Inspection on 09/01/06 for Alton House

This inspection was carried out on 9th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alton House 09/06/08

Alton House 05/11/07

Alton House 15/05/07

Alton House 23/11/06

Alton House 29/09/05

Alton House 26/01/05

Alton House 15/07/04

Alton House 01/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Alton House 22 Sunrise Avenue Hornchurch Essex RM12 4YS Lead Inspector Joanna Moore Unannounced Inspection 9th January 2006 09:30 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 DS0000027828.V277391.R01.S.doc Version 5.1 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. DS0000027828.V277391.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alton House Address 22 Sunrise Avenue Hornchurch Essex RM12 4YS 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) 01708 451547 Mr Frank Barrs Mrs Patricia Lilian Barrs Mrs Patricia Lilian Barrs Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places DS0000027828.V277391.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Alton House be registered to accommodate 19 older people of either sex, with the registration category of Old Age, not falling within any other category. 29th September 2005 Date of last inspection Brief Description of the Service: Alton House is a privately owned care home providing care and support to 16 older people. The home is owned by Mr and Mrs Barrs and is currently managed by Mrs Barrs. The home is situated in a quiet residential area of Hornchurch with access to local shops and transport links. The home is traditionally styled and in keeping with other properties in the area. It offers a warm, welcoming environment. DS0000027828.V277391.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the annual inspection program. The inspection took place between the hours of 9.30am and 2.45pm. As part of the inspection the inspector spent time chatting with three service users, staff and two visitors. A meal was also sampled. What the service does well: What has improved since the last inspection? What they could do better: The home is unable however to fully meet the standards until it is ascertained via an OT assessment what the service users needs in relation to adaptations DS0000027828.V277391.R01.S.doc Version 5.1 Page 6 and the provision of a second assisted bath. This is an ongoing recommendation Staff training records evidence that staff do not all receive training to a minimum standard and requirements have been made. The home must maintain sufficient staffing levels in line with the duty rota to provide care for service users. Service users are not fully protected by the homes recruitment procedures The manager must evidence that they have kept up to date with changes in practice and legislation through appropriate management training. 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. DS0000027828.V277391.R01.S.doc Version 5.1 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 DS0000027828.V277391.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Service users are admitted to the home following an assessment of need by the placing authority with supplementary assessments carried out by the home. EVIDENCE: The service user guide had been updated since the last inspection to reflect changes in the regulating authority. One service users file that had recently been admitted was viewed and this included a detailed pre-admission assessment. One service users family spoke of how helpful the staff were in supporting them and their relative through the admission process. This service user was able to carry out a number of visits including lunch time stays and then came into the home for a trial stay to “test drive” the home. At the time of the inspection the deputy manager was visiting a service user I hospital to ascertain whether they were ready to come back to Alton House. Standard 6 is not applicable as the home does not provide intermediate care. DS0000027828.V277391.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Service users needs are outlined in a plan of care and appropriate support is in place to address their needs. Service users privacy and dignity is maintained. EVIDENCE: All residents are registered with their local GP. The chiropodist, district nurse community psychiatric nurse, dentist and optician are involved in the home and attend as required. The home is supported by the local NRSS nursing team who provide support to the home to prevent unnecessary hospital admissions and GP call outs within office hours although the continuing availability of this service is not clear. The home has a link nurse who visits every two weeks who reviews any medical concerns raised regarding residents and provides advice and training upon request. Risk assessments were in place but not always updated regularly. Risk assessments must be reviewed at minimum annually or more often if there is a change in circumstances. DS0000027828.V277391.R01.S.doc Version 5.1 Page 10 One service user case tracked is a diet controlled diabetic. The registered person since the previous inspection has liaised with the placing authority and doctor to understand fully whether blood sugar levels require monitoring, how often and who will undertake this task. As a diet controlled diabetic the home had been advised that a district nurse would not visit the home to monitor blood levels. It is therefore recommended that the home arrange for the service user to visit the GP periodically to have their blood sugar levels checked. Care plans were recorded as checked monthly. For one service user the future placement and needs are unclear so the home have been liaising with the family. It is required that each service user file have a photo of the service user. Service users, and their relatives said that staff knock on doors before entering and treat them with respect and honour their dignity. One service user said that staff did not knock but that they didn’t want them to. Service users also said that staff are kind to residents with dementia. All consultations with medical staff take place in service users rooms and visitors are able to met in private in the resident’s room if the resident wishes it. DS0000027828.V277391.