Inspection on 22/10/05 for Woodlands Gate

This inspection was carried out on 22nd October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodlands Gate 10/06/08

Woodlands Gate 12/06/07

Woodlands Gate 19/01/06

Woodlands Gate 14/03/05

Woodlands Gate 13/09/04

Woodlands Gate 31/03/04

Woodlands Gate 02/02/04

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 Woodlands Gate 12 Dingle Road Stourbridge Dudley West Midlands DY9 ORS Lead Inspector Lesley Webb Unannounced Inspection 22nd October 2005 09:00 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 Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 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. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Woodlands Gate Address 12 Dingle Road Stourbridge Dudley West Midlands DY9 ORS 01562 885546 01562 885546 admin@solcare.co.uk www.sclcare.co.uk S.C.L. Care Limited 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) Mrs Patricia Jewess Care Home 21 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (13), Physical disability over 65 of places years of age (6) Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th March 2005. Brief Description of the Service: Woodlands Gate is a large converted domestic property located in a quiet residential area of Pedmore near to the town of Stourbridge with good public transport links. There is car parking to the front of the property. The garden to the rear is large and well established with a variety of shrubs, trees and plants. There is a patio area adjacent with a number of tables and chairs. The home is registered to care for 21 older persons and has 17 single bedrooms and two double rooms. Resident’s accommodation is on two floors accessed by a passenger lift. Bedrooms are all decorated individually and reflect resident’s different tastes and personality. Residents may bring some of their own furniture if they wish, after discussion with the manager. The home has a number of bathrooms with assisted bathing facilities located on the ground and first floors. There is a large lounge with a conservatory, a dining room and ‘quiet’ lounge/dining room all situated on the ground floor. Communal areas are decorated and furnished to a good standard. The home offers a range of stimulating social activities for residents. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 9am and stayed until 4pm. Time was spent observing care practices, talking to residents, interviewing the 3 members of staff on duty, looking at records and touring the building before giving feedback to the manager about the inspection findings. By the end of the visit the inspector was satisfied that generally the home offers a very good service. The inspector would like to thank residents and staff for their co-operation and assistance during the visit, where she was made to feel very welcome. What the service does well: When asking service users what they thought the best thing was about the home the inspector received an abundance of replies relating to the staff and management. For example one person stated, “ the staff and manager are lovely” and another person said, “ The staff do anything for you”. Additional praise was also given by the family of a service user who stated, “Whenever we visit we are always made to feel very welcome. Staff always keep us informed of what’s happening to my mother, they understand how important this is”. The inspector found that these comment reflected practices observed during the inspection, where visitors were made welcome by staff and positive relationships promoting privacy and dignity have been formed. The home is also very good at offering activities and choices at meal times. Again praise was given by residents for both of these services. Comments received include, “ the foods very good here, if you don’t like what’s on offer you can always have something else” and “they try to keep you busy with things such as bingo and exercises. You don’t have to join in if you don’t want to, but its nice to know there’s always something you can do”. During the inspection staff demonstrated excellent knowledge and understanding in relation to supporting residents to complain and adult protection. The inspector was satisfied that the people living at the home are safeguarded from abuse through staffs awareness of these topics. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 6 The building is furnished and decorated in a way that makes it feel ‘homely’. Furniture is domestic in nature and residents are allowed to bring personal items such as ornaments and pictures to personalise their bedrooms. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 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 Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 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 the following standard(s): 3 and 6. The home has a good admissions process that ensures prospective residents can be sure the home can meet their needs. EVIDENCE: The inspector sampled 3 residents files and found that they all contained assessments completed by the home as part of its admissions procedure. Senior staff also confirmed that information is sought from social workers and families of prospective residents prior to admission in order that the home obtains as much information when assessing suitability. Two residents that the inspector spoke to confirmed that their families had given information to the home before they moved in so that the home could be sure it was able to meet their needs. One resident explained to the inspector, “where I was living before I kept having falls, the staff here were told all about this and since I’ve been here I have only had one. The staff look after me and know what I need”. The home does not offer intermediate care. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 9 Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10. Generally care plans provide staff with the information they need to satisfactorily meet service users needs. Improvements to mobility, nutritional screening and medication processes must be made to ensure service users health needs are assessed and monitored in full. Personal support in this home is offered in such a way as to promote and protect service users privacy and dignity. EVIDENCE: The inspector interviewed 3 members of staff, all of whom could explain aims or goals detailed in service users plans of care, when they are reviewed and by whom. All care plans that were sampled contained assessments for the prevention of falls, continence, pressure sore management and moving and handling, however no evidence could be found of nutritional assessments being Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 11 completed. Staff informed the inspector that Dietary input is arranged for service users if concerns are identified. The inspector instructed that nutritional assessments should form part the care planning process for everyone, to ensure a proactive approach to health care monitoring takes place and to ensure previously unidentified conditions are identified and the appropriate action taken. The inspector found it difficult to assess if residents receive the appropriate treatment from specialists including chiropody, dentist and opticians as