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Inspection on 29/06/06 for 14 Marloes Walk

Also see our care home review for 14 Marloes Walk for more information

This inspection was carried out on 29th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service continues to provide a comfortable homely and spacious environment for people with profound physical and learning disabilities. Care is provided around a core group of staff who have worked with the people living in the home for a number of years, have a good knowledge of them, and who demonstrated a commitment to them having a good quality of life and good life experiences. Staff were positive about the service, as were relatives in their comments. The service works hard to see that residents enjoy experiences and activities that, because of their disabilities, require a great deal of support, organisation, commitment, and foresight.

What has improved since the last inspection?

The two areas of concern at the last inspection, that of medication errors and of a heavy reliance on agency staff, have much improved since then, with alterations and tightening up of medication administration procedures, and the recruitment of additional permanent staff, helping lessen reliance on agency staff unfamiliar with the residents` needs, and leading to greater consistency in working with residents.

What the care home could do better:

Notwithstanding the above improvements, a medication error had occurred a few days prior to the inspection. There is still a reliance on the use of agency staff. Where the service users are so reliant on a consistent staff group who are familiar with them, and with whom they are familiar, the aim for the service should be to have enough contracted staff as to only use agency staff as a last, and rare, resort.Although staff at the home receives plenty of training, much of appears to be of a general nature, rather than relating to the specific needs of people at 14 Marloes Walk.