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users benefited from a varied and regular activity plan within the home Service users were supported in keeping contact with family and friends. Service users benefited from plenty of varied wholesome and nutritious food. Service users are encouraged to have choice but a recommendation has been made to discuss further again with people the time they would like to be woken or got up. EVIDENCE: One service user said” we can do anything we want within reason”. One service user said they were woken up at 6am, which they did not want another said that staff brought them a cup of tea at 7am. This service user said that they were asked what time they wanted waking when they came into the home. It is recommended that service user are again asked what time they would like to be woken or brought a cup of tea as they may have changed their wishes since moving in. Service users and relatives said that a variety of activities were provided daily within the home included film shows, music, quizzes, name game, quoits, I spy, cards, dominos, sing alongs, reminiscence. Manicure and hairdresser DS0000027828.V277391.R01.S.doc Version 5.1 Page 12 sessions take place in the small lounge. Service users commented on a lovely Christmas party with an extensive buffet, entertainer and lovely decorations. The home was from documentation viewed, discussions with relatives, service users and the deputy manager able to evidence that visitors were made welcome at all times. Contact with family was maintained by making visitors welcome and assisting service users to make a phone call. Both visitors spoken to on the day said that staff were friendly to them and a welcoming atmosphere was around. The home was from documentation viewed, discussions with relatives, service users and the cook able to evidence that adequate amounts and variety of wholesome food were provided throughout the day. Diabetic and vegetarian diets can be catered for. A meal was sampled which was the same as that provided to residents this was home cooked and tasty. One service user said “The foods very nice I like it. They sometimes do me liver and bacon which is my favourite. You never go hungry. I have got no complaints”. DS0000027828.V277391.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home has robust policies in place and experienced staff are aware of what constitutes abuse and what action to be taken but the home must ensure that new staff attend adult protection training. EVIDENCE: The home has a copy of the local adult protection procedures as well as the homes own procedure. The deputy manager and manger are aware of the need to report any concerns to CSCI and the local authority adult protection co-ordinator and have familiarised themselves more fully with POVA since the previous inspection. The majority of the staff have been trained in adult protection but there is a need to ensure newly employed staff receive this training. Staff when interviewed were clear as what constituted abuse and the need to report it to their manager immediately. Complaints management was reviewed at the previous inspection and found to be satisfactory. DS0000027828.V277391.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Service users benefit from a home, which is pleasant and well maintained. The décor and furnishings are appropriate to the needs of the service users. The home is unable however to fully meet the standards until it is ascertained via an OT assessment what the service users needs in relation to adaptations and the provision of a second assisted bath. This is an ongoing recommendation. EVIDENCE: DS0000027828.V277391.R01.S.doc Version 5.1 Page 15 It is a generally well maintained and furnished home in a quiet rural area of Hornchurch. The shops are some distance away in central Hornchurch. Furniture provided was suitable for the client group. Each service user had their own bedroom most with either ensuite shower or bathrooms. All bedrooms viewed were decorated to a suitable standard and were furnished according to the users wishes. The home was clean and odour free. The home was warm and well ventilated. The Kitchen was clean and the counters have been replaced. Food temperatures were appropriate. The first aid box needed further supplies of blue plasters. At the previous three inspections the provision of a second assisted bathroom for the home has been recommended. At the three previous inspections it has also been recommended that an occupational therapy assessment of the home be carried out in order to ensure that appropriate adaptations are provided. The garden pond has since the last inspection is decoratively screened off to prevent accidental falling in the pond. The handrail to the steps leading to the back garden from the side of the building requires extending to the end of the steps to enable residents to maintain their balance. DS0000027828.V277391.