Inspection on 30/08/05 for Broomcroft House

This inspection was carried out on 30th August 2005.

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

Broomcroft House 22/03/07

Broomcroft House 18/11/05

Broomcroft House 02/11/04

Broomcroft House 06/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Broomcroft House Ecclesall Road South Sheffield South Yorkshire S11 9PY Lead Inspector Marina Warwicker Unannounced 30 Aug 2005 15:30hrs. 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 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. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Broomcroft House Address Ecclesall Road South, Sheffield, South Yorkshire, S11 9PY 0114 235 2352 0114 235 2351 broomcrofthouseall@bupa.com BUPA Care Homes (AKW) Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Andrea Dixon, proposed manager. Care home with nursing 87 Category(ies) of Old age, not falling within any other category registration, with number (87) of places House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2-Nov-2004 Brief Description of the Service: Broomcroft House is situated in the suburbs of Sheffield, with the city centre being approximately four miles away. Located on the edge of Ecclesall Woods; it is on a bus route and within easy walking distance to the local shops including the post office. This is a two storey purpose built stone building specifically to meet the needs of eighty-seven elderly people who require nursing and/or personal care. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on 30/08/05 between 3.30pm and 7.30pm. The inspector spoke to service users and staff and met some of the relatives who were visiting. A tour of the premise was carried out and staff on duty were interviewed. Some records were inspected. On the following day 31/08/05 the inspector visited the home between 10.30am and 3pm to complete the inspection. The manager was aware of this visit. What the service does well: What has improved since the last inspection? Staff had worked towards involving all service users who have the capacity during the planning of care and the monthly reviews. The management of medication has improved and the supplying pharmacist has been changed. The House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 6 staff completed the MAR sheets correctly. There were quality audits on meals served to the service users. Good team work within all levels of staff was noted. 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. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 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 standard(s) 1,3,4 & 5. Standard 6 does not apply to this service. The home provides the prospective residents and their families with sufficient information to make an informed choice. Before moving into the home service users take part in an assessment by the home’s manager to find out whether they are able to cater for the identified needs of the service users. Prospective service users are invited to visit the home and spend time among the residents to find out the suitability of the home before moving in. EVIDENCE: Six residents were consulted and they said that they and/or their relatives had the opportunity to visit the home and meet the residents and the staff before deciding on moving into the home. Since most residents are self-funding the staff at the home visited the residents at their homes or at the hospitals and carried out assessments before agreeing to accommodate them at Broomcroft House. The residents and the staff said that service users were invited to spend time at the home before accepting residency. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 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 standard(s) 7,8,9,10 &11 All residents have care plans. In order to meet individual needs the care plans are completed fully at the earliest possible opportunity by staff. The staff ensure that the health and social care professionals from the hospitals and from the community are involved when necessary to provide a seamless service. The qualified nurses managed the medication. The residents are treated with respect most of the time and the staff value their right to privacy. Therefore the residents are able to live in a comfortable and happy environment. Most relatives are consulted about funeral arrangements when the staff feel it to be appropriate, so that the residents’ last wishes are respected. EVIDENCE: On this occasion the evidence was gathered from consulting service users, staff on duty and through observation. Two care plans were checked briefly whilst checking some information about two service users. The information was available and helpful. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 10 The service users told the inspector that they were not aware of care plans and their monthly reviews. However, two service users said that they were confident that the staff gave them good care and that they were not worried about not being involved in the planning and reviewing of care. The others said that they were unable to comment, since they were never consulted. The manager was informed of this. The inspector noted that several service users were confused and two of them were noisy. One service user said that often a particular service user being noisy disturbed them. Discussions took place between the manager, the responsible individual and the inspector to address the changing needs and therefore change of category of the service users. The home had a clear specification of the staff job role. The care staff gave personal care to service users and they kept records of the care given on the personal care files. Two of these records were viewed by the inspector and found to be informative. Whilst writing the daily records the nurses referred to the personal care records. In one of the rooms a service user was using an indwelling catheter and there was unpleasant odour. The inspector noted that the catheter bag was full and the service user was given the evening meal. The inspector informed the care manager on duty. The staff during interview verbalised the daily routine, which included emptying catheter bags before meal times. However, this did not happen on this occasion. A service user informed the inspector that he/she was developing mobility problems and wanted to be referred to physiotherapy. The manager and the care manager were informed of this request. All service users had access to GP, dentist, chiropodist, optician and other professionals according to their needs. Two Medication Administration Records (MAR) were checked with a nurse. There were no records of service users’ allergies but the records were complete and satisfactory. The nurse had good knowledge of the medication. During conversation with the nurses it was established that information about the service users’ medication would be better used if it was available as part of the MAR sheets, so that it will be immediately accessible and therefore useful to staff. Two service users who were able to self-medicate had chosen not to do so since they wanted nurses to administer their medication. The inspector ascertained through interviews and observation that arrangements for health and personal care had been made giving particular regard to the service users’ privacy, dignity and respect. The staff had experience in looking after service users who were dying. They said the main aim was to keep the service users comfortable and maintain dignity. They also said that a critically ill service user was never left alone if the relatives were unable to attend. Some staff had received training on death and dying. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 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 standard(s) 12,13,14 &15 The service users have the opportunity to exercise their choice in relation to routines of the day, personal and social relationships, religious observance, choice of food, frequency of meals and meal times. There was provision for leisure and social activities to stimulate the residents and give them some self-worth and independence. Relatives and friends are encouraged to visit and residents are able to maintain contact with family, friends and members of the local community. Thus the residents are able to maintain outside contacts. Meals served at the home are of a good quality and the residents are offered a choice. The residents are able to have snacks and drinks in between meals if they so wish. EVIDENCE: The service users said that the home was very flexible when it comes to service users getting up in the morning and going to bed. They said that the staff helped them keep in touch with family and friends. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 12 Several service users said that they had a variety of activities provided and that they could choose which one to join in. One service user said that although he/she was aware that a lot of activities were on offer he/she did not want to participate and was happy with his/her own company. The residents and the relatives commented on the choice of food and how good it was. One service user said that the hostesses were very useful when giving out meals as they knew the resident’s likes and dislikes and that they were missed when they were on holiday. The staff were seen helping residents with feeding. During the inspection of the kitchen the inspector found one of the freezers needing replacement since the temperature was –12οC. The chef and the manager said that a replacement freezer was on order. The kitchen floor had been replaced and some tiles needed to be replaced to complete the job. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 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 standard(s) 16,17 &18 The relatives and the residents are given the opportunity to raise any concerns and complain to staff or the manager. This is to enable residents to voice their opinion of the service and also for the staff to review and make improvements to areas of concern. The residents are enabled by the staff to exercise their legal rights and for those who lack capacity, an advocate service is offered. Such arrangements help residents to receive independent advice and help. The home has a complaints policy The management gives opportunities for staff to attend courses on adult protection and allegation of abuse. This is to protect service users and staff. EVIDENCE: The home had a complaints policy, which the staff were aware of. The relatives said that when they have concerns they felt comfortable taking the issues up with the sister in charge of the floor. They said that they had been happy with the outcome. However, one service user and a relative raised some concerns about the night staff attitude with the inspector and said that they had mentioned this to the care manager and were now awaiting a meeting or response. The care manager was informed of this and it was brought to the inspector’s attention that this complaint has being investigated. The manager and the responsible individual agreed that this complaint will be formalised and investigated and the CSCI will be informed of the outcome. Staff told the inspector that when anyone complains, depending on the issue if appropriate they take immediate action to resolve it and then inform the person in charge. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 14 The staff were not familiar with Adult Protection policies and the procedures to follow if there were to be an allegation of abuse. The care staff said that they would tell the manager. Although this was correct the staff must be aware of the procedures and expected action to be taken by the management. Not all the staff had attended training in the above areas. The staff told the inspector that they had been given dates by the manager for future training on Adult protection and identifying and dealing with abuse. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22,23,24,25&26 The layout and the location of Broomcroft House is suitable for it’s stated purpose. The home is clean and some residents’ rooms are personalised. Domestics are employed to carry out housekeeping duties. The rooms are naturally ventilated with windows conforming to recognised safety standards. The home has an adequate numbers of toilets and bathrooms. There is a maintenance programme in order to keep the home in good repair. There are pleasant outdoor areas, which can be used by the residents and relatives during good weather. The residents use the lounges on both floors during day and night. The laundry is sited away from the kitchen and food preparation areas, thus preventing infected and soiled clothing from being carried through these areas. EVIDENCE: House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 16 The home has a routine maintenance programme. There had been some renewal of fabric and some decoration had taken place. During the environment check the inspector found the grounds were tidy attractive and accessible to service users. , It was noted that the dependency levels of service users had risen and as a result more service users were in need of moving and handling with the aid of hoists. The staff requested extra hoists. The inspector made the responsible individual aware of this request. There were areas for the service users and their families to use as communal lounges. The individual accommodation was adequate and some service users had their own possessions in their rooms. One service user commented that lately he/she was able to get sufficient furnishings in the bedroom without having to put up a fight. This comment was not aimed at the present manager. The maintenance person had records of hot water temperature, which was checked regularly. The temperature range was between (41-44) oC. The service users commented on the quality of clean laundry. They said that the staff made sure the correct items were received from the laundry. The laundry is situated away from the food preparing areas. A comment was made regarding the hygiene practice of staff whilst in the dining room. That too often the staff play with their hair and stroke other resident and do not wash their hands before handling food. The Responsible individual and the manager were informed of this comment. Staff were able to verbalise the infection control procedure and identified hand washing as the most essential precaution. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The staffing rotas are formulated taking into account the number of service users. The staff numbers and skill mix of qualified nurses and health care support workers are allocated so that the service users are able to receive appropriate care. There was documentation showing staff training and a thorough recruitment practice. Thus promoting a safe environment for service users. EVIDENCE: On the days (30-31/08/05) of the inspection the staff complement seemed adequate for the number of residents. However, the residents raised concerns that the staff were always rushed and that they did their best. During interviews the staff explained that the dependency levels of service users had increased and therefore service users are requiring more time and attention. The responsible individual and the manager were informed of this. Two service users raised their opinions on the named nurse and key worker system, They said that it was impossible to make this system work since they rarely see the same carer twice in a week. They requested that this system be discontinued and no further energy or time should be spent on it. The Responsible Individual and the manager agreed to bring this matter up at the next service users meeting to review the system. A number of the health care support workers have obtained NVQ level 2 & 3 awards and some of the others are training towards NVQ awards. Four recruitment files were checked. Although most information required by the regulation was made available in each file the following points were noted. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 18 The employment history on three files had gaps; these had not been explored. One staff member who had been transferred from another BUPA home did not have CRB clearance. Following conversation with the previous employer the manager informed the inspector that the nurse had applied for CRB and that she/he will not be left unsupervised without a satisfactory CRB. Five staff training files were checked. All had updates on mandatory training. Although care staff were trained on the job in tissue viability, continence care, assessment of nutritional needs of the service users; the care manager said that formal training had been explored. Staff who were interviewed had good understanding of the care needs of service users. The staff also had good support mechanism among themselves to obtain assistance. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 &38 The manager is a qualified nurse who is competent and experienced in the running of the home. The manager and her team ensure that their approach creates an open and positive atmosphere at the home. There are quality monitoring systems in place where service users are asked for their comments on the quality of care delivered, food served and the day to day running of the home. The responsible individual visits each month and carries out an audit of the home. All staff had annual appraisals. However, formal supervision of staff has recently commenced. Records of the service users, the staff and the home are kept safely at the home to adhere to the data protection act and maintain confidentiality.. The manager ensures as far as is possible that the health and welfare of service users and her staff are maintained to provide a safe working place. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 20 EVIDENCE: The service users and the staff were very positive about the manager. They said that the manager was approachable, her office door was always open and she listened to their comments. The manager is in the process of being registered with the CSCI. She is expected to obtain NVQ4 in management or an equivalent qualification. There had been service users and relative meetings and staff meetings. The issues raised at the meetings were addresses by the home following an action plan. The Inspector did not see the minutes of the meetings on this occasion. Service users said that they look after their own financial affairs and if they want to they will get their relatives to help. Care staff and nurses need to receive formal supervision at least six times a year. The supervision should cover all aspects of care practice, philosophy of care in the home and career development needs of the staff. Although it is advisable to give one to one supervision, the manager could use some staff meetings as group supervision and put together an agenda to address issues relating to the whole group. Discussions took place between the managers the responsible individual and the inspector relating to supervision. All records requested for inspection were safely kept at the home. The staff and the service users said that they live in a safe environment and that if any repairs needed to be done, the handy person attended to them without delay. The staff verbalised what types of incidents and accidents were reported to CSCI and other organisations. The staff said that they received induction training on all safe working practice. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 2 2 3 3 x x 2 3 3 House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement The staff must consult with the service users where appropriate as to how their needs in respect of their health and welfare are to be met. The service users and/or their relatives must be involved in any reviews and revision of care. Previous requirement 20/12/04 The staff must ensure that the service users with catheter bags are emptied and their personal hygiene is maintained at all times. The Medication Administration Sheet must contain records of any allergies the service user may have. Previous requirement Immediate All concerns and complaints must be investigated and complainents must be kept up to date with developments. All staff must receive training on Identifying abuse and adult protection. They must be familiar with the policies and procedures relating to these. Timescale for action 01/11/05 2. 8 13 immediate 3. 9 13 immediate 4. 16 22 27/09/05 5. 18 12,17 06/12/05 6. 7. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 23 8. 29 19, Schedule 2 9. 26 13 10. 31 12,9 11. 36 18,19 12. 8 4, 14 Staff must not be employed without a satisfactory CRB and POVA. All gaps in employment histories must be explored and the manager must be satisfied with the explanations. Staff must wash hands before handling food. Staff must wash hands between helping sevice users. The manager must be registered with the CSCI. The manager must have a recognisable management qualification. The CSCI must be informeed of the arrangement made to comply. All care staff must receive supervision at least six times a year and written records of the supervision must be kept at the home. Those service users whose needs have changed must be appropriately placed according to their category. immediate immediate 6/12/05 6/12/05 06/12/05 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 22 27 Good Practice Recommendations The management should review the moving and handling equipment within the home to reflect the present needs of the residents. Both residents and staff commented on the lack of staffing levels therefore the management should review the staffing levels according to the dependency of the residents. House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 Page 24 Commission for Social Care Inspection Ground Floor Unit 3 Waterside Bold Street Sheffield S9 2LR 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 House 20050830 Broomcroft House X00015 UN Stage 4 S21771 V219876 J55.doc Version 1.40 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. 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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