CARE HOME ADULTS 18-65 14 Marloes Walk 14 Marloes Walk Sydenham Leamington Spa Warwickshire CV31 1PA Lead Inspector Martin Brown Key Unannounced Inspection 29th June 2006 09:15 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 14 Marloes Walk Address 14 Marloes Walk Sydenham Leamington Spa Warwickshire CV31 1PA 01926 452804 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) Turning Point Ms Sally Barlow Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: 14 Marloes Walk is a care home with nursing for eight younger adults with severe learning disabilities and physical disabilities. The South Warwickshire Primary Care Trust owns the home and the service providers are Turning Point. The two bungalows were purpose built and the home was opened in 1994. Four service users are accommodated in each of the bungalows. The bungalows are connected and have a shared office, sensory room and laundry. The home is close to a small row of shops and is close to the town of Leamington Spa. All of the bedrooms are single without en-suite facilities. There are two adapted bathrooms and a sensory room. The home and gardens are suitable for wheelchair users. The service aims to provide care, support and a good quality of life primarily for people who have very little independent mobility, and very limited communication. The fees for each person, per week, are currently £1609. This does not include social activities, hairdressing, toiletries or magazines. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 9.15am on a weekday morning and lasted for six hours. Three residents were out at day services and were not seen on this occasion. Three residents were present throughout, and much interaction between them and staff was observed. Staff from both shifts, as well as the manager, were seen and spoken with, as were visiting professionals and a relative. All at the home were welcoming and helpful. Comment cards from relatives and the pre-inspection questionnaire returned by the manager also informed this inspection. What the service does well: What has improved since the last inspection? What they could do better: Notwithstanding the above improvements, a medication error had occurred a few days prior to the inspection. There is still a reliance on the use of agency staff. Where the service users are so reliant on a consistent staff group who are familiar with them, and with whom they are familiar, the aim for the service should be to have enough contracted staff as to only use agency staff as a last, and rare, resort. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 6 Although staff at the home receives plenty of training, much of appears to be of a general nature, rather than relating to the specific needs of people at 14 Marloes Walk. 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. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality for this outcome area is good. The home is able to assess and meet the needs of prospective residents, and would not consider admissions without a thorough and well-paced introductory process. EVIDENCE: The home is in the process of admitting a new resident. This is being done gradually, with frequent daytime stays, before an overnight stay and permanent admission is finalised. Comprehensive assessments and guidelines were seen from his current home, showing needs and how they are met. The manager and staff expressed confidence that these are all needs that can be met, and are being met with current residents. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The quality for this outcome area is good. Good, clear guidance supports staff in providing consistent care for residents. This can be compromised if all documentation is not updated in line with reviews. The home works hard to try assist and heed residents in decision-making. This can be compromised if residents are not at all aware at times that they are being moved, or why. EVIDENCE: There are a number of areas where the needs of residents and how they are met are documented. Information relating to those residents in the home at the time of the inspection were looked at. Folders kept in the lounge for ready reference showed clearly, with the use of photographs, how regular and vital care tasks were to be accomplished throughout the day. These are thorough, of excellent quality, and help ensure consistent guidance and practice in ensuring people have the right therapeutic support and treatment. Similarly, individual daily recordings were thorough, relevant, and gave a flavour of that person’s experience of their day. Communication diaries are in the process of being updated. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 10 Full individual service user plans are in individual bedrooms. Together, these all help staff, particularly those less experienced with individual service users, to better understand their communication. Several staff, having worked at the home for months, rather than years, stated that they are still learning about the communication and wants of people living in the home. Speech and language therapists came in during the inspection with the aim of increasing or reintroducing skills and independence for residents. They are keen to introduce, or reintroduce, objects of reference as communication aids. Although most information in individual files had been regularly and recently reviewed, it was noted that one item of information regarding a person’s swallowing, was out of date, and should have been changed or removed. The information in his bedroom was correct and up to date. Staff were generally observed to inform residents of what was happening and was going to happen, and through experience and/or the use of written guidance, ascertain what residents’ wishes were. However, there were several occasions observed when residents were moved in their chairs with little or no forewarning or explanation. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 The quality for this outcome area is good. The home works hard to minimise the impact of individual disabilities on the ability of residents to experience the outside world and stimulating, ‘mainstream ‘ activities. This approach also extends to activities within the home and to mealtimes. EVIDENCE: Staff were able to discuss holidays and other activities either planned or recently taken place. These include holidays abroad, shows as far away as Bristol, football matches and other sporting events, all of which, because of the needs of the residents, require considerable organisation. A staff member was able to give an example of a holiday abroad in which the delivery of necessary ‘peg’ feeds had been delayed at Customs, but in which the problem was resolved with the help of pre-arranged emergency procedures. The service strives to provide new experiences for residents, and staff gauge how much these have been enjoyed. One staff member observed that one resident had enjoyed a football event, but had been indifferent to a basketball match. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 12 Staff agreed that simple, service user-friendly individual activities records, that would detail/illustrate activities undertaken, could usefully show what had been achieved, and act as a reference point for future activities. One resident was being read to for periods. This same resident also responded positively to time spent in the sensory room. One resident’s bedroom shows how staff are catering for his age-related needs, with football and music magazines. He also likes toys designed for much younger people. These are stored in a large box named as his ‘toybox’. Staff and the manager were enthusiastic about the involvement of relatives, and appreciated the work done recently in the garden. One relative seen during the inspection was very complimentary about the care provided in the home. The home had been linking meals in with the world cup, offering menus linked to the teams playing England. Some service users require ‘peg’ feeds; others require a lot of support with eating, which was seen to take place appropriately. The home works with speech and language specialists to encourage swallowing reflexes and tasting of food where appropriate. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The quality for this outcome area is good. Clear guidance and the knowledge of experienced staff helps ensure that residents receive support in ways they are familiar with and comfortable with. Residents can be more confident that medication is administered and recorded properly. EVIDENCE: Clear guidance on individual care plans documents exactly how care and support is to be given. Staff were able to demonstrate their knowledge and were observed undertaking a variety of care activities competently, with nurse support being available when needed. Staff were seen to manage the many and varied tasks required to maintain residents’ well-being and safety, such as manipulation, and correct resting positions, throughout the day. Medication records were examined, and were seen to be correct, with the exception of one instance, which had been reported under regulation 37, and was fully discussed, including actions to prevent any such re-occurrence. The manager, whilst acknowledging that any error is an error too many, advised that this was the first such incident since January. This showed a considerable improvement over the previous half year. Peg feeds were seen to be managed appropriately. There had been no errors noted regarding the management of these since the last inspection. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The quality for this outcome area is adequate. Residents can be confident that staff continue to work to that ensure wishes are understood and heeded, but would benefit from staff ensuring that they always take time and care to explain so that residents are aware of what is being done and why. The open and transparent culture at the home, and the active involvement of relatives, helps to safeguard residents’ well-being. EVIDENCE: Staff were observed being very attentive to service users and were able to discuss knowledgably the signs and reactions they gave and what these were likely to indicate. These were confirmed in personal care plans. Communication guides are currently being revised; existing ones, as well as their intended replacements, were seen. Staff continue to show a commendable commitment to understanding and meeting service users’ needs and wishes, newer staff acknowledged that they are still not fully familiar with the likely interpretation of all the residents’ responses. One service user has an advocate; the manager advised that relatives are active in promoting the welfare and well-being of residents; this was supported by comments from staff and relatives. Observations of staff/resident interactions evidenced an open culture of respect and dignity, only occasionally marred by some movements of residents in wheelchairs without forewarning or explanation. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 15 These were discussed with the manager, who advised that she will ensure that staff are clear at all times of the need to keep residents informed about all aspects of their care. There have been no complaints received concerning the service; there are appropriate policies in place regarding the prevention of abuse. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 The quality for this outcome area is good. Resident’s benefit from a spacious, purpose-built environment that is much improved following extensive work that was required, and is made attractive and homely, particularly individual bedrooms. Minor improvements will enhance residents’ safety and well-being. EVIDENCE: The environment is spacious and suited to the needs of the people using it. Bedrooms, in particular, are personalised in line with the needs and interests of the individual, with lots of decorations, pictures and personal possessions. Outside each bedroom is a letter rack for post. Bathrooms now have suitable cupboards, for storage of toiletries. There is a sink in the laundry, principally for laundry use. There is no hand washbasin solely for staff use. In other areas, such as the kitchen, there are appropriate hand washbasins in use, which were frequently used throughout the day. The home was clean and hygienic on the day of the inspection. Pictures and decorations help make the home more ‘homely.’ The garden is now much more attractive and accessible. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 17 The doors directly into the garden still open out the ‘wrong’ way, meaning that the open door is then an obstruction making access to the garden with a wheelchair more difficult than it need be. The manager pointed out that lighting in certain areas is rather dim at times. This was hard to ascertain on a bright summer day. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 The quality for this outcome area is adequate. Residents are supported by an effective staff team who are aware of their special needs and how to meet them. This is compromised to a degree by the use of agency staff who may be less aware of their needs without referral to guidance, colleagues and management support. Training for staff could be more usefully focussed on the direct needs of people at the home. EVIDENCE: There were four staff on duty on both shifts, with the manager as supernumerary, and offering nursing support if required in the morning shift. Staff spoken to were able to demonstrate a good knowledge of residents, their needs and how to meet these needs. They were enthusiastic and positive about their work and keen to offer a range of new experiences to service users whenever possible. Discussion with staff, and examination of training records and plans, showed a firm commitment to training by the organisation. Staff commented that some of the training could be usefully focussed more on the specific needs of the people at 14 Marloes Walk. Staff records showed staff recruitment and induction being carried out appropriately; newer staff spoken with stated that they had been well supported and inducted. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 19 The home still relies on the use of agency staff, although this reliance is now less than it was, following the recruitment and retention of more permanent staff. Regulation 37 notices show that a high percentage of medication and other errors and omissions have involved agency staff. The home has put in place further systems and procedures to reduce these errors, with the result that there has been only one reported error in the last six months. It was a frequently expressed view within the home that staff need to work at the home for a prolonged period before they are effectively able to understand and meet the needs of the residents, and that agency staff were frequently only there for short periods. Agency staff details are noted on a pro-forma. Ones looked at showed evidence of a Criminal Records Bureau check, but not whether it was satisfactory, nor when it was obtained. Staff receive regular recorded supervision and yearly appraisals. Staff stated they found these useful and supportive. 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The quality for this outcome area is good. Residents continue to benefit from living a in a well-run home that promotes their health, safety and well-being. EVIDENCE: The pre-inspection questionnaire stated that all relevant safety checks continue to be up-to-date; all those spoken to were complimentary about the running of the home. Positive feedback was received from relatives concerning the running of the home; experienced staff remain committed and motivated, and newer staff were impressed with their experience of the home and made favourable comparisons with previous workplaces. Regulation 26 visits take place regularly; these are detailed and evidence that the organisation works well to monitor progress within the home and identify areas for improvement. The manager advised that a parents’ forum had been proposed, but that parents did not wish such a formal arrangement, as they were mostly all frequent visitors who felt comfortable to bring up any issues at any time. Comments from relatives were all very positive. 14 Marloes Walk DS0000058004.V301171.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x 14 Marloes Walk DS0000058004.V301171.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 YA7 Regulation 12 Requirement Staff must ensure that in performing any care task, including moving service users any distance in a chair, they inform them what they are doing and why. All risk assessments must be updated to reflect any changes in residents needs A broken kitchen drawer and cupboard door must be repaired. A suitable hand washbasin is required in the laundry All agency recruitment forms must state whether Criminal Record checks are satisfactory. Training must be designed to meet the specific needs of the people living in the home. Timescale for action 05/08/06 2. 3. 4. 5. 6. YA9 YA24 YA30 YA34 13(4) 23 23 18 18 05/08/06 05/08/06 05/10/06 05/08/06 05/09/06 YA35 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 23 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. Refer to Standard YA11 Good Practice Recommendations It is recommended that all individual residents have ‘activity yearbooks’ or similar, that document activities and achievements through the year in a simple, visual, userfriendly manner. It is recommended that the label ‘toy box’ be replaced with something more age appropriate It is recommended that a lighting audit informs any action needed to ensure that all areas of the home are sufficiently bright in all weathers. It is recommended that alterations to the doors accessing the garden be considered, with the aim of facilitating easier access to the garden. All agency recruitment forms should state what date Criminal Record Bureau checks were obtained. 2. 3. 4. 5. YA12 YA24 YA24 YA34 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 14 Marloes Walk DS0000058004.V301171.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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