Inspection on 08/05/07 for Birch Trees

This inspection was carried out on 8th May 2007.

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 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

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Birch Trees Hollist Lane Midhurst West Sussex GU29 9AD Lead Inspector Mr E McLeod Unannounced Inspection 8th May 2007 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 Birch Trees DS0000068854.V336103.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. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birch Trees Address Hollist Lane Midhurst West Sussex GU29 9AD 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) 01730 813260 01730 810923 Teerose Ltd Mr Teelaga Samy Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service Brief Description of the Service: Birch Trees is a care home with nursing, which is registered to accommodate up to 19 persons over the age of 65 not falling within any other category. The service is located near Midhurst, and has contacts with the local community. The service is operated by Teerose Limited, for whom the responsible individual is Mrs Samy. The registered manager is Mr Teelaga Samy. The premises are a detached residential property which has been adapted for its’ present purpose. There is parking on the property and a garden area which is accessible to people accommodated. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was arranged to carry out an assessment of how the service is meeting key national minimum standards for care homes for older people. Previous to the inspection visit we sent out surveys seeking the views of people accommodated and their relatives on how the service is performing, and replies received were used in planning the visit and have contributed to this report. An update on service provision was requested from the provider, and this information was sampled during the inspection visit and has been used in this report. We visited on the 8th May 2007 and were on the premises for the greater part of five hours. We spoke with five people living at Birch Trees, two members of staff, a visiting hairdresser, Mr Samy the registered manager, and Mrs Samy the registered provider. Four sets of care plans were sampled, including records relating to risk assessment and the review of care plans. Three sets of staff recruitment records were sampled, which included training records. A lunch was observed, and throughout the visit interactions between staff and people accommodated were observed. Policies and procedures, including those relating to the protection of people being cared for, were sampled. A partial tour of the premises was carried out. What the service does well: There is a good atmosphere in the home, and staff and managers are seen as caring and supportive. People are supported to access the health services they need, and can expect their health needs to be met in the home. People living at Birch Trees generally believe they have a lifestyle which suits them, and are able to maintain contact with family and friends, the local community and their faith. People receive meals they enjoy, and have a varied and nutritious diet. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 6 All areas of the home visited, including bathrooms, laundry areas and the kitchen were found to be clean, hygienic and odour free. The views of people on how the service can be improved is being listened to and acted upon. 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. Birch Trees DS0000068854.V336103.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 Birch Trees DS0000068854.V336103.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents are receiving information on the service and receive an assessment of their needs to assist them in making an informed choice about where to live. Each person has a contract or statement of terms and conditions including conditions of occupancy. The service does not provide specialist intermediate care. EVIDENCE: There is a statement of purpose for the service which sets out information on the service for people accommodated and prospective residents. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 9 Care plans sampled included the records of pre-admission assessments carried out by the referring agency, and records of the assessment carried out by the provider. These indicated that the needs of people being accommodated are being assessed before admission is agreed. People accommodated receive a contract or terms and conditions which set out for them their rights and responsibilities while living at Birch Trees. Examples of individual contracts were seen during our visit. Written responses to our survey indicated that people have received contracts and received good information on the service to be provided. The home does not provide intermediate care. Birch Trees DS0000068854.V336103.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of each person are set out in an individual plan of care which gives the person a say in how his or her care is delivered. People are supported to access the health services they need, and can expect their health needs to be met in the home. For the protection of people accommodated, medicines are being administered and stored safely in the home. People are being treated with respect and have their right to privacy upheld. EVIDENCE: Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 11 Four sets of care plans were sampled, which indicated that risk assessments and care plans are in place, and that reviews of the care plans are undertaken. One care plan review undertaken by a sponsoring authority which was sampled indicated that they believed that a high standard of care was being provided. Care plans and care information seen indicated how the person would like their care and support to be provided, although this is an aspect of the care plans which could be improved upon. However, as the provider is presently changing the care plan format, no requirement or recommendation was made concerning this at the time of the visit. Care plan records sampled indicated that a wide range of health care services are being accessed by people living at Birch Trees. Opportunities for appropriate exercise are being provided through music and movement sessions. Safety in the home has been improved by the fitting of additional grab rails which assist people with their mobility, and a new electronic system for door closing in the event of fire. Equipment recently purchased to improve moving and transfers includes two new hoists and additional sliding sheets. Staff interviewed felt that the new equipment had improved the safety of care in the home. Policies, procedures and training are in place for the storage and administration of medicines. A local pharmacy delivers medicines and also is contracted to inspect the arrangements and procedures for medicines in place in the home. Appropriate lockable storage for medicines is provided. We were advised by registered manager Mr Samy that no resident is responsible for his or her own medication. A number of medicine administration records were sampled, which had been completed clearly. The member of nursing staff administering medicines at lunch time was completing records for each medicine administered at the time administered. Staff interviewed gave examples of how they seek to ensure that the privacy and dignity of residents is observed when personal care is being provided, and during the visit all staff were seen to treat people with respect and kindness. People living at Birch Trees and their relatives who replied in writing to our survey said that staff are kind and meet the needs of people accommodated, one saying “the staff are always very helpful”. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 12 During the inspection visit there were no indications in actions observed or records sampled that people are being discriminated against on the basis of their disability or difference. Care staff interviewed said that each person has a key carer who assists in the liaison and contact with family and friends, and ensures that extra little things are done for the person. Staff interviewed felt that there were good relations with local health services including GP’s. Care records seen included the interests of people accommodated, and activities or outings the person had taken part in. In some of the care records seen the person had indicated their wishes in the event of their serious illness or death. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Birch Trees generally believe they have a lifestyle which suits them, and are able to maintain contact with family and friends, the local community and their faith. People are supported to exercise choice and control over their lives, which assists them in leading fulfilling lives. People receive meals they enjoy, have a varied and nutritious diet and eat in pleasing surroundings. EVIDENCE: Mr Samy said he was continuing to provide more activities and stimulation, such as music for health, and games. He said he is looking at ways to increase contact with the local community. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 14 The programme of activities seen for May included scrabble, exercise sessions, games, bingo and quizzes. Mr Samy said that people are assisted to go out for walks by a visiting physiotherapist, and there is a mini bus for outings. There is some one to one social support for people, such as reading out letters where this is requested, and time for chats. Staff and residents spoken to said that the garden is used a lot in good weather. Care records seen included the interests of people accommodated, and activities or outings the person had chosen to take part in. Records seen also indicated ways in which some people were enabled to follow their faith and maintain contacts in the community. One person living at Birch Trees said in replying to our survey “they do everything possible to keep the residents motivated”. Some people interviewed had individual hobbies or interests they followed, and staff indicated ways in which they are supporting people to continue those interests or hobbies. Interviews with staff provided examples of how they are assisting people to maintain contact with their friends and family, and people interviewed said they felt their relatives were welcomed when they visit the home. A recent open meeting for people, their relatives and advocates was well attended, and provided some useful comments and suggestions which the managers have acted upon. On a tour of the premises, it was noted that people have brought personal possessions with them and have individualised their bedrooms. Interaction between staff and people accommodated indicated ways in which people are being supported to maintain their personal autonomy and choice. Access to hot and cold drinks for visitors and residents has now been provided away from the main kitchen area. We observed a lunch being served on the day of the visit. Food was well cooked from fresh ingredients, and was wholesome and appealing. People who did not wish to have the main choice of meal were being offered an alternative choice. The lunch was being taken at a relaxed and unhurried pace and there was a sociable atmosphere. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 15 Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Birch Trees and their relatives and friends are confident that their complaints will be listened to, taken seriously, and acted upon. Arrangements are in place whereby people can expect that they will be protected from abuse. EVIDENCE: A policy and procedure on the making of complaints and recording of concerns is in place. The record of the individual concern or complaint is now held on the care record. We suggested to Mr Samy that the complaints book continue to be used to indicate complaints and concerns received, and should refer to where the investigation and outcome of the complaint is held. A summary of the complaints procedure is given to residents in the information they receive on the service. Written feedback from people accommodated and their relatives indicated that they knew how to complain and who to complain to, and felt able to say when they had concerns or complaints. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 17 The home’s procedure for ensuring the safety from harm of people accommodated was sampled. Staff training is being provided in protecting people, and Mr Samy advised that he has attended briefing sessions on changes to local safeguarding adults procedures. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, well maintained environment which meets their needs. There are safe and comfortable communal facilities, and outdoor areas are accessible and provide seating and shade. Specialist equipment to help maximise the independence of people living at Birch Trees is being provided. People live in safe, comfortable bedrooms with their own possessions around them. However, the provider needs to continue to review if people who share bedrooms are still happy to share bedrooms. All areas of the home visited were clean, pleasant and hygienic. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 19 EVIDENCE: There have been improvements to the premises since the registration of the service in December 2006. For example, the main lounge has been redecorated and has a new carpet, and also benefits from improved lighting and the purchase of a new television. A new boiler system has been installed which has improved heating in the home. There is a system in place to ensure the premises and grounds are being properly maintained. Records for maintenance tasks identified and when these have been completed were seen. Maintenance work was being carried out on the day of the inspection visit which was helping improve safety in the home. The main communal areas are the main lounge, the quiet lounge, and the dining room. The quiet lounge was being used for the hairdresser’s visit on the day of inspection. The grounds and garden are well maintained and accessible, and people said they enjoyed going out into the garden on good days. Eight bedrooms were visited, and were found to be decorated and furnished to a good standard. Staff interviewed said there was enough space in bedrooms to carry out care tasks and manoeuvre hoists. Two of the bedrooms visited were each shared by two people, and the provider needs to ensure that people sharing rooms are doing so out of choice and can have their needs for privacy and dignity respected in the arrangement of the shared room. The premises are decorated and furnished to a good standard and are homely and comfortable. We hand tested the hot water in some bedrooms, and found it to be set at safe levels. All radiators seen had radiator guards which provide safety for residents. All areas of the home visited had good but unobtrusive forms of lighting. All areas of the home visited, including bathrooms, laundry areas and the kitchen were found to be clean, hygienic and odour free. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 20 Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs are met by the numbers and skill mix of staff. People benefit from being supported by a staff team who have a programme of training in place. The provider needs to ensure that a suitable number of staff in the home are developing their skills and practice by undertaking qualification training. People are being supported and protected by the home’s recruitment policy and practices. EVIDENCE: Staff rotas are provided. On the day of the inspection visit, there were noted to be sufficient numbers of experienced staff available to meet the needs of the people accommodated. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 22 Records provided by the home indicated that 5 nurses and 10 care staff were employed at the time of the inspection visit. Mr Samy advised us that two of the care staff hold the National Vocational Qualification in care (NVQ) at a minimum of level 2, and that no other care staff were currently undertaking NVQ training. People responding to our survey indicated that staff are seen as helpful and kind, and there are enough staff on duty to meet the needs of each person. One resident replying to our survey said “there is always someone to speak to if needed”. Three sets of recruitment records were sampled which indicated that staff are being checked and their references received prior to them commencing employment in the home. Care staff said that they have found recent training such as adult protection, fire training, first aid and cross infection to be helpful. Staff said that the new providers were ensuring that staff training was being promoted in the home. Staff said that they were also able to attend courses on conditions such as continence and Parkinson’s disease which are provided locally. Some staff training certificates were seen, and there is a plan of training which includes one training session per month for staff. Discussion with staff and sampling of staff records indicated that induction training is in place which will assist new staff in getting to know the service and how they are expected provide safe care. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Birch Trees are benefiting from improvements made to the service and the good management of the home. The views of people on how the service can be improved is being listened to and acted upon. The home supports the financial independence of people using the service. Staff are being appropriately supervised, and the appropriate support of staff helps maintain a good atmosphere which benefits residents. The health, safety and welfare of people accommodated and staff is being promoted and protected. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 24 EVIDENCE: Staff interviewed felt that the home was being well managed, and that there had been an improvement in how care was being provided for people. The views of people living at Birch Trees and their friends, relatives and advocates are being recorded and contribute to the improvement of the service. Arrangements in place to record such views include satisfaction surveys and open meetings. A written record of an open meeting held with people accommodated, their relatives and members of the staff team in April 2007 was seen. The record indicated that positive feedback was received on the service, and suggestions for improvements were also made. Suggestions already taken up and implemented include the provision of baskets for individual laundry and the fitting of new grab rails. Access to hot and cold drinks for visitors and residents has also been provided away from the main kitchen area. Arrangements are in place for the supervision of staff, and records are made of supervision undertaken. Staff training in health and safety topics is being provided. We looked at records of risk assessments carried out on the building and individual rooms, and Mr Samy advised us of improvements such as new equipment purchased as a result of the risk assessments. Records seen indicate that fire safety checks, hazardous substances assessments and electrical equipment testing are being carried out. Safety in the home has been improved by the provision of additional grab rails which assist people with their mobility, and a new electronic system for door closing in the event of fire. Equipment recently purchased to improve safe handling includes two new hoists and additional sliding sheets. Staff interviewed felt that the new equipment provided had improved the safety of care in the home. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 25 Staff interviewed gave examples of measures they would take to reduce the risk of cross infection in the home. The Safer Food system is being implemented in the kitchen, where records are kept of this and other arrangements to ensure a clean environment and safe food. Mr Samy advised that the home does not manage the finances of anyone living there, and does not hold cash for anyone. There is a system in place whereby expenses such as chiropody treatments and hairdressing are met by the provider, and relatives are then billed for the cost. Records and receipts in relation to this were seen. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 26 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 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 27 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 Standard OP28 Regulation 18.1 (a) Requirement The provider shall ensure that at all times competent and experienced persons are working at the care home who are appropriately qualified to meet the health and welfare needs of people accommodated. Timescale for action 30/11/07 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 OP23 Good Practice Recommendations The provider should regularly review with people accommodated in shared rooms whether or not they wish to continue being in a shared room. Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Birch Trees DS0000068854.V336103.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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