Care Home: Rosewood Lodge

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What the care home does well There is a very good standard of care being delivered at Rosewood Lodge and it is apparent that the registered manager is strongly committed to maintaining as much as possible this good level of care and support to vulnerable people.The manager is always willing to listen to advice or any suggestions that could improve the service being delivered. This is demonstrated by some of the positive changes that have occurred. The home has a thorough and robust recruitment process in place, helping to protect and safeguard vulnerable people. A well-trained staff team are provided with good training opportunities to ensure they have the knowledge and skills to meet the needs of the service users. What has improved since the last inspection? Peoples care plans are more detailed than they were previously, especially containing some background information. This had been mentioned at the last inspection visit. People have their own individual files. This helps to maintain confidentiality and demonstrates a better level of organisation. There has been a varied increase in the activities made available to people, helping to demonstrate that people are receiving more stimulation and motivation. The provider is informing the commission for social care inspection (CSCI) of notifications. All health and safety inspection certificates are available for inspection. What the care home could do better: Continue with the renovation of the kitchen. This would enhance the work that has already been satisfactorily completed. Be more proactive with the redecoration programme. Some of the bedrooms are beginning to look old fashioned and trired. CARE HOMES FOR OLDER PEOPLE Rosewood Lodge 491 Clifton Drive North St Annes Lancashire FY8 2QX Lead Inspector Phil McConnell Unannounced Inspection 15th August 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rosewood Lodge DS0000064309.V370336.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. Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosewood Lodge Address 491 Clifton Drive North St Annes Lancashire FY8 2QX 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) 01253 721601 roselodge4910@yahoo.co.uk Lakeview Rest Homes Ltd Mrs Agnes Woods Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To Service Users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP The maximum number of Service Users who can be accommodated is: 24 Date of last inspection 28th July 2006 Brief Description of the Service: Rosewood Lodge is situated on the main bus route not far from the centre of St Annes and a short distance from the sea front. The home is registered to provide residential care for twenty-four service users of both sexes, above the age of sixty-five years. All the service users are accommodated in single rooms with en-suite facilities. The property is a two storey detached house, providing ample and varied lounge space. The home has a well-maintained garden, with a gazebo and seating areas. The present rate of charging is between £412. & £432. Per week. Rosewood Lodge DS0000064309.V370336.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 3 stars. This means the people who use this service experience excellent quality outcomes. Various information was gathered in order to assess the key standards that are identified in the National Minimum Standards for Care Homes for Older People including: the Annual Quality Assurance Assessment (AQAA) which had been completed by the registered manager, an unannounced inspection visit to the service on the 15th August 2008. An annual service review (ASR) was carried out in January 2008 and some of the findings from that will be included in this key inspection report. The registered manager (Agnes Woods) was available throughout the inspection visit. Four service users’ files were examined and all relevant documentation was in place. Four staff files were also examined and they contained all of the necessary information that is needed for inspection purposes, including recruitment documentation. (See staffing section) There was the opportunity to observe the support and care being provided to people who were using the service during the visit. There was also the opportunity to speak to some of the service users and to some of the staff who were on duty during the day. All of the discussions were very positive. The home’s policies, procedures and all other documentation including health and safety files and certificates were examined. (See management section). A full tour of the home was also carried out. (See environment section). What the service does well: There is a very good standard of care being delivered at Rosewood Lodge and it is apparent that the registered manager is strongly committed to maintaining as much as possible this good level of care and support to vulnerable people. Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 6 The manager is always willing to listen to advice or any suggestions that could improve the service being delivered. This is demonstrated by some of the positive changes that have occurred. The home has a thorough and robust recruitment process in place, helping to protect and safeguard vulnerable people. A well-trained staff team are provided with good training opportunities to ensure they have the knowledge and skills to meet the needs of the service users. 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. Rosewood Lodge DS0000064309.V370336.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 Rosewood Lodge DS0000064309.V370336.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 and 6. Quality in this outcome area is good. Service users are appropriately assessed before a service is offered, helping to give the assurance that people are only admitted to the home if the provider can fully meet the individuals care needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service users’ files were examined, including the last person to move to Rosewood Lodge, receive a respite service or receive intermediate care and their individual files contained detailed initial admission assessments including, Social Services and Rosewoods own pre admission assessment documents. The previous recommendation of having ‘separate individual files’ has been satisfactorily addressed. Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 9 There was documented evidence to show that service users’ families had also contributed to their relative’s assessment and the AQAA states, “an intense assessment procedure is carried out prior to a new resident being admitted to the home. This includes a visit to the person’s home, hospital ward or rehabilitation centre, with further information obtained from hospital staff and relatives to make sure that all the care needs are identified”. This helps to demonstrate that the provider gathers as much information as possible, in order to meet the care and support needs of the people who go to live at Rosewood Lodge. The pre admission assessments are completed either by the manager or senior staff, who are trained and sufficiently skilled to undertake this important process. Regarding intermediate care, the AQAA states, “Residents admitted for intermediate care are supervised to use equipment to assist them with mobility and any recovery programmes they may require. For example we tend to have people recovering from hip replacements”. Various equipment including, raised toilet seats, walking frames and a high chair were observed that would enable individuals to be recuperated and regain / maintain their independence. There was also documented evidence of physiotherapists being involved, in order to increase people’s mobility. ‘Residents are discharged from Rosewood Lodge once they are fit enough to return to their own home’. Rosewood Lodge DS0000064309.V370336.