Care Home: Ashville House

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What the care home does well What has improved since the last inspection? An activities co-ordinator had recently been appointed at the last inspection visit. The activities co-ordinator has now had the opportunity to establish the post and has made progress in supporting a number of residents to attend college and be involved in leisure and recreational activities. The activities coordinator regularly consults residents on activities in order to ensure the activities are geared around the needs of the individual. New care plans have been introduced. These are of an excellent standard and provide a greater level of information on meeting the resident`s needs. What the care home could do better: The registered manager left the home approximately 9 months ago. A temporary manager was appointed to manage the home for this period. A new manager has been appointed and is due to start working at the home in the near future. This person will need to apply to the Commission for registration as manager. The home environment is very well presented and maintained. However, there is one area of concern relating to the arrangements for smoking as all residents share one lounge and this is the designated smoking area. CARE HOME ADULTS 18-65 Ashville House 1 Ashville Road Birkenhead Wirral CH41 8AU Lead Inspector Debbie Corcoran Key Unannounced Inspection 9th October 2007 10:00 Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 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 Ashville House DS0000018862.V347335.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 Adults 18-65. 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. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashville House Address 1 Ashville Road Birkenhead Wirral CH41 8AU 0151 653 8786 0151 6539918 manager.ashville@makingspace.co.uk 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) Making Space Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 named elderly person with a mental disorder (other than learning disability) may be accommodated. 9th February 2007 Date of last inspection Brief Description of the Service: Ashville House is registered to provide personal care to 10 adults who need support with their mental health. The home is run by Making Space which was formed in 1982 and is a registered charity. Ashville House is a large, three-storey, detached building set in its own grounds on the edge of Birkenhead Park and is close to local shops, public transport and other amenities. It is within a short bus ride to the centre of Birkenhead. All resident’s bedrooms are single rooms and are situated on the first and second floors. On the ground floor is a lounge, dining area, laundry and kitchen. Access is not currently available to the front of the home for residents or others who are wheelchair users. There is a large car park to the side of the home. The gardens consist of lawns, shrubs, trees and flowerbeds. There is a patio area with seating provided. The fees for residing at Ashville House range between £340.01 and £366.97 per week. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to the home was not announced beforehand. During the visit the majority of the residents were met and spoken with and a number were spoken with on a one to one basis. Members of the staff team were also spoken with. A sample of resident’s records were looked at. Other records looked at include staff files, staff training records and health and safety records. A tour of the home was carried out which included all areas. The manager returned a quality assurance assessment on the service to the Commission. Some of the information contained in this has been used to inform the findings of the inspection. What the service does well: Residents were very positive about all aspects of the home and the support provided to them. One resident commented, “I love it here. I’ve lived here for a very long time and this is my home”. The home feels welcoming, homely and relaxed. Each resident has a detailed care plan. The level of information in these is very good and they provide a clear guide as to the needs of the person and how these are to be met. The care plans include information on the person’s likes, dislikes, strengths and needs and include goals for supporting the person to develop their skills and aim for a more independent lifestyle. Residents are well supported to remain healthy and staff support the residents to attend health appointments on a regular basis. Staff also support residents with their emotional and psychological well being. Residents meet with their key worker once per month to review their care plan and decide whether or not there should be any changes to their support. Residents meetings take place on a regular basis and residents are also given further opportunities to comment on the home through questionnaires. A high percentage of staff are qualified to a National Vocational Qualification (N.V.Q) level 2 in care. Staff are also provided with a good level of training and this covers topics such as equality and diversity, culture, adult protection, health and safety, food hygiene, medication, risk assessment and risk management. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 6 Staff support the residents with developing their personal and independent living skills and using the local community. The home environment is very well presented, clean, well maintained and the décor and furnishings and fittings in all areas are of a good standard. Health and safety procedures are in place so as to ensure the home environment is safe to residents, staff and visitors. The home is well organised and is run in the best interests of the residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place for ensuring the needs of prospective residents are assessed before they move to the home. EVIDENCE: There have been no new residents admitted to the home since the last inspection. Previous visits have evidenced that an assessment of needs had been attained from the referring agency before a person moves in to the home. There is also an in house assessment tool which can be used when appropriate. When a new resident moves into the home a member of staff completes ‘admissions information’. This is carried out with the resident and covers issues such as what their daily routine is, whether or not they want to administer their own medication, what they think of the menu and what food they like to eat, and what sort of support they would like with their laundry, cleaning their room, budgeting etc… and residents are provided with information on key policies and procedures which are relevant to them. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each resident has a plan of care which clearly reflects their needs and choices and residents are making decision about their life and the running of the home. Where a resident is thought to be at risk of harm information on this, and how to manage it, is recorded in their care plan. Resident’s confidentiality is protected by the arrangements for storing information. EVIDENCE: Care plans for two of the residents were looked at. Since the last inspection visit a new system of care planning has been introduced. The resident’s care plans are of an excellent standard. Care plans were found to be comprehensive, clear, informative and easy to follow. The plans include information on the strengths and needs of the person needs in areas such as their mental health, physical health, health care, personal care, social and recreational, cultural and religion and relationships. The level of information in Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 10 the resident’s care plans was pitched really well so as to provide staff with important information on the needs of the person. Part of the resident’s care plans focus upon the support the person requires to develop their independent living skills. These are in line with the needs and wishes of the resident. Residents are included in the development of their care plan and the plans are signed and dated by the resident. Residents have the opportunity to meet with their key worker on a monthly basis to review their care plan and make changes to their care plan. Residents are supported to take risks as part of an independent lifestyle. Where a resident is involved in activities which pose a risk to their safety then this is recorded in the person’s care plan along with information on what steps need to be taken to prevent the risk from occurring. The staff turnover is low and as a result many of the staff have worked at the home for a significant period of time and therefore they have had the opportunity to build relationships with the residents and to get to know the residents well. As at the last inspection visit residents were very positive about all aspects of their support and appeared confident that staff were meeting their needs and providing good care and support. Residents who were spoken with said that they are making their own decisions as to their daily support and their routines within the home. Staff consult with residents and ask residents to sign their agreement on issues such as whether or not they manage their own medication or their own finances. Residents have the opportunity to attend residents meetings whereby they can discuss the running of the home with staff on a more formal basis. All personal and confidential information is stored appropriately and staff are aware of their responsibilities in this area. Residents sign agreements for staff to maintain their personal records securely on their behalf. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to develop their independent living skills, to develop and maintain relationships and to be involved in local community activities. Residents are included in decision making on the running of the home. Residents are provided with a varied diet of home cooked food. EVIDENCE: Residents care plans include a good level of information on how to support the person with using and developing their independent living skills. From discussions with residents it was clear that they are supported to develop their independent living skills as appropriate to their individual needs. Residents are encouraged to make choices about the running of the home and their care. Residents confirmed that they are making choices and they gave examples such as choosing when to get up, when to go to bed, their meals, Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 12 their daily routine, how to spend their day and this will include going outside of the home on their own if they have the skills to be able to do this independently. Residents are supported to manage their own affairs when possible, for example managing their own money or their own medication. Residents are able to express their needs and preferences and contribute to changes at the home. Residents have the opportunity to attend a residents meeting on a regular basis and are given the opportunity to complete surveys to give feedback on the home. Residents gave good feedback on their support with pursuing leisure and social activities. Residents are going out and using community resources independently when they are able to and with support from staff when needed. An activities co-ordinator had recently been appointed at the time of the last inspection visit. This person has now had the opportunity to consult with residents and plan a variety of recreational and educational activities. Discussions with residents confirmed that residents are supported in activities such as shopping, walking, games, swimming, going to music events and going to the library. A number of residents are now being supported to attend college. In order to assess the meals and food provided the menu was checked, the kitchen was checked including food storage and health safety in the kitchen, and many of the residents were asked to comment on the food. The home has a designated cook who is responsible for the main meals of the day. The kitchen was found to be very well organised. Food was stored in good supply and stored safely. The menu was varied and appetising and all feedback on the food and meals was positive. Resident’s records include information on their likes and dislikes of food and meals and the cook was aware of the individual needs and choices of the residents. In addition to the main kitchen residents have a kitchen area in the dinning room where they can make their own food and drinks. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported with their personal, emotional, physical and health care needs and medication is well managed. EVIDENCE: The resident’s care plans include a good level of information on how to support the person with their emotional and physical health and well being. During discussions with the residents they felt that staff support them well. Residents are encouraged to use their independence in personal care and all residents appeared well supported in their presentation. Records showed that the residents are well supported to remain healthy and to attend health related appointments on a regular basis. Well documented records show that residents are supported to see their GP, nurse, dentist etc on a regular basis. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 14 Resident’s care plans also include a good level of information on the resident’s needs with health care and health appointments. Regular reviews take place in relation to the resident’s physical health needs and their mental health needs. Medication storage was checked and a random sample of administration records were checked. These showed that medication is safely managed. Staff have been provided with medication training. Medication stock is checked on a daily basis. Residents are encouraged to manager their own medication when this is appropriate and a risk assessment is carried out to ensure that residents who do manage their own medication are able to do this safely. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and practices are in place for dealing with complaints and for aiming to protect service users against abuse or neglect and systems are in place for dealing with allegations of abuse. EVIDENCE: The home has a complaints procedure which is time scaled appropriately and includes contact details for the Commission. A copy of the complaints procedure is available to residents and is on display in the main hallway. As at the last inspection visits residents said that if they weren’t happy about something then they would tell the staff. There have been no complaints made to the home since the last inspection. The home has an Adult protection procedure. This procedure provides information on adult protection and responsibilities for contacting relevant authorities. Care staff have been provided with training in adult protection. The manager was asked how she would respond to an allegation of abuse and she was able to provide an appropriate response to this. A record of key events is maintained for example incident reports and accident reports. These were checked and found to be maintained appropriately and there were no areas of concern identified. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a well presented, well maintained, comfortable, clean and safe home environment. EVIDENCE: A tour of the home was carried out. Accommodation is provided over 3 floors. The ground floor comprises of one large main lounge, a dinning room and an office. Resident’s bedrooms and bathrooms are located on the first and second floors. Each resident has there own bedroom and a sample of these were checked and found to be well presented and furnishings and fittings were of a good standard. Resident’s bedrooms were personalised with their own belongings and each room is fitted with a lock so as to ensure resident’s privacy. When asked about their rooms residents said that they were happy with them. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 17 The home has a large rear garden which is well maintained and provides a good amount of outdoor space for residents use. The home is comfortable, clean and well maintained. The only area of concern with the home environment is that there is only one lounge and this is used by residents who smoke and residents who are non smokers. The manager of the home must seek advise from the Environmental Health Department so as to ensure the home meets the new legislation regarding smoking. The home has health and safety practices and procedures which are aimed at ensuring the home is safe, clean and free from hazards to the health and safety of residents and staff. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by qualified, trained and well supported staff. Staff numbers are appropriate to ensure that the resident’s needs are being met effectively. Evidence of staff recruitment and selection practices were not available to evidence that these are thorough and aim to protect residents. EVIDENCE: Discussions with the residents and staff indicated that staff are supporting the aims and objectives of the home in encouraging residents to make choices, develop their independent living skills and use their local community. There are 9 members of care staff and of these 7 have attained a National Vocational Qualification (N.V.Q) level 2 in care. In addition to care staff the home employs a number of domestic staff and cooks. The training records for a number of members of staff were looked at and these showed that staff have been provided with good training opportunities. This training includes topics such as ‘putting principles into care’, equality and Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 19 diversity, culture, adult protection, health and safety, food hygiene, medication, risk assessment and risk management and supervision skills. Residents gave positive feedback about the staff. Residents and staff appeared to interact with each other with warmth and respect. Staff turnover is low and therefore many of the staff have been supporting the residents for a significant period of time and have had the opportunity to get to know the residents well. There have been two new members of staff since the last inspection. The records for the recruitment of these members of staff were not available for inspection as they were reported to be temporarily held at head office. The manager reported that she has seen the pre employment checks for these members of staff but there was no written information to confirm this. The manager must ensure that they can provide evidence that all relevant pre employment checks have been carried out before a person starts working at the home. Staff recruitment and selection practices were assessed at the last inspection visit and it was evident that Making Space as an organisation carry out thorough recruitment and selection practices. Staff are provided with regular supervision meetings and regular team meetings take place. These provide an opportunity for staff to explore their practice, explore new ways of working and to make and communicate decisions as to how to develop the service. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well organised and is run in the best interests of the residents. The health, welfare and safety of residents and staff is promoted and protected. EVIDENCE: The registered manager left the home approximately 9 months ago and a temporary manager has been in post. The manager reported that a new manager has been appointed and is expected to commence in the forthcoming days. This person will need to apply to the Commission for registration as manager. The home is well organised and all required information was readily at hand. Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 21 Residents contribute to daily decision making in the home and alongside this residents are also invited to comment on the home through residents meetings and through completing surveys on the home on annual basis. The home is visited by a representative from the organisation on a monthly basis and reports of these visits are forwarded to the Commission. The home has numerous policies and procedures in relation to the health and safety of residents and staff and staff are provided with training in core health and safety related skills. Fire safety and health and safety practices are adopted. Records of fire and health and safety checks were checked and found to be up to date. Risk assessments were in place for safe working practices and these are regularly reviewed. Ashville House DS0000018862.V347335.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 4 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 3 X 3 X X 3 X Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13 (4) (a) Requirement The registered person must consult with relevant authorities and review the arrangements for designated smoking areas in the home. Staff recruitment records must be available to show that recruitment practices are thorough and aim to safeguard residents from potential abuse. An application for registration of a suitably skilled, experience and qualified manager must be made to the Commission. Timescale for action 09/11/07 2. YA34 19 (1) (b) 09/11/07 3. YA37 9 09/12/07 Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 24 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 Standard Good Practice Recommendations Ashville House DS0000018862.V347335.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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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