Inspection on 28/02/06 for Castleton Lodge Care Home

This inspection was carried out on 28th February 2006.

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

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

Other inspections for this house

Castleton Lodge Care Home 31/07/08

Castleton Lodge Care Home 29/11/07

Castleton Lodge Care Home 17/01/07

Castleton Lodge Care Home 07/09/06

Castleton Lodge Care Home 17/08/05

Castleton Lodge Care Home 15/02/05

Castleton Lodge Care Home 17/08/04

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

CARE HOMES FOR OLDER PEOPLE Castleton Lodge Care Home Green Lane New Wortley Leeds LS12 1JZ Lead Inspector Valerie Francis Unannounced Inspection 27 February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 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. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Castleton Lodge Care Home Address Green Lane New Wortley Leeds LS12 1JZ 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) 0113 231 1755 0113 231 9789 Tamaris Healthcare (England) Ltd (wholly owned subsidiary of Four Seasons Health Care Limited) Ms Elaine Fitzgerald Care Home 60 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability (2), Terminally ill over 65 years of age (1) Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The place for TI(E) is for the service user specified in the NCSC letter dated 17 December 2003. The places for PD are specifically for named service users Date of last inspection 17th August 2005 Brief Description of the Service: Castleton Lodge Care Home is a detached purpose built property located in Armley, which is on the outskirts of Leeds. The home is owned and managed by Four Seasons Health Care Ltd. The property is set in its own grounds with ample car parking facilities available at the front of the premises. There is a bus service along the main road; service users can register with the Access bus, which will drive up to the home. The home is owned and registered to Four Seasons Health Care, as a care home with nursing for up to 60 older people, 30 of which have Dementia or related mental health problems. The accommodation consists of 60 single rooms, all of which have en suite facilities. There are 8 communal lounges, as well as a large reception area for service users. There are two dining rooms and a central kitchen. There are five communal bathrooms, two showers and eight communal toilets. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year; these may be announced or unannounced. During this inspection year the home has had three inspections all of which was carried put on an unannounced basis. The prior inspection carried out was on the 17 August 2005. The people who live in the home prefer the term resident, and this is the term that will be used throughout this report. The purpose of this inspection was to gain an overview of the care, services and facilities provided. The registered manager was on annual leave, the Deputy manager was the person in charge. Two inspectors carried out the inspection, the lead inspector focusing on the specialist Dementia unit Moor side and the other focusing on Cleaven unit. During the inspection records were looked at, some parts of the home were seen, such as bedrooms and lounges and bathrooms. The inspectors looked at records, observed care practices and spoke to staff, visitors and residents. Nursing and care staff were seen carrying out their work; conversations were held with the senior staff on duty, nurses and care staff. Seven relatives were spoken with and a good proportion of residents. Survey cards were left at the home for residents, relatives or visitors to complete and return to the Commission for Social Care Inspection (CSCI). These cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way will be shared with the provider without revealing the identity of those who replied. Three were received from relatives who said they were happy with the care given to their relatives living at the home, one person said the “life of their relative has improve since moving into the home.” What the service does well: Relatives said staff take what little time they had spare to talk to them and they are informed of any changes in the care of their relatives living in the home. The atmosphere at the home is warm and friendly. Residents said staff are willing to help. Staff are committed to meet the needs of the people living at the home. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The home’s Statement of Purpose must have information on the specialist care provided at the home. The registered manager must make sure that the person carrying out the assessment, collects sufficient information that would provide them with a person centred plan of care taking into account the wishes of the resident. A care plan of the action taken to minimise potential risks must be in place. More effort must be made to make sure that relatives or the person involved in the care of the residents be actively involved in the care of the their individual. The registered provider must make more effort to meet the cultural needs of residents living the home. All effort must be made to meet the social and recreational needs of resident. Staff must be given designated time to provide residents on the specialist unit with meaningful social and recreational activities. The manager must work closely with catering staff to make sure that culturally sensitive meals are offered to residents from a different cultural background. The registered manager must make sure that all staff have updated training on adult protection awareness. The registered provider must repair the heating so that it works in all areas and make sure that portable heaters are not used. The registered provider must give staff support in providing Moorside with equipment and decorations that will meet the specialist care needs of the residents living in this unit. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 7 The home must continue with the system in place to have 50 of staff with an NVQ.(National Vocational Qualification.) Detailed records should be kept of all assessments carried out. Some consideration should be given to have a system in place to remind residents what meals are on offer for the day. 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. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 8 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 Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 5. There is no real information about the specialist care the home provides. The assessment information does not give enough information to put together a full care plan, so that all needs are identified and they would be fully met. EVIDENCE: The home’s Statement of Purpose and Service User Guide has recently been reviewed and updated, with information on the services and the care provided at the home. However, additional information is needed to provide relatives and carers with information that people with dementia and other related mental illness. The pre admission assessments were inspected for a service user recently moved into the home. This gave the home very little information about the personality and strengths of resident and was limited to ‘needs nursing care’. The assessment carried out by the home before admission gave a brief overview of physical care needs. But there was no information on diet, activities of daily living, personal habits, routines, or preferences. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 10 Nutritional assessments are carried out and residents are weighed monthly. However these records must be fully dated and it is recommended residents are weighed when they first arrive in the home to provide the home with a base line to work from. Residents spoken with confirmed that they or their family had visited the home prior to their admission. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. Effort has been made to create a person centred approach of care planning. Residents could be at risk from not having a plan of action to minimise the risk identified. EVIDENCE: Care files included a section on health care which showed when and which GP had visited. Body charts and photographs were used to monitor skin integrity, with fluid intake and output charts and turning charts correctly maintained for people with higher dependency of needs. Risk assessments were seen in the files but the action plan to manage risk (which is the point of the exercise) was not easy to see. Since the last inspection all effort has been made for a care plan approach that was person centred, putting the person first and not the dementia or illness, recognising that the needs and emotions of the residents are important. Residents and relatives should be involved in putting together life history information, which would help staff to have good background information about the residents in their care and also put together a comprehensive care plan. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 12 More effort must be made to meet the culture needs of the residents from different culture background. The checking, storage and administration of medication is the responsibility of the trained nurses. A medication sheet and the controlled drug records were checked against the medication held and were found to be in order. A care worker said that staff are kept informed of any changes in medication, the reason the medication is being given and any possible side effects. Staff were observed speaking to residents kindly and with respect. Assistance with personal care was given discretely. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Social activities for service users are limited and provide little variety, which is providing the opportunity for boredom. Residents are encouraged to maintain links with their friends and family and to exercise choice and control over their lives. EVIDENCE: The designated activity organiser and care worker said staff try to introduce activities, usually in the afternoons. More effort is needed however for the further activity for the resident on Moorside so that they are stimulated and not allowed to get bored. However on the whole activity for all residents needs to be meaningful so that those who wish to be involved finding it interesting. . There was some information in some care files to show peoples’ interests but no activity seen other than the TV and CD player. Relatives and residents and felt activities could be developed further. One resident said it would be nice if there were a library service to the home. Spiritual needs were catered for but this was not evidenced in the care files. Since the last inspection a new cook has been appointed and there has been some improvement in food served. However the matter of meeting the cultural dietary needs of the African Caribbean residents still needs to be addressed. It was event from the Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 14 inspector’s conversation with one of the residents that if they were offered a meal of their choice, it would be gladly accepted. One resident said the quality of the meals had improved under the new cook. A resident described it as ‘poor’ and said he was only eating it so that he wouldn’t be hungry. Residents stated they have no idea what the meals for the day is until it arrives on the trolley. The meal looked good and other residents appear to be enjoying it. Staff were attentive during the meal assisting and encouraging residents to eat in an appropriate manner. Resident sees their visitors in the privacy of their bedroom or in the communal sitting rooms. During the inspection there was also a constant flow of visitors to residents. Some of the visitors collected residents to take them out for the day and other visitors made contact with staff and were updated on matters relating to their relative. Three visitors were spoken with said that they were “happy” with the care their relatives were receiving and were informed of any changes in the care needs or incidents regarding their relative. For those residents without families, Age Concern Advocacy would be contacted and an advocate found to advocate on their behalf. This makes sure that they have some one outside of the home would speak up for them taking into account their rights and choice. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 15 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): 16,17 & 18. Residents and relatives feel comfortable in raising concerns on a day-to-day basis and have access to a formal complaints procedure that is clear. More training for staff on understanding and recognising abuse is needed. EVIDENCE: There is a complaints procedure that is clear. This is included in the statement of purpose and service user guide and is also posted on notice board in the home. During discussion with visiting relatives they understood that they could complain and raise concerns and feel comfortable in talking to staff or the manager about things that worry them, and felt that staff listen to them and took their complaints seriously. There are adult protection policies that link to the Leeds multi agency procedures and there is a whistle blowing policy. Some staff had received a day’s training some time ago. Updated and formal training is needed for all staff to make sure they have the understanding and recognise abuse and what to do. They must be made aware of the policy and procedure, and the whistle blowing procedure to enable them to report bad practice without any feeling of retribution. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 22, 24 & 26. Many of areas of the building such as communal sitting rooms and some resident bedrooms was in the process of being redecorated and furnished since the recent flood in the home. More effort needs to be made for the physical appearance of Moorside the dementia to reflect the care provided on this unit. The home has aids that make things like bathing and toileting easier. Standards of cleanliness are good. EVIDENCE: The home employs a maintenance person. Each unit has a repair and maintenance book which staff complete as work comes to their attention. At the time of the inspection the maintenance person was redecorating one of the lounges on the first floor. The corridor carpet has been replaced. A resident and his family member said the radiators in parts of the home do not always work that’s why the small electric fan heater’s are used, which makes your throat very dry and sometimes you get a irritating dry cough. The registered provider must resolve the heating problem in the home, to eliminate the use of portable heaters. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 17 Deep cleaning is required in the kitchen, cups that are chipped should be replaced as well as the plastic glasses that are badly stained. The food trolleys could also do with a good cleaning. A selection of communal spaces gave scope for residents to move around freely with a minimum of restriction. Specialist beds, hoists and pressure relieving cushions were in use as required. Most bedrooms seen were pleasantly furnished with a good array of personal items. Efforts have been made to make minor adaptations to the environment of Moorside such as the painting of toilet and bathroom doors to provide visual prompts for people with dementia, and help them maintain some independence. The manager said she is working with an outside agency to make sure that Moorside is decorated with signs that would enable the people living on Moor side to maintain their independence. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 & 30. Staffing levels needs constant review to make sure there is enough staff available to residents especially those needing specialist care so that there is enough staff to meet their needs. EVIDENCE: The staff spoken with and observed appeared relaxed and confident and had an understanding of their role. There is a good programme of training, which includes NVQ. Eight care staff have gained an NVQ Level 2 and 2 are working towards the award. The deputy manager is an undertaking the work based assessors course, D32 and 33. Since the last inspection, three new full time care staff have been recruited. The two last recruited staff files was examined, these files showed that two written references were in place and confirmation that POVA (Protection of Vulnerable Adults) First checks were in place before employment was offered and dates arranged for induction training. Enhanced CRB (Criminal Records Bureau) disclosures were requested at the same time as the POVA First and confirmation that these were satisfactory were seen, as was a copy of the terms of condition of employment. The manager said that systems have been put in place for on going training to makes sure that staff have the knowledge to meet the needs of the residents. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 19 Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36,37 & 38. The home is well managed and the interests of the residents are the main concern of the manager and staff. Record keeping, safety checks and systems of communication make sure that the home is a safe place to live. EVIDENCE: The manager is first level Registered Mental health Nurse who has completed the Registered Manager’s Award. She has experience of working with the older people needing specialist care and managing a care home. The deputy manager is a first level registered nurse who has experience of working with older people. The deputy manager support the manager with staff supervision and other management tasks, so that this is carried out effectively the organisation should give some supernumerary time to the deputy manager to carry out these support roles. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 21 The atmosphere in the home is warm and friendly and the residents and relatives said that they like this. A staff member said that there is an appraisal system approximately three monthly. Staff are able to discuss the care needs of residents and any problems they may be having meeting care needs or within the staff team. The appraisal generates an action plan. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 22 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 3 2 X 3 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 3 3 3 3 2 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 3 2 Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 23 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 OP1 Regulation 4 Requirement The home’s information must have information on the specialist care provided at the home. The registered manager must make sure that the person carrying out the assessment collect information that would provide them with a person centred plan of care taking into account the wishes of the resident. Last agreed date 31/1/06 A care plan of the action taken to minimise potential risks must be in place More effort must be made to make sure that relatives or the person involve in the care of the residents be actively involve in the care of the their individual. The registered provider must make more effort to meet the cultural needs of residents living the home. All effort must be made to meet the social and recreational needs of resident. A designated staff must be given DS0000044491.V283989.R01.S.doc Timescale for action 29/05/06 2 OP3 14 29/05/06 3 4 OP7 OP7 15 15 25/05/06 25/05/06 5 OP7 15 25/05/06 6 OP12 16 2(m & n) 25/05/06 Castleton Lodge Care Home Version 5.0 Page 24 7 OP15 12 (3) 8 OP18 18 (1)(i) 9 OP38 23 10 OP19 23 11 12 OP28 OP24 18 23 time to provide residents on the specialist unit with meaningful social and recreational activities. The manager must work closely with catering staff to make sure that culturally sensitive meals are offered to residents from a different cultural background. The registered manager must make sure that all staff have updated training on adult protection. A response is required from the provider regarding the repair the heating, so that it works in all areas of the home and that portable heaters are not used. The registred provider must give staff support in providing Moorside with equipments and decorations that will meet the specialist care needs of the residents living in this unit. The home must continue with the system in place to have 50 of staff with an NVQ. Door locks have not yet been provided to service users’ private accommodation. Last agreed date 07/02/06 15/05/06 19/06/06 22/05/06 22/05/06 30/11/06 27/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP3 *RCN Good Practice Recommendations Detailed records should be kept of all assessments carried out. The registered provider should give supernumerary time to the deputy to carry out the management role. DS0000044491.V283989.R01.S.doc Version 5.0 Page 25 Castleton Lodge Care Home 3 OP15 Some consideration should be given to have a system in place to remind residents what meals are on offer for the day. Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Castleton Lodge Care Home DS0000044491.V283989.R01.S.doc Version 5.0 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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