Inspection on 28/07/05 for WCS - Westlands

This inspection was carried out on 28th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

WCS - Westlands 10/10/06

WCS - Westlands 29/12/05

WCS - Westlands 03/11/04

WCS - Westlands 26/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE WCS - Westlands Oliver Street Rugby Warwickshire CV21 2EX Lead Inspector Louise Thompson Unannounced 28 July 2005 09.30am 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 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. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service WCS - Westlands Address Oliver Street Rugby Warwickshire CV21 2EX 01788 576604 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Warwickshire Care Services Limited CRH Care Home 38 Category(ies) of OP Old age (27) registration, with number DE(E) Dementia (11) of places WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 3 November 2004 Brief Description of the Service: Westlands is a three-storey purpose built care home. The home is currently owned and managed by a voluntary organisation, Warwickshire Care Services. Westlands underwent a major refurbishment in 1998. Westlands is located close to Rugby town centre, bus and railway stations and is located within a community, which provides local services such as shops, public houses, restaurants, coffee bars and clubs. The home provides both long-term residential care for 38 frail older people, and a day care facility, which accommodates up to eight older people. Accommodation is located on three floors. Each floor has two lounges with dining areas. All rooms are single, some have en-suite facilities. Service users can furnish and redecorate to their own taste if they wish. The gardens are attractive, well maintained and accessible. There is a variety of garden furniture including sun umbrellas and tables. There is a ramp available, which allows easy access to the patio area. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection and took place over one day between the hours of 9.30 am and 5pm. This was the first visit for this inspection year. Staff co operated fully with the inspection. The manager was present throughout the inspection. The inspection process involved a tour of the home, talking with the manager, examining records and care plans, observation of care practices along with discussions with residents, staff and relatives who were visiting on the day of the inspection. Within the past year the home has had three different managers, which has led to changes in leadership, guidance and direction for the staff. As a result of these changes a number of requirements made at the previous inspection in November 2004 remain unmet or partially met. The recently appointed manager has demonstrated that he has a good understanding of the areas in which the home needs to improve and is developing a suitable action plan to ensure that these are addressed. What the service does well: What has improved since the last inspection? What they could do better: There are a number of things that the manager and staff need to do to make sure that the residents get the care that they need from staff that are well trained. Staff training needs to be planned and staff need to receive regular supervision. This includes training on health and safety matters and specialist dementia care. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 6 Assessment and care planning must improve so that the staff are able to know what to do for each resident. The recording and storage of medicines needs review to ensure that medicines are given correctly. A letter was left at the home to inform the owner and manager that this should be put right immediately. Arrangements for meeting individual residents, social and leisure needs requires further development so that residents are able to continue to maintain their interests. The most serious concern from this inspection was: Staffing numbers not being maintained within previously agreed levels. A letter was left at the home to inform the owner and manager that this should be put right immediately. 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. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 4 Minor review of information provided to prospective residents is needed to enable an informed choice about where to live. Lack of suitable training for staff particularly in dementia care and health and safety issues has the potential for practices, which do not promote the health, safety and wellbeing of residents. EVIDENCE: Staff training records available were not up to date and therefore it was not possible to accurately identify the numbers of staff attending. The manager said that he had observed some training records and identified that a number of staff on the dementia care unit had not yet attended suitable dementia care training. One staff member told the inspector that she had completed dementia care training at a previous home but had not attended any training at Westlands. A further staff member said that she had not yet had the opportunity to attend specific dementia care training but was hoping to later in the year. The inspector spent some time with residents and staff on the dementia unit. During this time staff were available to the residents and were observed to be kind and caring. Three residents were seated at the table in the lounge talking and playing with the cat. Two were asleep in the armchair and one had visitors. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 9 Training records demonstrated that a number of existing staff and newly appointed staff members had not attended manual handling, fire and other training. Training records indicated that none of the staff had attended training in meeting nutritional needs. The manager and two staff spoken to said that recent training had been provided for all staff on the management of PEG feeds. This was supported by a conversation with a resident and her relative. Residents and relatives spoken to said that their care needs were being met and that the staff were kind to them. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Care plans require review to provide the staff with the necessary information to meet individual residents health, social and personal care needs. Systems for the management and administration of medication are poor in some areas. These shortfalls have the potential to place residents at risk. Personal support is offered in such a way as to maintain residents’ privacy and dignity. EVIDENCE: The home has recently introduced a new care planning and quality management system. The records of four residents including one on respite care were observed during this inspection. The quality of the assessment and care plans was poor. Three out of the four files viewed had no evidence of a written care plan, this was despite their care needs frequently changing. Discussions with the manager and staff suggested that some care needs were being addressed, even though there was a lack of clear plans and guidance. This approach is dependent upon staff memory and good verbal communication systems. Records for the respite resident were incomplete and there were no care plans available. Good risk assessments were observed with ongoing monthly reviews of these, which enable staff to monitor changing dependency levels. