Care Home: Coombe Hill And Blenheim Lodge Nursing Home

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What the care home does well "You hear so much bad about homes but not here", "I didn`t want to come here but it`s a home from home" and "its lovely here" were comments from the people who use the service. Relatives or friends said "my friend has improved enormously both in physical and mental health since being here", "I couldn`t be more pleased", "there is a very friendly feel about the place" and "they make the residents feel cared for and welcome". Staff are receiving better levels of training and regular supervision. Individual staff feel that they are able to approach their manager to discuss any issues. The home now has a good senior structure in place and is clearly moving forward. What has improved since the last inspection? A new manager is in post who has experience in managing care homes and is suitably qualified. She is supported by an experienced team who know the service well. New care plans are being introduced that are much more person centred. Medication is now managed well by the service for the people who live there. Improvements have been made to the ground floor communal areas and the outside areas. What the care home could do better: The home needs to develop the culture within the service to one where activity and occupation is ongoing and not limited to certain times of the day. The good work being done by the occupational therapists needs to be built upon to make sure that people are leading meaningful and purposeful lives. Mealtimes could still be made better for the people who live there. The focus needs to be on making these times of the day more enjoyable and enabling people to have choice and to be as independent as possible. Two relatives or friends suggested that the home should have its own transport to help people get out into the community more easily. Hot water temperatures must be regularly monitored with full records kept. CARE HOMES FOR OLDER PEOPLE Coombe Hill And Blenheim Lodge Nursing Home 1-3 Adelaide Road Surbiton Surrey KT6 4TA Lead Inspector Jon Fry Key Unannounced Inspection 10:00 25 September 2008 th 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 Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coombe Hill And Blenheim Lodge Nursing Home Address 1-3 Adelaide Road Surbiton Surrey KT6 4TA 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) 0208 399 3388 0208 399 8771 info@titleworth.com Titleworth Ltd Care Home 40 Category(ies) of Dementia - over 65 years of age (31), Learning registration, with number disability (9), Old age, not falling within any of places other category (31), Physical disability (9), Sensory impairment (40), Terminally ill (40) Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2007 Brief Description of the Service: Coombe Hill and Blenheim Lodge Nursing Home is situated close to Surbiton town centre. There are good bus and train links to surrounding areas and central London. Coombe Hill provides residential and nursing care for up to 31 older people, some of whom may have dementia. The other part of the home known as Blenheim Lodge provides care for up to 9 people who have physical disabilities aged eighteen and upwards. The Registered Persons have produced a Statement of Purpose and User Guide, which includes information on the aims and objectives of the service. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. One inspector and an ‘expert by experience’ carried out this unannounced inspection and they spent approximately eleven hours in the home. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. We spoke to ten people who live at the home, two relatives or friends of individuals, the manager and three staff members. We looked at records and documents kept at the service including four people’s care plans. Completed surveys were received from one person who lives there and four relatives or friends of individuals. The organisation completed an Annual Quality Assurance Assessment (AQAA) to tell us about the service provided, how it makes sure of good outcomes for the people using it and any future developments being planned. What the service does well: What has improved since the last inspection? Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 6 A new manager is in post who has experience in managing care homes and is suitably qualified. She is supported by an experienced team who know the service well. New care plans are being introduced that are much more person centred. Medication is now managed well by the service for the people who live there. Improvements have been made to the ground floor communal areas and the outside areas. 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. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good information is available to people about the service. Assessments are completed before people move in to make sure that the home can meet their needs. EVIDENCE: In the AQAA, the home told us that each person is supplied with a copy of the Statement of Purpose and User Guide. The Guide is available in larger print and is in Plain English. We have recommended that the service continue to look at other formats to make it as user friendly as possible. Photographs of key people and places may help individuals to use the information more easily. The manager told us that she was already planning to look at alternative formats. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 9 We saw that assessments are completed before someone moves into the home. The format for these has been reviewed and updated since the last inspection took place in September 2007. The manager and her staff are in the process of changing the care plans over to new more person centred documents. These are used in a philosophy of care called the Eden Alternative. Eden aims to create person centred communities that maximise independence and support individualised care. Once this work has been done, there may be opportunities to further improve the assessments to make sure they capture the right information. As a signpost to good practice, we have recommended that the home look at how Equality and Diversity is addressed at the assessment stage. The prompts published by CSCI for care homes may help with this as well as recent bulletins about providing services for black and ethnic minority people. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are in the process of being made more person centred. People’s health needs are met well. Arrangements for the handling, storage and administration of medication are good. EVIDENCE: People we spoke to felt that their individual needs are being met by the home. Comments included “I can’t fault them – they try to help you” and “I ask and they get it”. A relative or friend of an individual said that they thought the service was good at “looking after the residents particularly in meeting their needs” and another individual said that the home provided “a much better standard of living” for the person they knew “than before coming here”. One relative or friend Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 11 however said “the overall impression is that residents exist rather than have an active life”. As stated previously the service is in the process of changing the care plans over to new more person centred documents. We saw one of the newly produced care plans and this gave much more individualised and person centred information. The managers told us that they are producing these new style care plans for the people living in the Blenheim Lodge part of the home and then for everyone else living there. We think that this very important and will help to change the culture of the home to be more person centred and less task based. The daily notes kept by staff also need to be looked at. These were very repetitive and said things like ‘due medication given’, ‘due care given’ and ‘a pleasant and comfortable night’. Many of the written notes could be applied to any of the individuals living at the home. Care staff need to think about what information is useful to record and how daily notes could be used to shape the care being provided. Approaches, interactions and ways of providing support that work need to be captured so that all staff can use them and be put into the care plan. It is recommended that the home look at developing life storybooks with the people living there and these could then be shared with others in the home. This may also help staff to relate to people as individuals and encourage more interaction. Staff may also wish to develop their own life storybooks as part of this process. We looked at the medication and saw that this area is managed well by staff. Administration records are kept up to date and items stored properly and securely. This is an improvement from the September 2007 inspection. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals are generally satisfied with the food provided to them but mealtimes could be improved to be a more pleasant social occasion. People using the service are able to take part in a variety of activities within the home. EVIDENCE: “I like it”, “good”, “it’s excellent”, “mediocre” and “we get a choice” were comments from people about the food. Comments from relatives or friends included “the food has improved lately with the recruitment of a new chef”, “the catering could do better – it is not up to the standard that is expected” and “need more traditional British meals”. The people we spoke to were generally satisfied with the food provided. The home has made some improvements since the September 2007 inspection with new menus and increased choice for each mealtime. A hotel services Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 13 manager now oversees standards and consults regularly with individuals about their preferences. Napkins are also now used instead of bibs at each mealtime. We think the mealtime experience could still be improved for the people living there. Some people had to wait a long time before their meal was served to them and two people said that their food is sometimes cold by the time it gets to them. The staff need to keep trying to make each mealtime an enjoyable and social event. The work done in the homes ‘Breakfast Club’ could be transferred to more mealtimes within the service. Other ideas such as protected mealtimes, people serving themselves at the table from serving bowls and staff eating their meals alongside the people living there could be tried. Activities are provided each day with two Occupational therapists organising a number of regular clubs for the people who live there. These include the previously mentioned ‘Breakfast Club’, ‘The Men’s Group’ and the ‘Lady’s Pamper Group’. Other events have included Carnival day, Harvest Festival and a trip to the theatre on the day we visited. Daily activities are also available in the main communal lounge between 3.30 and 4.00 including skittles, reminiscence and music. We have recommended the service keeps looking at developing the culture within the service to one where activity and occupation is ongoing and not limited to certain times of the day. Individuals could be more involved in daily tasks such as food preparation, gardening, laundry and shopping. Care staff need to see engagement with individuals as a primary part of their role but may need help from a role model or champion to do this effectively. As discussed later in this report, the lounge needs to have more items that can be used to engage people and provide occupation. Two relatives or friends suggested that the home should have its own transport as people can be limited as to how often they get out. We have recommended that the service seriously consider having its own adapted vehicle. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has procedures to make sure peoples’ concerns are listened and responded to. Measures are taken by the home to protect individuals from abuse. EVIDENCE: “No complaints”, “I’d talk to the manager” and “I’m happy – I have no complaints” were comments from the people who live there. A complaints procedure is included within the information about the home. We recommend that the procedure be made available in other formats. It would be good to have pictures of the manager or other senior staff so people can see who to go to if they are unhappy. The home has received one formal complaint within the last year. We saw that this had been fully investigated and lessons learned as appropriate. There is an organisational procedure for staff to follow in the event of any allegations of abuse being made and the Local Authority Safeguarding procedure is also available. Staff training in this important area is also provided. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Significant improvements have been made to the ground floor and external areas to the benefit of the people who live there. EVIDENCE: The ground floor areas have been much improved since the September 2007 inspection. The lounge and garden areas are now very pleasant areas for people to spend time in. Individual bedrooms have been re-decorated and this refurbishment is ongoing. We have recommended that staff keep looking at how the environment can be made more homely and also provide stimulation particularly for people with dementia. Things to consider include lots more items in the lounges, memory Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 16 boxes by bedroom doors and more points of interest in all areas. Occupational items could include dressing tables, workbenches, typewriters, hat stands, rummage boxes and boxes of soft toys / dolls. The first floor presents poorly compared with the rest of the home but this is the next stage of the renovation programme. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals are generally happy with the care they receive and feel they are treated politely and respectfully. Staff recruitment practices help to protect the people who live there. The training provision is improving. EVIDENCE: Comments from the people who live there included “excellent”, “the nurses are lovely”, “they’re lovely people” and “they are ok”. Feedback from relatives or friends of individuals included “the care staff always seem attentive and friendly”, “very caring” and “very kind staff”. Two people felt that there were still too many agency staff and the home needed more trained full-time staff. We saw that staff had a good attitude towards their work and would go up close to people when speaking to them and waited to make sure they were hearing. For those who were unable to communicate they waited to get a response and got some nice smiles from some individuals. The staff did go and talk to people when they were able to. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 18 We looked at the records kept for three members of staff. Recruitment checks are completed and these include a Criminal Records Bureau (CRB) check. A new computerised system has been introduced to keep better track of staff training and qualifications. We saw that this system flags when individuals need any mandatory training updated. We saw that the organisational programme of training also included the Common Induction standards for new staff with workbooks completed. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is well run. Satisfactory Health and Safety checks are carried out to help keep people safe. EVIDENCE: A new manager is in post who has good experience of managing similar services for older people and has the NVQ level Four managers qualification. She is supported by an experienced senior staff team who clearly know the service very well. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 20 Feedback from the staff we spoke to was positive. Individuals said that they felt well supported and had good access to the training they needed. Comments included “approachable” and “you can talk to the managers”. Staff receive regular supervision with their line manager and good records are being kept of these individual sessions. The home has meetings every two months with the people who live there and their relatives or representatives. A newsletter has just been started which is to be published every other month when there is not a meeting. The manager told us that a meeting had been held on the evening before we visited and the discussion had included menus, activities and the ongoing refurbishments. We saw that a very comprehensive quality assurance audit had been carried out by an independent auditor in August 2008. The results of this were available and were being used as a baseline for the new manager to work from. Further audits are planned to help measure progress in making improvements. Regular checks are carried out to make sure that people in the home are safe. One issue was highlighted where two weekly checks of hot water temperatures have not been completed consistently. We have made a Requirement for the home to make sure that this happens. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 4 X 2 Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 22 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 OP38 Regulation 13 (4) Requirement In order to ensure the welfare of people living there, hot water temperatures must be regularly tested with full records kept. This is with particular reference to baths and showers where there is total body immersion. Timescale for action 01/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP3 Good Practice Recommendations The user guide to the home should be made available in other formats such as audiotape or pictures. The home should look at how Equality & Diversity is addressed at the assessment stage. The related guidance from CSCI could be used to help with this. The assessments could also be looked at to make sure that the right information is being captured for the new Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 23 care plans being introduced at the home. 3. OP7 Daily notes should be reviewed to make sure they capture useful information and can be used to help evaluate the support being provided. Life story books could be developed with the people who live there. Care staff could also make their own story books to share with individuals. Staff need to continue to look at the routines in place and how they can be flexible in their practice. Time spent with people and increasing wellbeing should be priorities of the service. The use of ‘Champions’ within the service should be progressed. 6. OP12 The work of the Occupational Therapists needs to continue and be expanded. Care staff still must be encouraged to be actively involved with this provision. More use of rummage boxes, sensory items and soft toys / dolls should be considered. Points of interest and occupational items could be provided – dressing tables, workbenches, hat stands, dolls houses, typewriters. 7. 8. OP12 OP14 It is strongly recommended that the home have its own minibus or similar vehicle available. Care staff should continue to look at how people could be more involved in the daily life of the home. This could be helping with preparation of meals, serving food and drink, helping with laundry or cleaning. Mealtimes need to be reviewed to make sure they are a positive occasion for all concerned. The way meals are provided needs to be looked at to make sure that individuals are not left waiting for long periods and that the meals are not cold when served. Practices such as protected mealtimes, staff eating with people who live there and people serving themselves should be considered. Picture menus should be used to help people know what is being served that day. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 24 4. OP7 5. OP12 9. OP15 10. OP16 The complaints procedure should be made available in alternative formats to help people use them when they need to. Coombe Hill And Blenheim Lodge Nursing Home DS0000026251.V364551.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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