Care Home: Norman Hudson Nursing Home

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What the care home does well On the day of the visit the atmosphere was relaxed, and staff were seen to demonstrate good interactions between them and the people in their care. Staff maintained the privacy and dignity of people and spoke to people in an appropriate manner.The Director and Manager listen to what people say, and as a result of concerns regarding cleanliness, senior staff carries out quality checks of peoples bedrooms each day, to ensure that good standards of hygiene and the appearance of the rooms are maintained, and there was documented evidence of this. What has improved since the last inspection? The care plans have improved and now include risk assessments that are up to date and reflect the changing needs of people. There was evidence to suggest that medication is now regularly audited to ensure that safe practices are maintained. To ensure that people are protected from abuse, all staff have two written references obtained prior to employment. In the interest of staff and people`s safety, all staff have fire training at regular intervals during the year, and movement and handling training annually. What the care home could do better: In the interest of people`s safety, the fire alarms must be tested at regular intervals as agreed with the fire safety officers. The furniture that is showing signs of wear should be made good or replaced. A minimum of 50% of care staff should have an NVQ 2 in care. The Manager should complete the Registered Managers Award to ensure that he has the managerial skills to run a care home. CARE HOMES FOR OLDER PEOPLE Norman Hudson Nursing Home Meltham Road Lockwood Huddersfield West Yorkshire HD1 3XH Lead Inspector Karen Summers Unannounced Inspection 14th October 2008 08:30 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 Norman Hudson Nursing Home DS0000045225.V372766.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. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norman Hudson Nursing Home Address Meltham Road Lockwood Huddersfield West Yorkshire HD1 3XH 01484 451669 01484 426960 NormanHudson@parkhomesuk.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) Park Homes (UK) Ltd Manager post vacant Care Home 42 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (42) of places Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Can provide accommodation and nursing care for one named service user under 65 years. Can provide accommodation and care for one named service user, category DE (E). No more than 21 beds can be used for the category DE (E) Date of last inspection 16th October 2007 Brief Description of the Service: Norman Hudson Care Home is a stone, purpose built home set back from the main road in the Lockwood area of Huddersfield. The home provides care and nursing for up to forty-two people in total; twenty-one of the places are registered to provide care and nursing for people with dementia care needs. All the bedrooms have en suite facilities. Thirty-four of the places in the home are in single rooms, with the remaining beds provided in four double rooms. Bedroom accommodation is provided on the first and second floor, with lounge and dining areas on the ground floor. All floors are accessed via a passenger lift. The home is within a few minutes’ walk of the local amenities, including a bus route. There is a garden to the rear of the building, which people can use. There is ample parking at the front of the home. The provider informed the Commission for Social Care Inspection on 14/10/08 that fees range from £374.32 to £663.90 Additional charges include hairdressing, private chiropody, newspapers, dry cleaning and some selected activities. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Norman Hudson Nursing Home DS0000045225.V372766.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 two star. This means the people who use this service experience good quality outcomes. This report refers to an inspection, part of which included an unannounced visit by two inspectors, on the 14th October 2008, commencing at 8.30 am, and the length of the inspection was 7.75 hours. There were 38 people living at the home on the day of the visit. During the visit we spoke with members of staff and relatives of people who receive care to obtain their views. We also looked at a sample of care records, staff recruitment, and training records, quality assurance audits and looked around the home. One of the inspectors also spent two hours sitting in the lounge with people who have dementia. This was to get a picture of peoples well being and the amount of activity that takes place. To enable people who use the service to comment on the care it provides, we sent surveys to people living at the home, and due to the illness of people none of these were returned. Ten surveys were sent to relatives/advocate/friends, four of which were returned, ten to staff, three were returned, and five to local doctors and health care workers (social workers, community nurses), none of which were returned at the time of writing this report. The comments in the surveys varied between individual relatives however, they were generally positive about the standard of care provided by the staff at the home. We would like to thank all the people who gave feedback about this home, and would like to thank the Director, Manager and Staff for their co-operation throughout the inspection process. What the service does well: On the day of the visit the atmosphere was relaxed, and staff were seen to demonstrate good interactions between them and the people in their care. Staff maintained the privacy and dignity of people and spoke to people in an appropriate manner. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 6 The Director and Manager listen to what people say, and as a result of concerns regarding cleanliness, senior staff carries out quality checks of peoples bedrooms each day, to ensure that good standards of hygiene and the appearance of the rooms are maintained, and there was documented evidence of this. 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. Norman Hudson Nursing Home DS0000045225.V372766.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 Norman Hudson Nursing Home DS0000045225.V372766.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): 3 Standard 6 - the home does not take people who require intermediate care. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are assessed prior to them moving into the home and are able to visit the home to establish whether or not it is the right place for them. EVIDENCE: The care records of three people who use the service were examined, all of which contained a pre-admission assessment carried out by the funding local authority. Each assessment contained detailed information about the person’s current needs, and in addition to this there was evidence that the home had also carried out an assessment of the persons needs. The information in the last annual quality assessment document confirmed that people are able to visit the home and spend some time there before making a decision to move in. Three survey received from relatives of the person living at the home also said that they usually received enough information about the Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 9 home before they decided that it was the right place for them. One person said never, as they said that they had limited choice of the type of home that was available to meet their relatives needs. Norman Hudson Nursing Home DS0000045225.V372766.