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. Quality in this outcome area is good. The medication administration procedures are thorough helping to give the assurance that people are protected and safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service users’ care plans were examined and they were found to be up to date, with relevant and appropriate information regarding a persons’ personal and health care needs. The previous inspection report highlighted the need for care plans to contain more detailed information. This has been satisfactorily addressed; with peoples’ care plans giving very clear and specific information and guidance on how to provide a persons’ assessed needs. Care plans are reviewed on a monthly basis and the manager commented, “More frequently if needed” and “if possible a family member signs the reviewed care plan”. Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 11 The manager also said, “Care plans are now more clearer, with more information and less writing to do, with family able to make comments”. Documented information was observed regarding individuals’ specific health needs including, hospital appointments, GP appointments, physiotherapist and opticians. Each persons’ file contained a ‘hospital form’ in the event of a person being admitted to hospital with relevant details including, NOK, GP, medication, any allergies, communication and mobility. This important information, demonstrates that the provider is proactive in ensuring that the correct information and needs of the service are made readily available to provide a continuity of care and health needs. During the inspection visit there was the opportunity to have a brief positive discussion with a visiting District Nurse, she has visited the home over a period of ten years and usually visits people to give injections or change dressings. Some of the comments made were, “This home is pretty good” “the staff are always helpful and appear to be respectful to everyone” and “the manger is brilliant, if you want anything, she will sort it”. The medication administration records (MAR) and procedures were examined and they were found to be of a good standard. A member of staff was observed administering medicines and this was done in a professional, unhurried and sensitive manner. Everything regarding the medication process was satisfactory including, fully detailed individual medication files, with a photograph of the person, information regarding the medication, a front ‘information sheet’ also containing a photograph of the service user, relevant personal information, GP and NOK details. It was evident that medication reviews are carried out by GP’s and when GP’s visit the home they are also asked to write down peoples’ medical details any changes to medication and to date and sign the document. If a person administers their own medicine, they are requested to sign a ‘disclaimer form’. This shows that people are enabled as much as possible to maintain their own independence. In observation throughout the inspection visit and in the feedback received it was apparent that people are treated with respect and dignity. Rosewood Lodge DS0000064309.V370336.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. Quality in this outcome area is good. The provision of activities and outings has increased, helping to give the assurance that people are adequately stimulated and motivated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was evidence to demonstrate that a number of activities are provided within the home and varied outings are also regularly arranged including weekly mini-bus trips to local places of interest. The previous report suggested the activities that people participate in should be more fully recorded. This has been adequately addressed, giving information of what is being provided and who has attended. The AQAA states, ‘All activities are displayed on the main board for everyone to see what is coming up. We also take photos when we go out or have activities in the home’. There was also evidence that there has been an increase of available activities, with the AQAA stating, ‘There are much better activity choices for residents to choose from’ and ‘we are doing more activities with the residents’. ‘The activities programme is reviewed and discussed at residents meetings, Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 13 changing any activity which is not popular and introduce new activities’. It is evident that the provision of activities is now more frequent, helping to show that people are receiving more stimulation and motivation. The AQAA says, “Rosewood does not have a strict visiting time. Family and friends are welcome to visit their loved ones at any time”. It was evident that the home does have an open house policy with visitors to the home being made welcome and service users are encouraged to maintain relationships with their families and friends. Overall it was evident that people are encouraged and enabled to maintain contact with friends and relatives. There was the opportunity to have a meal at the home, which was very good. An alternative menu was also available. A brief discussion with the homes cook showed that there is a clear awareness of individual dietary needs, for example one person needed their food to be liquidised and another five people had diabetes. It was apparent that the kitchen is very well organised with peoples’ dietary needs being paramount. Some of the comments from the service users were, “Very nice food, its much nicer than the hospital I was in” “I am able to have my meals in my room, which I prefer” and “the meals are really good”. Rosewood Lodge DS0000064309.V370336.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. Quality in this outcome area is good. There is a policy with clear procedures, regarding the protection of people from harm or abuse. This helps give the assurance that people will be safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A comprehensive complaints policy and procedure is in place, with a copy of the complaints procedure being provided to all new service users who are admitted to Rosewood. The statement of purpose and the service users guide, both contained guidance on how to make a complaint. There is a copy of the complaints form prominently displayed in the home. There was also a ‘care aware’ helpline advertised, this gives people the added opportunity to seek advice or raise any concerns, that is independent of the home. No complaints have been received since the last key inspection visit. In feedback received it was apparent that people are familiar with the complaints procedure and are aware of how to make a complaint, if they need to. Rosewood Lodge DS0000064309.V370336.