presently the home records this information in 3 different places (doctors log sheet, daily records and the homes diary). The inspector discussed this practice with the manager who agreed with the recommendation to amend this practice so that this information is collated in one place for effective monitoring. Residents that the inspector did however state that they were pleased with the support they receive from the home to access medical professionals. For example one person stated, “when I came here I had lost my false teeth and staff arranged for a dentist to visit to sort this”. When sitting observing care practices the inspector noted that some residents were being assisted around the home using wheelchairs. When looking at the care plan for these people no evidence could be found that confirmed that a suitably qualified person had completed assessments for this practice. The inspector was concerned that the use of a wheelchair could reduce the service users mobility and/or if a full assessment had not been completed a wheelchair that does not meet that persons needs could potentially place the individual at risk. Staff confirmed that several service users did not have their own wheelchairs, had not been assessed and used communal chairs to aid their mobility. All records relating to the receipt, administration and disposal of medication were found to be in order. It is the practice of the home that the senior on duty is responsible for administering medication, with all these staff holding accredited medication training certificates. When observing staff administer medication the inspector was concerned with what she saw. Staff were witnessed giving residents medication but not observing them take it (turning their back whilst administering medication to other service users) and not signing the medication administration sheet at the point when the medication was administered but doing this after medication was given to all the residents. The inspector raised concerns about this practice immediately to the manager who agreed that it was not acceptable and then spoke to the member of staff who had undertook this task. The inspector also recommends that the home seek advice from its supplying pharmacist with regards to stocking of medication, as presently it maintains a cupboard of ‘spare’ medication. As the home orders medication on a monthly basis and receives a supply on a weekly basis the inspector could find no satisfactory explanation for the practice of over stocking. Throughout the inspection staff were observed treating service users with dignity and respecting their rights to privacy. For example staff were Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 12 witnessed knocking on bedroom and bathroom doors before entering and talking in a respectful manner to service users. These practices were further reinforced as the norm by staff when interviewed. For example one person stated, “its important to listen to what residents have to say, to be sure they want my help and to act on their wishes” and another said, “I always like to talk to residents to find out their feelings”. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15. Activities offered by the home provide daily variation and subjects of interest for the people living there. The atmosphere within the home is friendly and welcoming towards visitors, creating an inclusive place for service users to live. The meals in this home are good, offering both choice and variety and catering for special dietary needs. EVIDENCE: Activities are arranged on a monthly basis with a timetable displayed at the entrance of the home. The home arranges for an activity to take place daily with records maintained of those who chose to participate and those who declined. Activities arranged include sing-a-longs, dominoes, bingo, armchair exercises and watching church services on television. Staff and residents also confirmed that day trips are arranged. These have included visits to Dudley zoo and Walsall illuminations. The inspector spoke to a family visiting at the time of the inspection, who confirmed that they are made to feel welcome and were very happy with care Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 14 provided by the home. When asking staff how they support service users to maintain links with their families a variety of examples were given including, “when they visit we offer drinks, answer any questions they may have. We also invite them to parties at Christmas and at other times in the year”. At lunch time the inspector sat with the residents in the dining room and ate with them. The meal was both tasty and appealing in appearance, with many residents confirming their enjoyment. It is the practice of the home that two choices are offered at lunchtime, with residents making their choice at the time of serving. The inspector praised this practice because although it has the potential to lead to higher levels of wastage it allows residents to express preference once the options have been viewed. It was also noted by the inspector that as well hot and cold drinks residents are offered glasses of wine when celebrating birthdays. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Staff have excellent knowledge of complaint processes, ensuring residents views are listened to and acted upon. Staffs understanding of adult protection issues provides a safe environment to protect residents from abuse. EVIDENCE: The inspector examined the complaints log for the home and found that no complaints have been received since 2003. The complaints procedure is displayed at the entrance to the home and is also included in the homes statement of purpose. Upon examination of this the inspector instructed that the contents of the procedure be amended to inform complainants that they have the right to refer a complaint to the Commission for Social Care Inspection at any time, should they wish to do so. In its present form the procedure indicates that this can only take place once a complaint has been investigated by the home. Staffs knowledge of supporting residents to complain was found to be excellent, with explanations received including, “ I would report any complaint to the senior, but also enquire from the resident what outcome they would like to be achieved. I would also go back to the resident to make sure the complaint had been resolved and that they were happy. If not I would take it higher to the manager”. All residents that the inspector spoke to confirmed that issues were addressed by the home, resulting in no formal complaints being made. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 16 When asked by the inspector how they ensure residents are protected from abuse all staff demonstrated knowledge and understanding of their roles and responsibilities in this area. For example one staff member stated, “ I observe the residents all the time, look for changes in mood and talk to them. Report any concerns to the senior or manager”. Records confirmed that all staff at the home undertook adult protection training in 2004. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 17 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 the following standard(s): 19. Generally the standard of the environment within this home is good, providing residents with an attractive and homely place to live. EVIDENCE: The inspector was shown around the building by a senior care assistant and found that generally the home is maintained to a high standard with furnishings and fittings that create a homely atmosphere. When inspecting the kitchen the extractor fan was found not to be working resulting in the temperatures in this room being very oppressive. Staff informed the inspector that this is going to be addressed as part of a refurbishment of this facility that is due to take place once the appropriate contractors are found. Records confirmed that the environmental health department visited in March 2005 making several requirements, all of which had been addressed by the home. When looking at storage facilities in the fridge the inspector recommended that raw meats be stored below fresh products to reduce the possible risk of cross contamination. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 18 It was also noted by the inspector that the toilet seat in room 3 is broken and requires repairing or replacing. All bedrooms that were viewed were individually decorated with items that residents had brought with them to the home including ornaments and photographs, again adding to the homely atmosphere within the home. Two residents beds were found to have bedrails in place and records seen by the inspector confirmed that these had been appropriately assessed and consented to in order to maintain the wellbeing of those using the facility. The manager was instructed that the home must purchase the relevant covers for this equipment, to further enhance the safety of residents. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed at this inspection. EVIDENCE: Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 37 and 38. The manager encourages involvement and communication, creating a positive and inclusive atmosphere. Improvements in staff training must take place in order to promote and safeguard the health, safety and welfare of service users, staff and visitors. EVIDENCE: The manager has worked at the home for many years and demonstrated knowledge and experience appropriate to her role. In addition to holding a NVQ level 4 in care the manager stated that she had recently completed the Registered Managers Award for which she is awaiting certification. In the main records required by regulation for the protection of residents and for the effective and efficient running of the home were found to be up to date and accurate. Residents’ records are securely maintained separately from the Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 21 staffs with only the manager or senior on duty able to access. The home has notified the Commission for social Care Inspection (CSCI) in line with Regulation 37 of the Care Homes Regulations 2001 when deaths have occurred at the home but not when residents have been admitted to hospital. The manager and inspector discussed this situation, with agreement made that this would be rectified. The inspector also recommended that the home maintain a copy of any Regulation 37 notification sent to CSCI as evidence that it is meeting its obligations. The inspector viewed the homes accident book and found that accidents were appropriately recorded and acted upon. The environmental health department visited the home in June 2005 to complete an inspection in relation to health and safety at work. Several requirements were made all of which have been acted upon by the home. One of the requirements relating to the visit was to devise a safe system of work with specific regard to the movement of vehicles on site. Records seen by the inspector confirmed that a risk assessment had been implemented in relation to this. The inspector recommends that this be displayed at the entrance to the home in order that visitors are aware it its contents. Training certificates were examined for staff in relation to first aid, food hygiene, health and safety, infection control and fire. 5 of the 15 staff were found to hold up to date first aid certificates, 8 of the 15 staff health and safety certificates and 6 of the 15 staff infection control certificates. All staff hold moving and handling and fire certificates however both of these were found to be out of date. The homes employs 2 cooks both of which hold up to date basic food hygiene certificates (along with all other staff at the home). One of the cooks also holds a City & Guilds certificate in cookery. The inspector instructed that the remaining cook undertake an intermediate food hygiene training course in order that her qualification is commensurate to her position. Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x 2 2 Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No 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 Residents who use wheelchairs must be assessed by a qualified person as requiring this facility and records maintained in the plan of care The practice of using communal wheelchairs must cease, with risk assessments implemented until such time as individual assessments for residents have been completed Nutritional screening and assessments must take place for all residents Staff must sign the medication administration sheets at the point when administering medication to a resident Staff must observe that residents take their medication and not leave them unattended until this is done The complaints procedure must be amended so that complainants are aware that they can refer a complaint to CSCI at any stage should they wish to do so DS0000024974.V255063.R01.S.doc Timescale for action 31/01/06 2 OP7 15 30/11/05 3 4 OP8 OP9 12(1) 13(2) 31/01/06 22/10/05 5 OP16 22(1) 31/01/06 Woodlands Gate Version 5.0 Page 24 6 OP19 16(1) CSCI must be notified in writing 30/11/05 of the date that the refurbishment of the kitchen will commence and that this will include repair/replacement of the extractor system The toilet seat in room 3 must be repaired or replaced Padded covers must be purchased and used on all bedrails 7 8 OP37 OP38 17 13(3-6) 9 OP38 13(3-6) CSCI must be notified in line with Regulation 37 whenever a resident is admitted to hospital All staff must undertake first aid, health and safety, infection control, moving and handling and fire training, with certificates maintained in the home Any persons employed as a cook must undertake a food hygiene course commensurate to this position 22/10/05 31/01/06 31/01/06 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 3 4 Refer to Standard OP8 OP9 OP19 OP37 Good Practice Recommendations All information relating to health appointments/actions/outcomes should be collated in one place Advice should be sought from the supplying pharmacist with regards to stocking of medication Raw meat products should be stored below fresh fruit/veg/salad items The home should maintain a copy of any Regulation 37 notification that is sent to CSCI DS0000024974.V255063.R01.S.doc Version 5.0 Page 25 Woodlands Gate 5 OP38 The risk assessment relating to the movement of vehicles at the front of the building should be displayed at the entrance to the home Woodlands Gate DS0000024974.V255063.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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