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 -10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s care plans outline the level of support and care each person requires in ensuring their health and welfare needs will be met. People are treated with respect. The recording and administration of medication is satisfactory. EVIDENCE: One of the inspectors spent two hours sitting in the lounge with people who have dementia, and watching how people and staff interact. This was to get a picture of peoples well being and the amount of activity that takes place. During this time staff were seen to be meeting peoples needs in a sensitive and caring manner and assisting people to make choices. Part of this observation took place at lunchtime and people requiring assistance to eat were helped to maintain their dignity. Three peoples care records were seen. The care plans contained sufficient information to make sure that they receive the support they need in a consistent manner. Peoples social and health care needs are fully assessed and the plan of care is drawn up in line with peoples personal preferences. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 11 The manager said that the doctor from the local practice visits the home every Thursday mornings to review peoples care, and also during this time should a person need to see the doctor. Evidence was seen of involvement from people’s doctors, physiotherapists, opticians, dentists and other healthcare professionals where needed. Relatives said that they were kept up to date with important issues affecting their friend/ relative, and that the home usually meets the needs of their relative/ friend. A random sample of peoples medication and records were inspected and found to be correct. Records were clear, and medication was stored correctly. The manager said that regular audits of the medication take place to ensure that staff maintain safe practices, and documented evidence was seen to suggest that this take place. Norman Hudson Nursing Home DS0000045225.V372766.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 – 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are offered a range of activities that take into account their needs and capabilities. Meals provided are good, and offer a variety of choice. EVIDENCE: A dedicated activities co-ordinator continues to be employed Monday to Friday. When speaking with the activities person, and listening to him speak with people using the service, it was evident that he knew the people well. Within the care records, staff had recorded the individual person’s likes and dislikes and how they like to spend their time. A record of the person’s previous hobbies and interests were also documented. Relatives of people who live in the home said that they are usually supported to live the life they choose, and one person said sometimes. The person who stated, Sometimes, also said, More activities are needed, this comes at a cost! When asked, How do you think the care home can improve? One person said, that there should be a quiet area for people to sit. Another person said, Strong need for recreational activities. Make the garden more attractive. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 13 A member of staff who completed a survey, when asked, What could the service do better? Said, activities aimed at dementia clients. People living at the home said that they enjoyed the food served. The main meal of the day is served at lunchtime and on the day of the visit there were two choices of main course and dessert. The meal served was a choice of either sausages with Yorkshire pudding, or pork pie, both served with fresh vegetables and potatoes, followed by bread and butter pudding or jelly and ice cream. Norman Hudson Nursing Home DS0000045225.V372766.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 &18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are protected from abuse and they can be confident that their complaints will be listened to and acted upon. EVIDENCE: The home has a complaints leaflet and the information is in the statement of purpose that is given to each person when they are admitted to the home. The procedure is also located in the reception area of the home. The information in the last annual quality assessment document said that the home has robust policies and procedures for managing complaints and adult protection issues, and that staff receive regular training to provide them with knowledge in these areas. Staff that were spoken with on the day knew the complaints procedure and the procedures to follow for safeguarding (protection of vulnerable adults.) Two relatives were spoken with both of who had raised concerns about the recent care of their relatives. They both said that their concerns had been handled quickly and properly. With exception of one relative who completed the survey, people said that they knew how to make a complaint and that the complaint had been responded to appropriately, and that the manager had taken on board the complaint and that action had been taken. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 15 The home has a whistle blowing procedure, and staff that were spoken with were aware of the procedure to follow. Records showed that with the exception of one staff everyone who was on sick leave; all staff had received safeguarding (adult protection) training, which provides information on how to protect people from abuse. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home offers people a clean, odour free and homely environment. EVIDENCE: As part of the inspection a tour of the home was conducted which included the communal areas, and a number of people’s bedrooms. Areas around the home had been redecorated since the last inspection, including the lounge at the front of the building, and new chairs have also been purchased, and a new floor covering fitted. The layout of the down stairs lounges and dining room had also been altered in readiness for the increase in dementia care beds, (by eight,) and decrease in general care (by eight). Due to the alteration of the communal space, the Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 17 general care part of the home has decreased. One relative commented, The home is very crowded, and I dont think there are enough staff. This will improve when the general care numbers decrease. The Director said that within the refurbishment programme, the dining room has also been identified to be redecorated and new blinds/ curtains fitted. At the time of the visit the painter and decorator visited the building to arrange a date when he would start the work in the dining room. There were areas around the home that the Director identified that would be redecorated within the redecoration programme. Discussion was also held regarding the dining room table legs and