed, and there are good systems in place, which protect the health, safety and welfare of residents. People’s valuables are not protected due to inadequate procedures. EVIDENCE: The Providers AQAA states that ‘we have regular team meetings, to develop a more stable management and closure supervision of the team. Gather feedback from other professionals and continuously review all aspects of the service by carrying out surveys’. The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 21 The providers have appointed a new manager in October 2007 and the registered manager has successfully completed the ‘fit person’ process undertaken by the commission for registering the manager in March 2008. The manager has twenty-five years experience in various posts in working with the elderly. Since the manager has been in post she has made several improvements, for example, ensuring all staff have regular supervision where they can discuss care practices and raise any issues, planning a training programme and the refurbishment of the home. Staff said they ‘have found the manager to be very good and you can go to her if you have a problem. She is very relaxed and has done a lot for the home’. Residents spoken to said ‘they really like the new manager very much, but they don’t see a lot of her’. However, they stated that ‘she always stops to talk and have a joke with you’. The manager has also introduced a system for residents, relatives and visitors to be involved in the day to day running of the home. This audit system for reviewing and improving the quality of care provided in the home has just started. The manager is aware that outcomes from the surveys must be posted on the notice board for the information of residents and visitors. The manager confirmed that there has been no change in how records of any monies held on behalf of residents is maintained, which is kept in a safe place. We looked at two residents files and no record had been made about clothing items or any valuables that the residents may have brought with them on admission. The providers AQAA identified that there are a range of policies and procedures available in the home relating to the health and safety of residents and since the previous visit one member of staff has completed health and safety training and further training is planned for new staff. This document also showed dates when equipment was serviced and fire alarm checked. The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 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 3 3 x 3 x 2 3 The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13(1)(2) Requirement A system must be established to ensure that medication is dispensed safely to resident and a record is kept of medication given. A system must be established to ensure that all residents who self medicate have a risk assessment so as to show the level of risk for this procedure. A system must be established to ensure that individual residents privacy and dignity is recorded and acted upon. A system must be established to ensure that resident’s valuables are recorded accurately during the admission procedures. Timescale for action 26/06/08 2. OP9 13(1)(2) 26/06/08 3. OP10 12(4) (a) 27/06/08 4. OP37 16(2) (l) 27/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000057752.V362259.R01.S.doc Version 5.2 Page 24 The Grove Residential Home Standard The Grove Residential Home DS0000057752.V362259.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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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