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 11 Daily statements and risk assessments identify changing care needs, which were not reflected in care plans. The manager said that a new care manager has been appointed and commences early August. The care manager will be responsible for the implementation and development of care plans. Care files viewed showed involvement of members of the multidisciplinary team in assessing and meeting residents’ care needs. One resident was receiving care from the district nursing services for the management of a wound there was no suitable care plan/documentation maintained by the home. Procedures for the assessment and management of nutritional status require further development. One resident was being fed artificially the care documentation was unsuitable and fluid balance charts were not being maintained. The resident and relatives said they were very happy with the care and were pleased that staff had taken additional training on the management of PEG feeds so that the home could continue to meet the resident’s care needs. Systems for the management and administration of medications were observed and the following issues of concern were discussed with the manager. • • • • • • Medications transcribed by hand had been written incorrectly. MAR sheets did not record dates of changes to prescribed medications. It was not possible to track medication changes in care records. Frequent omissions on MAR sheets. Keys to medicines trolleys and cupboards were not held by the senior staff at all times but stored in a kitchen cupboard. Staff administering medications had not attended training provided by suitably qualified personnel. Controlled drugs records were completed incorrectly. The recently appointed manager had completed an audit of medications prior to the inspection and had identified these areas during his audit. An immediate requirement was made at the time of the inspection as these shortfalls have the potential to place residents at risk. Throughout the inspection it was observed that staff knock on residents’ doors, offer choices and ensure that all personal care and consultations are conducted in private, this assists in maintaining the residents privacy and dignity. Residents and relatives who were visiting during the inspection said that they were very happy with the care provided and spoke highly of the new manager and care staff. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed as part of this inspection. EVIDENCE: The manager told the inspector that the range and frequency of social and leisure opportunities was currently limited. He has identified this as a key area for development in his action plan. Plans include the appointment of a staff member for activities and relocation and refurbishment of day care services and lounge facilities. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Systems for the management of complaints are satisfactory residents can be confident that their concerns are listened to, taken seriously and acted up on. EVIDENCE: Relatives visiting at the time and residents told the inspector that if they had any concerns about any aspect of the service they would discuss these with the manager. The complaints procedure is located on a notice board in reception. The inspector observed the complaints records, which included details of investigations and any action taken as a result. The CSCI has not received any complaints since the last inspection visit. Compliments and recent letter of thanks record “ A lovely friendly home.” “… in the remaining months of my mothers life she was clearly loved and cared for by her carers.” WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26. The standard of décor and furnishings is fair with evidence of ongoing planned improvement and maintenance. The home presents as comfortable and homely for residents. EVIDENCE: Westlands is registered as a care home providing personal care to older people; this includes a registration for the care of 11 older people with dementia. The dementia unit is situated on the lower ground floor. Each floor has a lounge and dining area, which have been fitted with kitchenettes. A passenger lift to each floor, and ramps leading to outside areas, ensure easy access to all areas of the home. Furniture and furnishings are homely, the manager told of future plans to refurbish the dementia care unit, re locate day care facilities and upgrade communal lounge/dining areas. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 15 Generally the home was found to be clean and tidy. A number of carpets in resident rooms and some corriodor areas were observed to be heavily stained the manager said that these are being replaced. There were no obvious odours. A tour of the laundry at the time of the inspection found this to be satisfactory. Sluice areas are located on each floor none of these were locked and potentially place residents at risk particularly on the dementia unit. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The procedures for the recruitment of staff are not robust with appropriate pre employment checks not being carried out, potentially leaving residents at risk. The number of staff available particularly during the weekends is below agreed levels and is not sufficient to meet residents’ needs. EVIDENCE: Duty rotas examined demonstrated that care staffing numbers were not being maintained within previously agreed levels particularly at weekends. There is no laundry cover at weekends and only minimal domestic cover. At the time of the inspection there was only one domestic and there was no laundry staff due to holidays. Care staff assist with the laundry and this potentially reduces the amount of care available to residents. Staff on the dementia unit said that recently dependency levels of residents had increased and two care staff were required for some aspects of personal care. Occasionally this meant that there were insufficient staff members to provide this care and supervise the remaining residents on the unit. An immediate requirement was made at the time of the inspection. The manager arranged suitable cover using agency staff. The staff files of three recently appointed staff members indicated that previous managers had not completed all the necessary recruitment checks to ensure the protection of residents. Two references were only available on two of the three files viewed, gaps in employment were not recorded and one file contained no evidence of training. Two of the files contained little/no evidence of personal identification. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 17 Each file contained evidence of suitable CRB/POVA checks. The file of one staff member lacked clarity as to whether a work permit was required. The file of one future staff member appointed by the new manager was observed this contained all evidence as required. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36 and 38. The newly appointed manager has a clear vision for the home and a good understanding of the areas in which the home needs to improve. The home has failed to progress the implementation of a suitable system for staff supervision. This could potentially lead to inconsistencies in care and practices that do not promote and guard the health, safety and wellbeing of residents. Systems for the management of health and safety are satisfactory. EVIDENCE: The home has had three managers within the past year and has led to changes in leadership, guidance and direction for staff. The manager said that formal supervision systems have not been fully implemented; this could potentially lead to inconsistencies in practices. The current manager has recently been appointed and is applying for registration with the CSCI. Conversations with the manager demonstrated that he has a good understanding of the areas in which the home needs to improve and is developing a suitable action plan to ensure that these are addressed. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 19 Certificates were seen during the inspection for the maintenance and service of most major systems. Maintenance on fire doors and inspection of lifts and hoists was being undertaken during the inspection. Copies of a recent Health and Safety Audit were seen, this is available in reception. Training records available during the inspection were not fully up to date and it was not possible to accurately identify the numbers of staff attending. Records indicate that some staff are still to attend training in fire, manual handling and other health and safety issues. Accident records were observed, occasional records lacked sufficient recorded detail with regards to the accident/incident. These are reviewed regularly by the manager and reported to the head office as part of the quality management system. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 1 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x x 2 x 2 WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 21 YES 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 OP 1 Regulation 4, 5 Requirement The Statement of Purpose and Service User guide must be reviewed. A copy of the completed documents are to be forwarded to the Commission.(old time scale of 31.03.04 not met) The registered manager must ensure that all staff on the dementia unit receive suitable training in dementia care. A copy of the training programme must be provided to the Commission.(old timescale 30.11.04 not met) The registered manager must ensure that each resident has a care plan. Care plans must set out in detail the action needed to be carried out to ensure that all aspects of the health, personal and social care needs of each resident is met. Care plans must be up to date and reflect the current needs of individual residents. These must be reviewed monthly as a minimum. Opportunities must be given for residents and or relatives to be involved in care planning and E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Timescale for action 31.10.05 2. OP 4 18 31.10.05 3. OP 7 15 30.09.05 4. OP 7 15 30.09.05 WCS - Westlands Version 1.40 Page 22 5. OP 8 18, 17 6. OP 8 17 7. OP 8 17 8. OP 9 13 9. OP 9 18 13 care reviews. Signatures to agreements should be obtained where possible. Staff should document where residents/relatives have chosen not to do so.(old time scale of 28.02.04 and 31.01.05 not met) The manager must ensure that staff competence for the management of PEGs are assessed and records kept. Responsibilities and accountabilities must be clarified with the Primary Care Trust and agreement to care staff administereing feeds and medications via this route sought from the resident. Accurate records must be maintained of dietary/fluid intake for those residents whose nutritional intake is impaired.(old timescale of 30.06.04 unmet) The registered manager must ensure that care plans regarding pressure area care and pressure area prevention are current and that any action taken/outcomes are recorded.(old timescale 30.01.05 not fully met) The registered manager must review the systems for the management and administration of medications.Medicine administration records must be accurately maintained and the correct codes inserted. Advice must be sought for medications administered via PEG tubes. A copy of current prescriptions must be obtained and MAR sheets checked against this.(old time scale of 30.11.04 unmet) Staff responsible for administering medications must receive training from an appropriately qualified person. A timed action plan for the 30.08.05 29.07.05 31.08.05 28.07.05 28. 08.05 WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 23 10. OP 12 11. OP 26 12. OP 27 13. OP 29 14. OP 38 achievement of this must be forwarded to the commission. 16 The registered manager must ensure that suitable and varied social and leisure opportunities are available to residents. Specific attention should be given to the needs and capacities of those residents with dementia. 13 , 16, Sluices must be locked when not 23 in use. The manager must forward a copy of the refurbisment plan for the home to the CSCI. This is to include timescales. 18 The registered manager must ensure that staffing levels and skill mix are maintained within previously agreed levels.These should be based on resident dependency and assessed care needs. The manager should inform the commission of any shift where staffing levels are not maintained. 19,26 The manager must ensure that Schedule all information and pre 2 employment checks are completed for new staff prior to commencing duty. This includes a CRB and POVA check and two written references, one of which must be from the previous manager. Gaps in employment history should be fully explored and records kept. Work permit arrangements for staff must be clarified. A review of current staff files must be undertaken and ensure that all information as specified in Schedule 2 of the Care Homes Regulations 2001 is maintained on file. 18, 13, 23 The registered manager must ensure that staff receive training in moving and handling, fire and infection control. A copy of the E53 S4270 WCS Westlands V239989 280705 Stage 4.doc 31.10.05 31.08.05 28.07.05 30.09.05 30.11.05 WCS - Westlands Version 1.40 Page 24 training plan should be forwarded to the CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP 7 OP 36 Good Practice Recommendations The inspector recommends that where residents require a hoist for moving and handling the records indicate the type of hoist to be used and the sling size. The inspector recommends that the manager continues to implement the system for staff supervision. WCS - Westlands E53 S4270 WCS Westlands V239989 280705 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 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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