furniture in this room that were looking warn. Whilst visiting the bedrooms the one of the carpets in the en-suite rooms had not been cleaned. The manager said that the cleaner had not finished the cleaning, and that the room had not been cleaned. The cleaner also confirmed this. The remainder of the home was clean and there were no odours present. One of the four relatives who completed the surveys said, The care home looks after hygiene and general welfare well. Another person said, There is at times room for improvement to cleanliness in the bedrooms. In some areas patients are sitting in cold areas. The home was warm at the time of the visit. A third person said they had complained about the cleanliness of their relatives toilet, and that it was unacceptable. They also said that the Manager had taken action about this. The Director of the Company said that he has employed a housekeeper to improve the standards of the home, and that she was due to start work at the beginning of November. He also said that the cleaning hours would increase at this time. The Director and Manager said that as a result of concerns regarding cleanliness, senior staff carries out quality checks of peoples bedrooms each day, to ensure that good standards of hygiene and the appearance of the rooms are maintained, and there was documented evidence of this. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported by qualified, competent and experienced staff in sufficient numbers and that has had all the necessary checks before working with people so that they are kept safe. EVIDENCE: The Manager and Director said that care staffing levels had been recently increased, and staff who were spoken with confirmed this. The duty rotas were also looked at, and evidence suggested that there were sufficient staff on duty to meets the needs of people in their care. Staff in the surveys commented on the increase in staff, and how this ensured that they could provide a good standard of care to the people in their care. Relatives of people who use the service had completed their surveys prior to the increase in care staff. One person said that they believed that the care staff do their best, but there were not enough staff for the number of people that they cared for. Please also refer to Standards 19 & 26 regarding cleanliness and the appointment of a housekeeper. The home are also in the process of recruiting a full time cook, and a handyman. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 19 Evidence was seen to suggest that care staff are encouraged to have an NVQ level 2 in care, and the manager confirmed that thirty percent of care staff have the qualification, and a further forty percent of staff are registered to start the qualification. Staff recruitment files of three members of staff were looked at in detail and they contained the required information and employment checks. These checks are necessary to help protect people from potentially unsuitable staff. The staff that were spoken with confirmed that they had received induction training when they came to work at the home, which provides them with knowledge and skill to look after people in their care. There was also evidence that staff had dementia care training and a number of staff confirmed this. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People benefit from the management approach of the home and the manager ensures so far as is practicable that the health, safety and welfare of people and staff are protected. The home is run in the best interest of people who live there. EVIDENCE: The Manager is a qualified nurse, and has many years experience in caring for older people, and people who have dementia care needs. The Manager also said that he is looking into enrolling to do the Registered Managers Award. The Operations Manager, on behalf of the company, visits the home monthly and one of the purposes of the visit is to ensure that the home is meeting its Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 21 objectives. Records were also seen of quality monitoring systems for each area of the home. Surveys are sent out by the home to people who use the service and their relatives every three months, and a sample is sent to different people each time. The surveys are returned and looked at by the Company Operations Director and then the Manager of the home has to respond to the information that has been received. Previously feedback has been given at the monthly peoples and relatives meetings however, there have not been regular meeting taking place. The manager said that he has scheduled a meeting each month up until Christmas, and there was evidence of this on the notice board in the entrance corridor of the home. Surveys are also sent out with the home’s welcome pack. This is to monitor and improve the quality of the pre admission assessments and admission procedures. A sample of returned surveys were seen, and the comments were positive. Small amounts of personal monies are kept on behalf of people living at the home, and the three records and monies that were checked were correct. There was evidence that staff have regular supervision, and the Manager said that he would ensure that all staff have supervision six times a year as stated in the National Minimum Standards. Staff confirmed that they did have supervision and records were seen however, staff did say that they were not having regular one to one supervisions. The Director and Manager said that they would ensure that one to one supervisions did take place. Records showed that the weekly fire alarm tests have not always taken place since March. The Director and Manager said that they would ensure that the weekly alarm testing takes place, and that up to date records would be maintained. There was evidence to suggest that all staff have up to date fire, and movement and handling training. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A 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 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 X 2 Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 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 OP38 Regulation 23.(4)(c)(iv) (v) Requirement In the interest of peoples safety, the fire alarms must be tested at regular intervals as agreed with the fire safety officers. – The manager telephoned following the inspection, to say that the homes fire facilitator had forgot to record the alarm testing the previous week. Timescale for action 21/10/08 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. 3. Refer to Standard OP9 OP28 OP31 Good Practice Recommendations The furniture showing signs of wear, should be made good or replaced. A minimum of 50 of care staff should have an NVQ 2 in care. The Manager should complete the Registered Managers Award to ensure that he has the managerial skills to run a care home. DS0000045225.V372766.R01.S.doc Version 5.2 Page 24 Norman Hudson Nursing Home 4. OP38 In the interest of peoples safety, the fire alarms need to be tested and recorded every seven days as agreed with the fire safety officer. Norman Hudson Nursing Home DS0000045225.V372766.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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