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Staff training records evidence that staff do not all receive training to a minimum standard and requirements have been made. The home must maintain sufficient staffing levels in line with the duty rota to provide care for service users. Service users are not fully protected by the homes recruitment procedures. EVIDENCE: Staff were deployed according to the rota in line with previously agreed staffing levels as follows: 7-9 am 2 Care staff and deputy manager 9am-3pm: 3 care staff and deputy/ manager 3pm- 7pm: 2 care staff 7pm- 11pm: 2 care staff 11pm-7am: 2 waking night staff. It was noted however that on the day of inspection RB was scheduled on the Rota to be covering care duties but during the whole inspection this staff was carrying out administrative duties leaving only two carers to complete the care tasks. This left these staff hard pressed and the home therefore fell below the agreed staffing level on that shift. The registered person is required to ensure that care staffing levels are maintained and that the rota is an accurate reflection of the duties performed by staff. The accuracy of the staff duty rota is a repeated requirement from the previous inspection. DS0000027828.V277391.R01.S.doc Version 5.1 Page 17 “The staff are all very nice and they look after me well. When I was not well a couple of weeks ago they kept popping in on me all the time to see I was okay and whether I needed anything.” Ohh I have my favourites “A” come and chats with me every day and she has a really good sense of humour.” At the previous inspection the deputy manager provided the inspector with a list of staff employed and the training they had undertaken. A variety of staff training has been provided including health and safety, dementia awareness, fire training, nutrition, adult protection, diabetes, medication, food hygiene, first aid, moving and handling, continence promotion. The training record provided however indicates that not all staff have attended basic mandatory courses which are relevant to their role for example 6/14 have attended health and safety, 9/13, first aid, 9/13 manual handling, 8/13 dementia awareness, 10/14 fire training, 11/13 adult protection. The registered person is required to ensure that all staff attend these basic training sessions. The training record provided does not specify dates that training took place and this limits the usefulness of the training monitoring as will not identify when time limited courses such as first aid have expired and will therefore fail to prompt people to update training. It is recommended that dates be added to the training monitoring record. This is a repeated recommendation. The deputy manager is according to the training information provided undertaking the registered managers award and is an approved NVQ assessor. Four care staff are undertaking NVQ in care. In order to meet the national minimum standards more staff must undertake this training. This is a repeated recommendation. Staff recruitment at the previous inspection was found to be satisfactory other than two requirements. The first requirement was the need for a current photograph to be held on file for each staff, this remains outstanding but the inspector was advised that the home had purchased a digital camera and would be photographing staff within the next few weeks and attaching the photos to the file. The second requirement related to the securing of either a CRB or POVA first check prior to the commencement of any new staff. A Crb is now in place for one of the staff and the home is awaiting the second CRB. The induction provided by the home is recommended to be further developed in line with TOPPS induction program. DS0000027828.V277391.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 The home fails to adequately support staff by regular formal supervision. The home must develop an effective quality assurance system. The building whilst well maintained and having established its safety thorough statutory checks as essentially safe presents a significant number of hazards to both service users and staff which need addressing. The manager must evidence that they have kept up to date with changes in practice and legislation through appropriate management training. EVIDENCE: A staff supervision program could be evidenced as now being in place. Staff files viewed recorded two supervisions since February with an annual appraisal in addition. In order to meet the national minimum standards however DS0000027828.V277391.R01.S.doc Version 5.1 Page 19 supervisions should be held six times per year. The member of staff without the CRB in place should be supervised on weekly basis however there were no records of this happening. The registered person is required to supervise staff who did not have a valid CRB weekly and keep records of this. The home believes that four service users manage their own finances. Families and friends manage the remaining service user finances with the home holding small petty cash sums for the majority of residents. The main expenditure incurred by residents is for chiropody and hairdressing. One service users petty cash records were viewed which tallied with the amount held expenditure was evidenced through receipts. The home advised that they were in the process of developing a quality assurance survey. The registered person is required to develop an effective quality assurance system. Health and safety risk assessments were recorded as last having been implemented/ reviewed in February 2004. Health and safety risk assessments are