Inspection on 18/09/06 for Castle Meadows

This inspection was carried out on 18th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Castle Meadows 112 Dibdale Road Dudley West Midlands DY1 2RU Lead Inspector Mr Richard Eaves Key Unannounced Inspection 18th September 2006 10:00 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 Castle Meadows DS0000066285.V311544.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. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castle Meadows Address 112 Dibdale Road Dudley West Midlands DY1 2RU 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) 01384 254971 01384 211017 Mimosa Healthcare Group Limited Carol Linfield Care Home 51 Category(ies) of Dementia - over 65 years of age (51), Old age, registration, with number not falling within any other category (49), of places Physical disability (2) Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users in the category PD(E) may be 51 years and over. Castle Meadows is able to provide intermediate care(GP respite) for up to 4 service users. 17th October 2005 Date of last inspection Brief Description of the Service: Castle Meadows is a large Care Home owned by Mimosa Healthcare Group Limited, providing nursing and residential care, being first registered in 1987. The Home has been developed from a detached property with long historical associations. The original three-story house has been extended to provide a purpose-built wing and has a large conservatory at the front of the building. The Home is located approximately one mile from Dudley town centre, has local amenities close by and is easily accessible by public transport. Facilities include car parking to the front of the Home and gardens and patio areas to the sides and rear. Accommodation is provided on three floors, in two separate wings. There are 45 single bedrooms, most of which have en-suite facilities and three double en suite bedrooms. There are four day rooms used as sitting/dining rooms. The Home currently has 5 bathing and 3 showering facilities and 12 toilets. The Home offers 4 of its beds for GP (General Practitioner) respite care. Fees range from £346 to £467 per week. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is of the key unannounced inspection, the visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the announced inspection in October 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire and records held at the home. The inspection involved a full tour of the bedrooms, communal rooms and service areas and provided an opportunity to speak with most of the service users and a number of visitors. What the service does well: What has improved since the last inspection? What they could do better: The manager should ensure that assessment and care plans are completed in a timely way and that these are kept under regular review to ensure that changes are addressed as soon as reasonably practical. While monitoring arrangements for the temperature of the medicines room is consistent it is necessary to document responses made to temperatures exceeding recommended levels. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 6 The home should seek to provide information on advocacy services available locally with particular consideration of the needs of short stay service users. The home has not progressed the implementation of staff supervisions, this is somewhat tempered by the assessment processes undertaken on a regular basis to achieve the national vocational qualification. As it is now three months since the manager was transferred the acting manager is advised to re-instigate meetings with relatives to assure that communications are maintained. The current practice of providing an evening supper of sandwiches, biscuits and milky drinks should be included on the daily menus to enable service users to choose what and when to eat in the full knowledge of what is available. The manager must ensure that staffing arrangements for replacement or additional staff are effective in ensuring needs of service users can be fully met at all times. 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. Castle Meadows DS0000066285.V311544.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 Castle Meadows DS0000066285.V311544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–6 The overall quality in this outcome area is good. Service users and prospective clients including intermediate care users and their supporters are provide with good sources of information about the home and are invited to spend time at the home prior to admission to enable them to make an informed decision about entering the home this is confirmed at admission by contract. The staff group are stable well established and collectively have the knowledge and skills to assess needs and to meet these assessed needs of the current service users. Confirmation that assessed needs can be met furthers enables service users to make informed decision about entering the home as does the opportunity to visit and trial the services offered. Designated staff provide skilled intermediate care in a clearly defined area maximising the opportunities for rehabilitation. EVIDENCE: The statement of purpose and service users guide (welcome pack) have been subject to review during January of this year while service users and prospective clients including intermediate care users and their supporters continue to have good sources of information about the home it was disappointing that the previous recommendation to provide detailed Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 9 information specific to the needs of respite service users has not been included. Prospective clients are invited to spend time at the home prior to admission to enable them to make an informed decision about entering the home, this is confirmed at admission by contract and detailed terms and conditions. In the absence of a nurse manager a senior nurse undertakes preadmission assessments for nursing service users while the acting manager assesses for the residential wing. The staff group are stable well established and collectively have the knowledge and skills to assess needs and to meet these assessed needs of the current service users. In the sample of case files used for case tracking, one of the four GP respite service users had not been risk assessed fully despite the risks being apparent and worsened since admission due to a side effect of therapy. Confirmation that assessed needs can be met furthers enables service users to make informed decision about entering the home as does the opportunity to visit and trial the services offered. Designated staffs of Physiotherapist and Occupational Therapists from the PCT provide skilled rehabilitation care in a clearly defined area On the first floor west wing lounge maximising the opportunities for rehabilitation. Dedicated bedrooms are also allocated for respite care. Castle Meadows DS0000066285.V311544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 The overall quality in this outcome area is good. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Extended review periods may diminish the effectiveness of the care plans. Health care needs of service users are fully met. Medications are well managed facilitating the promotion of service users health but storage room overheating could undermine this. Service users are treated with respect and their privacy upheld. EVIDENCE: A sample of four case files from both nursing, personal care and respite areas were case tracked and each found to be well developed with evidence of service user and supporters in the assessment and care planning process. Each file is set out in a consistent way with the assessments, care plans and evaluations at the front, followed by a range of health risk assessments and monitoring records, these comprehensively direct care requirements. One case file was seen for a long standing service user had not been reviewed for two months and another respite service users risk assessments were incomplete. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 11 The case files show that service users all are allocated to a GP and receive other allied healthcare inputs on a regular basis. The home provides a plentiful supply of equipment for the promotion of tissue viability and the prevention and treatment of pressure sores. The home recently changed pharmacy supplier but continues to use a monitored dosage system for the administration of most medications. The inspection showed that the management of medicines is robust and complies with guidelines. Medication administration is undertaken by nursing staff and senior carers on the residential wing who have completed an accredited course of training. Arrangements for the disposal of medications complies with the recently introduced regulations. On the day of inspection the room temperature was within safe limits but the records identify that the maximum safe temperature for storage has been reached with no record of any action being taken to bring the temperature down to an acceptable level. It was observed that insulin had been left in a tray and not returned to the refrigerator. Service users wear their own clothes at all times and on the day of inspection everyone appeared neatly attired. Service users rights, dignity and respect are given prominence during the induction of new staff and the interaction between staff and service users was observed to be easy, thoughtful and considerate, staff were also noted to use preferred names and clearly identified in the case file, meeting this element of the standard. Currently no rooms are shared and should medical examinations be required service users are returned to their room. Castle Meadows DS0000066285.V311544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The overall quality in this outcome area is good. The home provides a limited but appropriate and varied social and recreational activity programme that provides interest and pleasure for the service users. An open visiting policy assists service users to maintain contact with their family and friends. Service users exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste. EVIDENCE: The home continues to provide a programme of activities both within the home led by an activities coordinator, the opportunities to organise outings were missed over the summer due to the absence of staff. The range of in-house activities maintained by care staff included sing-a-longs, exercises, bingo, games, relaxation and memory lane these and other are now continued by the return of the co-ordinator. Hairdressing, manicures and facials are provided on a regular basis. A bar-b-q was held during the summer and a bric-a-brac sale and car wash to raise additional entertainment funds, raised sufficient to purchase wide screen TV’s for the lounges, being the choice of service users. The home has an open visiting policy, which was observed in action with visitors arriving and leaving during the inspection. Previous relative meetings Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 13 have not been maintained since the manager transferred at the end of June. The acting manager is recommended to arrange one to ensure communications are maintained and preparation commenced for the Christmas period. The home provides support and assistance to service users to handle their financial affairs but in practice most engage family to act in their interest. Where safe keeping of personal allowances is undertaken full accounting procedures are in place. The homes policies provide for service users to bring personal possessions including furniture into the home with them and this was observed to be the case in some of the rooms visited. The home provides a 4 week rolling menu providing choice and variety with cooked options at the three main meals of breakfast, lunch and tea; evening snack and drink is provided at 9pm and also available on request over the 24 hours. The lunch served looked appetising and service users expressed their satisfaction with that meal and meals in general. The menus are reviewed twice yearly for summer and winter and opportunity given for service users to provide ideas for inclusion. Since the last inspection the cook has introduced soft and pureed meals to be set in moulds to improve the appearance of the meal. Supper, snacks and fresh fruit are provided but supper is not included in the menu. Castle Meadows DS0000066285.V311544.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 The overall quality in this outcome area is good. The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Service users rights to participate in the political process are upheld with arrangements enabling them to vote in elections. The lack of information of local advocacy schemes may leave individuals feeling isolated and without support. EVIDENCE: The complaints procedure is displayed in the reception area and contained in the service user guide in each bedroom. The home has received 1 complaint since the last inspection, this has been acknowledged and is currently being investigated. Arrangements have been made to include service users names on the electoral roll. The notice boards readily accessible to service users had no information on local advocacy services. The Home has a copy of the Local Authority multi-agency Adult Protection policy and procedure and has developed its own policies and procedures relating to the protection of vulnerable adults. The training records evidence that all staff have attended training relating to abuse and service user welfare. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 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 the following standard(s): 19 & 26 The overall quality in this outcome area is good. The home provides a good standard of décor, furnishings and managed services providing a safe, disabled accessible environment and an attractive, and homely place to live. The bedrooms have bathrooms in close proximity for the convenience of service users. The home is clean, free from odours and hygienic. EVIDENCE: The Home is set in well-maintained gardens with ample parking to the front of the building. Internally the home has a variety of communal areas providing comfortable homely settings and service users are advised that they are welcome to use any whichever setting is preferred. The small lounge/diner on the first floor west wing is designated for use by respite care service users and the second floor lounge is largely used as a training room. Most rooms have en-suite facilities and there are toilets and bathrooms appropriately dispersed around the home in numbers that meet current standards and fitted with aids for the disabled. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 16 Individual bedrooms are furnished to meet the needs and wishes of service users and the requirements of the standards, most were observed to be decorated with personal possessions such as pictures, photographs and ornaments. A programme of redecoration is recently completed and new carpets are due to be laid in the corridors and stairs. The environment is well managed to ensure it is safe and comfortable with appropriate monitoring and servicing of utilities such as heating and hot water, the monitoring records and sample tests show these to be within a safe range. Fire equipment, testing and drills are in date as is the emergency lighting monitoring and servicing. On the day of inspection the home was observed to be clean and odour free. Laundry, sluicing and infection control arrangements are satisfactory and meet the requirements of the standards. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The overall quality in this outcome area is good. The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: The home is consistently staffed with adequate numbers and skill mix of Nurses and carers over the 24 hour period, being 1 nurse and 8 carers in the morning, 1 nurse and 6 carers afternoon and 1 nurse and 3 carers at night. It is of concern that these numbers while meeting minimum numbers appear inflexible and not responsive to activity and dependency levels. The reduction of carer numbers by 1 on each shift has had a demoralising impact on staff who feel they struggle to cope particularly when faced with short notice absences that cannot be replaced. NVQ training is ongoing in levels 2 and 3; the acting manager has achieved the NVQ 4 award for care management and 66 (22 staff) hold NVQ at level 2 or higher. A further 11 care staff are currently enrolled on NVQ studies. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 18 A sample of three staff files were inspected including the most recent starter and show that recruitment and selection is completed to a good standard All staff have an individual training record and a training matrix of statutory and other regular training required. These records show mandatory training to be up to date. The next programme of compulsory training for staff commences during October led by the company’s’ appointed trainer. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The overall outcome for this group of standards was judged to be good. Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The home regularly reviews its performance but has not sought the views of service users and their families since the change of ownership. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff do not receive supervision and direction so service users are not assured of consistent quality care. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 20 EVIDENCE: The designated deputy manager who is well experienced and recently achieved the Care Managers award currently manages the home. The company quality assurance systems are extensive and completed on a monthly basis, although some of these have been omitted since the manager left. The area manager undertakes Regulation 26 visits on behalf of the company with copies of reports shared with the Commission. Since the change of ownership no surveys had been undertaken of service users and relatives views of the service but this is currently underway. The majority of service users money is managed by their families, although service users can manage their own finances if they wish to. Secure facilities are available for the safe keeping of service users personal money and valuables. Records are available for all transactions which detail the reason for the withdrawal, receipts are available as proof of purchases. The staff supervision programme has been disrupted over the period of manager change and requires being re-established. The home has an up to date health and safety policy. Inspection of the health and safety monitoring records show these to be up to date and that very good standards are being maintained consistently. Certification of services and equipment are all in date. Staff training in health and safety, fire safety training is satisfactory. Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 3 3 3 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 2 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 3 Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP17 Regulation 12(1)(a) Requirement The registered person will make arrangements for the promotion of advocacy services for service users. Previous timescale 30/11/05 not met. The responsible person must ensure that assessments are completed and kept under review in a timely way. The responsible person must ensure that the service user’s plan is available to the service user and kept under review at least monthly. The responsible person must ensure that medications are stored at the correct temperatures at all times. The registered provider must appoint a manager. The responsible person must ensure that individual supervision sessions are undertaken at least six times each year. Timescale for action 30/11/06 2 OP3 14(2) 30/11/06 3 OP7 15(2)(a) (b) 30/11/06 4 OP9 13(2) 30/11/06 5 6 OP31 OP36 8(1)(a) 18(2) 30/11/06 31/03/07 Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP13 OP15 Good Practice Recommendations The manager is recommended to further review the statement of purpose with a view to expanding the information available to intermediate care service users. The manager is recommended to implement regular relative meetings both individually and as groups. The manager is recommended to include the evening supper on the menu to provide service users with advanced notice when making meal choices and to demonstrate that the time between meals does not exceed twelve hours. The registered person must ensure that at all time suitably qualified competent and experienced persons are working in such numbers to meet the needs of service users and that systems are adequate to respond to unexpected shortfalls. 4 OP27 Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Castle Meadows DS0000066285.V311544.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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