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 and 26. Quality in this outcome area is good. Environmentally, the home is of a good standard, with satisfactory systems in place to manage the control of infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A full tour of the home was completed and throughout it was found to be of a good standard, it was clean, homely and fresh smelling. The home is now ‘smoke free’ and the old smoke room has been turned into a quiet / reception room, which enables service users to meet any visitors in private. The last inspection visit highlighted the need for the kitchen to be renovated to bring it up to an acceptable standard. This has been satisfactorily addressed, with new stainless steel tops, new ceiling and a new permeable floor. It was Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 16 suggested that new cupboard doors would further enhance the renovation of the kitchen. The manager said, it was being considered. The AQAA says, “We have decorated most of the bedrooms downstairs and replaced some carpets”. However some of the other bedrooms are in need of redecorating and the manager gave an assurance that it is planned for these rooms to also be done. Peoples bedrooms are all ensuite and they were observed to contain their own personal belongings, helping to demonstrate that people are encouraged to bring in these particular items, in order to promote familiarity, and comfort. The home maintenance book was observed and it was up to date, showing repairs and jobs that had been carried out. The homes laundry is well equipped to meet the needs of the people who live at Rosewood. Throughout the home hand washing facilities were conveniently placed, in order to help with infection control. The outside grounds are maintained to a good standard, with a recently fitted security gate, which gives the assurance that peoples’ safety is seriously taken into account. The comments received regarding the environment were all very positive, helping to give the assurance that people live and work in a safe, comfortable and pleasant atmosphere. Overall since the last inspection visit a number of positive changes have taken place, making the homes environment much safer, comfortable, pleasant and enjoyable for the people who live and work at Rosewood. It is envisaged that the provider will continue to make further improvements to the home. Rosewood Lodge DS0000064309.V370336.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. Quality in this outcome area is excellent. There is a committed and experienced staff team, giving the assurance that people receive a good quality service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing levels for Rosewood were examined and they were found to be satisfactory. There is a consistent and well-established staff team, helping to give the assurance that service users are confident and trusting of the team. Four staff files were examined and they contained information with regards to the experience, skills and training that staff have received with a full and thorough mandatory-induction programme being in place. The files examined contained all of the necessary recruitment information including, application form, two written references, contract of employment, and job description. Criminal records bureau checks (CRB) and POVA checks had also been carried out, prior to the commencement of employment. The recruitment procedure is robust and thorough, helping to give the assurance that people are protected and safeguarded from harm or abuse. Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 18 As previously mentioned people were observed to be treated with respect and dignity and it was apparent that a good rapport and trusting relationships existed between the staff and the service users. All of the feedback received regarding the staff team was very positive. The staff training ‘matrix’ was examined and it was evident that the provider is committed to providing good and regular courses, helping to demonstrate that people are sufficiently trained and skilled to provide a good level of care and support. The national vocational qualification in care (NVQ) training programme is ongoing and there was evidence that the provider is committed to ensuring that this NVQ training is accessed for all staff, with the majority of (75 ) staff having achieved this award at level2. Rosewood Lodge DS0000064309.V370336.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 and 38. Quality in this outcome area is excellent. The home is very well managed and organised, ensuring as much as possible that people receive a consistent and a good quality of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has a number of years experience in care work and has managed Rosewood Lodge for the past twelve years. She has relevant qualifications for the post of registered manager, including a certificate in management, NVQ level 4 in care management, and a Diploma in Management. She has also been actively involved in the ‘Taste for Life’ Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 20 scheme, which is an initiative set up by the food standards agency. This programme has been focusing on food safety, cleanliness in the kitchen and nutrition with older people. The comments regarding the management received from service users, relatives and staff were all very complimentary. One visitor to the home said, “the manager is absolutely brilliant” and the general feedback from staff was that, ‘she is very supportive’, ‘really approachable’ and ‘the best manager I have ever had’. The home continues to maintain the investors in people award, for its sixth successive year. This is an external quality assurance-monitoring organisation. The health and safety policy was up to date, with comprehensive, individual and corporate risk assessments, promoting the health, safety and independence of service users. The home maintains it’s own internal quality monitoring assurance system and sends out regular survey questionnaires to relatives and friends of service users. Some of the returned surveys said, “It has proved to be much better than we expected ” and “There is always a pleasant welcoming atmosphere to visitors and residents alike”. All staff have received relevant and appropriate training, including: safe moving and handling techniques, operating equipment, food safety, fire risk assessment, first aid, COSHH and infection control. There is a person trained in first aid on duty at all times and water temperatures are checked weekly. The homes health and safety certificates were inspected and they were all found to be up to date and in order, including: Gas inspection, legionella bacteria check, electric inspection, fire alarm and emergency lighting inspections, lift servicing certificate and a recent satisfactory environmental health report stating, “the kitchen is clean and tidy with good systems in place”. It is clear that as much as possible is done to ensure the health and safety of people living and working at the home. There were procedures in place, regarding service users’ finances, with appropriate and adequate records and receipts being kept, helping to ensure that people’s finances are safeguarded. Rosewood Lodge DS0000064309.V370336.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 X X 3 X X 3 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NONE. 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. Standard Regulation Requirement Timescale for action 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 Rosewood Lodge DS0000064309.V370336.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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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