required to be reviewed at minimum yearly and more frequently should relevant circumstances change. On telephoning the home at a later date than the inspection the inspector was advised the manager and deputy had gone off duty and carers staffed the home. Staff were unclear in these circumstances as to whom was in charge of the home. There is required to be a clearly designated person in charge of the home at all timed. In the absence of the manager and or deputy a carer may fill this role and the person in charge should be detailed on the rota. The manager and owner Mrs Patricia Barrs has been managing the home for many years. Mrs Barrs has no management training. In order to meet the National Minimum standards it is required that Mrs Barrs undertake training in management and inform the commission of the date that she is enrolled to begin as the timeframe for completing the training in line with the national minimum standards has expired. Systems and records were in place to evidence regular checking and maintenance of fire prevention systems. Fire equipment was last service on 22.8.05. Valid Gas (16.3.05) and electrical safety certificates (26.2.03) were in place. A fire risk assessment was available. The registered person is required to carry out a full and proper risk assessment regarding the garden and the pond identifying all the risks and then to address them to protect residents from harm. The Environmental Health officer visited on 15.9.05 and reported that the kitchen surfaces require renewal this has been done. Chemicals were stored in a locked area. DS0000027828.V277391.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 x 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 x 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x 3 2 2 2 DS0000027828.V277391.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? 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 2 Standard OP8 OP8 Regulation 17 13 Requirement It is required that each service user file have a photo of the service user. Risk assessments must be reviewed at minimum annually or more often if there is a change in circumstances. The registered person is required to ensure newly employed staff receive adult protection training. The registered person is required to develop an effective quality assurance system. The first aid box needed further supplies of blue plasters. The handrail to the steps leading to the back garden from the side of the building requires extending to the end of the steps to enable residents to maintain their balance. This is a repeated requirement. Previous timescale given 1/11/05 The registered person is required to ensure that a CRB or Pova first check is in place for every staff prior to commencing employment and that a current photograph is held on file. This is DS0000027828.V277391.R01.S.doc Timescale for action 01/03/06 01/03/06 3 4 5 6 OP18 OP33 OP26 OP38 13 35 13 23 01/03/06 01/03/06 10/02/06 10/02/06 7 OP29 19 10/02/06 Version 5.1 Page 22 8 OP27 17 9 10 OP27 OP30 18 18 11 OP36 19 12 OP31 18 13 OP31 37 a repeated requirement. Previous timescale given 24/10/05 The registered person is required to ensure that the rota is an accurate reflection of the duties performed by staff. This is a repeated requirement. Previous timescale given 24/10/05 The registered person is required to ensure that care staffing levels are maintained. The registered person is required to ensure that all staff attend training in health and safety, first aid, manual handling, dementia awareness, fire training and adult protection. This is a repeated requirement. Previous timescale given 1/12/05 The registered person is required to supervise staff weekly who do not have a valid CRB and keep records of this. There is required to be a clearly designated person in charge of the home at all timed. In the absence of the manager and or deputy a carer may fill this role and the person in charge should be detailed on the rota. It is required that Mrs Barrs undertake training in management and inform the commission of the date that she is enrolled to begin. 10/02/06 10/02/06 01/03/06 10/02/06 10/02/06 01/03/06 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 Good Practice Recommendations DS0000027828.V277391.R01.S.doc Version 5.1 Page 23 1 2 Standard OP8 OP14 3 4 OP30 OP30 5 6 7 OP30 OP36 OP37 It is therefore recommended that the home arrange to have the service user visit the GP periodically to have their blood sugar levels checked. It is recommended that service users are again asked what time they would like to be woken or brought a cup of tea as they may have changed their wishes since moving in. It is recommended that dates be added to the training monitoring record. This is a repeated recommendation. Four care staff are undertaking NVQ in care. In order to meet the national minimum standards more staff must undertake this training. This is a repeated recommendation. The induction provided by the home is recommended to be further developed in line with TOPPS induction program. This is a repeated recommendation. In order to meet the national minimum standards supervisions should be held six times per year. This is a repeated recommendation. It is recommended that the proprietor undertake a review of all policies and procedures to ensure they accurately reflect practices within the home. This is a repeated recommendation. DS0000027828.V277391.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000027828.V277391.R01.S.doc Version 5.1 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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