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Inspection on 12/12/06 for Blakesley House Nursing Home

Also see our care home review for Blakesley House Nursing Home for more information

This inspection was carried out on 12th December 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.

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

Staff in the home were observed to treat service users with respect and kindness. Relations between service users and staff appeared friendly and relaxed. The service users looked comfortable and well cared for on the day of the inspection. The standard of meals continues to be maintained with service users commenting favourably on the quality of meals served in the home. Eleven responses were received from CSCI surveys that had been sent out to service users prior to the inspection and all were positive.

What has improved since the last inspection?

The home has complied with all of the previous inspection`s five requirements. All the staff have had recent updated Protection of Vulnerable Adult training. The Registered Person reported to the Inspectors that the home now has a better working relationship with its GP.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Blakesley House Nursing Home 7 Blakesley Avenue Ealing London W5 2DN Lead Inspector Ms Jean Bovell Key Unannounced Inspection 12th December 2006 10:30 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 Blakesley House Nursing Home DS0000010942.V322462.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. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blakesley House Nursing Home Address 7 Blakesley Avenue Ealing London W5 2DN 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) 020 8991 2364 020 8991 5256 Mrs Margaret Nyambura Lane Mrs Margaret Nyambura Lane Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 16 Nursing beds for the care of the elderly 6 Personal care beds Date of last inspection 25th April 2006 Brief Description of the Service: Blakesley House is a care home for twenty-two older people. There are sixteen beds for older people who need nursing care and six beds for service users who require personal care. The Registered Manager is also the owner of the home which is a four storey detached house located in a quiet residential area of Ealing. The home is close to Ealing Broadway, with its shopping centre, buses, and underground and main line station. There are eleven shared bedrooms and five bathrooms within the home. The lounge, separate meeting room, kitchen and conservatory which is also used as a dining area, are situated on the ground floor. There are no communal areas on the upper floors. The home has a passenger lift and it can be accessed from the lounge via steps or a portable ramp. Laundry facilities and a food store are within an out-building that is located in the rear garden. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two Inspectors over a period of late morning to late afternoon. The Inspectors spoke to a number of service users, interviewed staff including the Registered Person, examined documentation and toured the building. The home had eleven service users on the day of the inspection. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken with, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. What the service does well: What has improved since the last inspection? The home has complied with all of the previous inspection’s five requirements. All the staff have had recent updated Protection of Vulnerable Adult training. The Registered Person reported to the Inspectors that the home now has a better working relationship with its GP. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 6 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. Blakesley House Nursing Home DS0000010942.V322462.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 Blakesley House Nursing Home DS0000010942.V322462.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): 1, 2 and 3 (Standard 6 was not assessed because the home does not provide intermediate care). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home has a service user guide there was no evidence to suggest that service users had received a copy. Similarly, although the home had copies of contracts, which highlighted the cost of the placement, service users interviewed were not aware of the nature of their contracts. The home has all appropriate assessments in place. Pre-assessments are undertaken prior to admission as well as an assessment undertaken when a service user is admitted. EVIDENCE: The Inspector interviewed three service users who all indicated that they had not received a copy of the home’s service user guide. Similarly, although the Registered Person was able to produce copies of contracts for these three Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 9 service users, none appeared to know the contents of these contracts or have any input into them. The Inspector examined three service users’ case records and found that all had had detailed pre-assessments undertaken and another assessment undertaken on admission. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has a detailed individual plan of care that incorporates the physical, mental health and cultural needs of each service user. The home has satisfactory medication systems for dispensing and storage in place and service users were observed being treated with respect and their dignity was being maintained. EVIDENCE: The Inspector examined three service user care plans. Each incorporated a detailed assessment of mental health, physical and cultural needs from which a plan of care was based. Assessments in this plan of care included moving and handling, behavioural patterns, pressure care, nutrition and falls. The assessment format has a numerical weighting that indicates the level of dependency. These assessments were reviewed monthly. Two care plans had been signed by the individual service user in receipt of this care. The plans of care also indicated how each service user personal care was delivered. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 11 The home has a key working system and there is a daily record written about each service user. One of the service users has recently moved into the home from another home also owned by the Registered Person and his/her care plan requires updating to reflect his/her new environment. The Inspector examined the medication systems used by the home. The home has a monitored dosage system in place that is supplied by a local pharmacist. The Inspector examined the medication administration records (MAR) and found them all in order with no gaps. The assistant manager informed the Inspector that only qualified staff dispense medication. All medication is stored in a purpose built medication trolley that is secured to the wall of the office in which it is stored. The Inspector also checked the home’s supply of controlled drugs, which were all properly accounted for. The Registered Person reported that the home now has a better working relationship with its GP and that any service user that needs to go to hospital is always accompanied by a staff member. Staff were observed interacting with service users in a kind, friendly and attentive manner. Service users spoken with by Inspectors confirmed that staff treated them with respect and kindness. Drinks were readily available to service users and cold drinks were in easy proximity to service users should they require them. The Registered Person confirmed that, on the day of the inspection, there were no service users with pressure area concerns. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities that are being provided to the service users are adequate for meeting their social and religious needs. Contact with relatives and/or friend are encouraged and facilitated and service users are offered choices in relation to their daily living routines. Varied and nutritional meals are being provided at the home. EVIDENCE: Although no organised activity occurred at the time of the inspection, an activities programme was in place and it was indicated that a Church of Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 13 England Service was held at the home each month and that there were weekly sing-along, exercise and bingo sessions. The Registered Person confirmed that the home employed a part-time Activities Co-ordinator who engaged in one-to-one activity with the service users such as manicures. A hairdresser also called on a regular basis. Special occasions such as Birthdays and Christmas were celebrated. The Inspectors were informed by the Registered Person that relatives were invited to a party, which was being held at the home on Christmas day. Service users were observed watching television in the lounge and/or singing amongst themselves. Others were involved in individual activity within their separate bedrooms. Service users who spoke to the Inspectors indicated overall satisfaction with the activities that were provided at the home and appeared settled and content within their environment. The home’s visiting policy was in place and contact with relatives and friends are encouraged and facilitated. The Registered Person reported that the service users chose what they wore, make up/hairstyles, when they got up in the mornings/retired at night, activities and meals. Service users were also able to remain in their bedrooms and have meals delivered to them, or sit with others in the lounge. Service users were observed having a variety of snacks and drinks during their morning break. They were also offered ample portions of wholesome and appealing lunch choices. Varied and nutritional meals were listed on the menus and drinks and snacks were readily available. Service users that were spoken with expressed satisfaction with the quality and quantity of food provided at the home. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place but not all service users are aware of it and have a copy of this procedure. Nursing and care staff have received updated b training on the Protection of Vulnerable Adults and the service users are being protected from abuse. EVIDENCE: The Inspector spoke with three service users and asked whether they had been made aware of the home’s complaint’s procedure and had a copy of it. Only one of the service users was aware of the complaints procedure and had a copy of it, although another service user interviewed indicated that they felt confident that they could bring any concern to a senior staff member in the expectation that their concern would be dealt with. The records indicated that refresher training on the Protection of Vulnerable Adults had been delivered to all care and nursing staff. This training was recommended following an adult protection investigation. It was discovered that staff failed to carry out appropriate adult protection procedures in relation to a serious incident that occurred while personal care was being delivered to a service user. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 15 Three members of staff who were spoken with indicated an understanding of ‘whistle blowing’. Service users monetary allowances are held in safekeeping at the home. A number of related financial records were examined at random and no discrepancies were identified. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is safe and adequately maintained but cleaning in specific areas and redecoration of communal areas is required. EVIDENCE: The communal areas at the home are adequately spacious, comfortably furnished and appropriate for shared or individual activity. There was, however, an inappropriately small television in the lounge and a payphone in the meeting room was out of order. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 17 A ‘Programme for Redecorating, Refurbishing and Maintenance’ dated 2006 was in place. Nonetheless, general redecoration and overall cleaning incorporating ceilings, walls, the outer areas of waste bins and skirting areas, were required. The boiler was inspected and it was indicated that the central heating system had no impact on the availability of hot water. The rear garden was reasonably well maintained and accessible to wheelchair users. There were no issues relating to the laundry. Despite attention being required in specific areas, overall the home was adequately maintained, safe, warm and hygienic, and there were no offensive odours. The atmosphere was calm and pleasant. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are adequate and care staff are appropriately trained and qualified for meeting the needs of the service users. The home’s recruitment policy and practices are satisfactory. EVIDENCE: Six Registered Nurses, one Enrolled Nurse, five Care Assistants and one Cook are employed at the home. It was indicated on the staff rotas that one Registered Nurse and two Care Assistants are on duty during waking hours and one Registered Nurse and one Care Assistant cover waking duty at night. The Registered Manager reported that three Care Assistants had achieved level 2 National Vocational Qualification in care. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 19 A number of recruitment files were inspected at random and were found to contain the required documents including application forms, references, photoidentification and signed contracts/statement of terms and conditions. CRB disclosure certificates were held in a separate folder. Staff training certificates were viewed and it was reflected that training delivered during 2006 included Fire Safety, Health and Safety, Infection Control, Manual Handling, Medication, Food Hygiene and Protection of Vulnerable Adults. Service users that were spoken with reported that the nurses and care assistants were friendly, respectful and considerate. Care staff who were present during the inspection appeared committed to meeting the needs of the service users and were observed being attentive and competent. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not managed in a way that encourages and utilises staff skills and experience. There are insufficient systems in place to create and consolidate in staff an ethos of mutual support between management and staff. Staff need to feel valued by the Registered Person so that they can deliver a good level of care to ensure that the home is run in the best interests of service users. The health and safety of the service users are being satisfactorily protected. EVIDENCE: Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 21 The Inspectors spoke at length with the Registered Person and discussed her management style in the light of information received prior to the inspection about the way she dealt with staffing issues. Also discussed was the financial effect occupancy levels have on the financial running of the home, the Registered Person’s use of adaptation nurses with her existing work force and staffing costs. The Registered Person was of the opinion that she valued her staff and thought herself approachable and supportive of staff. Information received prior to this inspection raised concerns about the Registered Person’s style toward individual staff members, which was not supportive or consistent. This was discussed in detail but the Registered Manager was adamant that her approach to staffing matters was supportive. The home does not have any effective quality assurance system in place that would indicate to the Registered Provider that the level of service provided by the home consistently meets the needs of its service users. Currently the home only has a 50 occupancy level and this inevitably has financial implications for the future of the home. At the time of the inspection no additional potential service users were expected into the home. Also discussed as part of ensuring that service users receive a good level of service from staff was the need to properly financially remunerate staff. The Registered Person indicated to the Inspectors that staff pay would be a priority for her to address. The need for an effective payroll system was also discussed. The Registered Person indicated that she had spent money recently on the home that included new specialised beds and mattresses and linen. The use of adaptation nurses was discussed. The Registered Person told Inspectors that although they work at the home in a care assistant capacity, for which she does not pay them, they are used in addition to the existing group of staff she employs. The Registered Person confirmed that she did not terminate existing staff contracts in order to employ adaptation nurses. The Registered Person also told Inspectors that she thought that the number of adaptation nurses being sent to her by a local University would be decreasing because of changes in government regulations restricting the amount of overseas nurses being allowed to work in the UK. Interviews with staff indicated that they received time concessions in relation to family commitments. However, expectations relating to salary increases were not being realised and salaries were not paid on a specific date or time each month and may be paid at the end of four weeks or five weeks. This impacted negatively on staff morale and was suggestive of management failure to appreciate and properly reward its staff. Moreover, line management Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 22 supervision and team meetings which are fundamental forums for ensuring that information is shared, working practices discussed and training needs identified, were not being held. The records were indicative of health and safety checks being up to date. These included fire alarms, emergency lighting, extinguishers, water temperature, portable appliances and gas maintenance. Fire drills were carried out on a three monthly basis. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 23 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 2 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 24 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. 2. 3. Standard OP1 OP2 OP7 Regulation 5 (2A) 5A (2) 15 Requirement The home must supply each service user a copy of its service user guide. The home must supply each service user a copy of its contract with that service user. The service user plan for one service user recently admitted to the home must be updated to reflect his/her change of environment. The Registered Person must ensure that the payphone in the meeting room is in good working order. The Registered Person must ensure that all areas within the home are kept clean and reasonably decorated. The Registered Person must ensure that her management style encourages and enhances an open and mutually supportive atmosphere for her staff team. The Registered Person must put in place an effective quality assurance system. The Registered Person must ensure that all staff receive DS0000010942.V322462.R01.S.doc Timescale for action 12/02/07 12/02/07 28/02/07 4. OP19 23 (2) (C) 31/01/07 5. OP26 23 (2) (d) 30/04/07 6. OP31 9 (2) 22/01/07 7. 8. OP33 OP36 24 18 (2) (a) 12/02/07 12/02/07 Blakesley House Nursing Home Version 5.2 Page 25 regular supervision and team meetings are held regularly. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP18 OP19 Good Practice Recommendations The Registered Person should ensure that a written copy of the complaints procedure is provided to any service user who requests it. A larger television should be provided in the communal lounge. Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Blakesley House Nursing Home DS0000010942.V322462.R01.S.doc Version 5.2 Page 27 - 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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