Inspection on 16/11/06 for Chelwood Avenue (7)

This inspection was carried out on 16th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chelwood Avenue (7) 22/07/09

Chelwood Avenue (7) 24/07/08

Chelwood Avenue (7) 28/06/07

Chelwood Avenue (7) 20/02/06

Chelwood Avenue (7) 09/06/05

Chelwood Avenue (7) 29/10/04

Chelwood Avenue (7) 22/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Chelwood Avenue (7) 7 Chelwood Avenue Childwall Liverpool Merseyside L16 3NN Lead Inspector Jeanette Fielding Unannounced Inspection 16th November 2006 09:30 Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 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 Chelwood Avenue (7) DS0000025236.V303809.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 Adults 18-65. 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. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chelwood Avenue (7) Address 7 Chelwood Avenue Childwall Liverpool Merseyside L16 3NN 0151 722 2854 0151 722 6502 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) www.c-i-c.co.uk Community Integrated Care Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 Brief Description of the Service: Chelwood Avenue is home to two adults with learning disabilities run by Community Integrated Care, a major local not-for profit organisation. The home has recently chosen to reduce the registered number of service users who can be accommodated to two due to the small size of the third bedroom. 7 Chelwood Avenue is a semi-detached house in a quiet suburb of Liverpool, close to a small parade of shops, the M62 and bus routes to Liverpool city centre. Downstairs there is a large lounge, dining room and a kitchen. Upstairs there are two spacious single bedrooms, a bathroom and a small room that is currently used as a staff sleep-in room. The former garage has been converted to an office and utility room There is a large garden to the rear and side of the house. One of the service users has a minibus that is used for both service users, with the other making a financial contribution to its running costs. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on one day over a period of six and a half hours. During the inspection, the records relating to the care required by, and afforded to, service users were inspected. Many of the records held were outdated and did not reflect the current needs of the service users. Records are held in various parts of the office and were not fully accessible to staff. Staff records were inspected and were found to be in order. Inspection of the premises showed that new furniture has been provided and that staff strived to provide a homely environment for the service users. The acting manager of the home is currently absent and appropriate management arrangements are to be put in place during this absence. Safety issues have been addressed as required and risk assessments have been undertaken to ensure that risk management plans can be prepared. One recent incident within the home has identified the need for reporting systems to be reviewed to ensure that full information is passed to the appropriate persons. What the service does well: What has improved since the last inspection? What they could do better: A stable management of the home is required to address recent shortfalls in the day to day management of the home. Training has been given to staff in relation to abuse, however, the reporting system has not proved to be effective and requires to be addressed. A programme of reviewing all files, and archiving unnecessary paperwork will ensure that only relevant information is given to staff. A full audit of medications, and a daily record of medications held, is necessary to ensure accuracy of documentation. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 6 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. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent good. This judgement has been made using available evidence including a visit to this service. A detailed assessment procedure is in place to ensure that the home could meet prospective service users needs. EVIDENCE: The present service users have lived at the home for many years and no new admissions are planned for the home. The company has produced a comprehensive assessment procedure for the admission of new service users in the event of a vacancy becoming available. This would include visits and short stays at the home to introduce the service user to the staff and to enable the staff to clearly identify with the service users needs and abilities. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A review of the documentation and archiving of outdated information would enable staff to clearly identify service users specific needs. EVIDENCE: Individual care plans have been prepared for the service users. It proved difficult to find much of the necessary information due to the disorganisation of the filing system currently in effect. The care file for one service user identifies that a two storey house is not suited to the service user and consideration should be given to ensuring that appropriate accommodation and facilities are reviewed and, if necessary, made suitable. Considerable documentation is held on the files, which is now outdated, due to the changing needs of the service users. New documentation has been prepared but had become lost within the unnecessary paperwork within the office. Some documentation could not be found during the inspection, but this does not mean that it was not in place, but was just not accessible. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 10 Risk assessments had been undertaken and were held with copies of outdated risk assessments, which proved difficult in some cases to identify which were current. All assessments need to be clearly dated and signed by the person making that assessment. Discussion with staff on duty at the time of the inspection confirmed that all were fully aware of the service users individual needs, but the documentation to clarify those needs could not be confirmed. It is advised that each service users needs are fully reviewed and all appropriate care plans, risk assessments and risk management strategies placed within the current file, and outdated documentation archived. Neither of the service users have verbal communication skills and staff were able to demonstrate that they were fully aware of each service users needs by observation and body language. Little information is recorded to explain the different means of communication of the service users which would enable new and bank staff to have greater understanding of how the service users express themselves. Service users are given every opportunity to make their own decisions with a risk management strategy. Discussion with senior management of the company, subsequent to the inspection, confirmed that a programme of review and reorganisation of the documentation had begun immediately following the inspection. It is hoped that records will be more accessible at future inspections of the home. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities is available to both service users who are given the opportunity to demonstrate their preferences as to whether they participate or not. EVIDENCE: The service users participate in a range of activities that are suited to their individual needs and preferences. One service users attends a day centre on five days each week and enjoys swimming, bowling, horse riding and trampoline at the centre. Both service users are taken out by staff in the minibus and enjoy looking out of the window, but are not too fond of stopping to get out at places of interest. The minibus belongs to one of the service users and the other makes a contribution to the running costs, but the funding of the minibus is due to be review in a few months time. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 12 All activities are recorded in the care file and staff liaise with the day centre staff regarding the activities that the one service user, who attends the centre, participates in. One service user maintains contact with the family who take the service user out on a regular basis. Risk assessments regarding these trips out are being reviewed to ensure the protection of the service user and others. Both service users are given healthy diets, however, more information is required to be recorded regarding these. The advice of the Speech and Language Therapist is sought regarding one service user and staff were aware of the fortified diet that is to be served, although little information regarding this diet is held on the file. The menu is based on those meals that service users have previously enjoyed and the record of what has been served shows that the meals are varied and nutritious. Service users go shopping with staff members whenever possible and are encouraged to assist as much as they are able. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have a good understanding of the service user’s personal support needs and provide support accordingly. EVIDENCE: Personal care is given to service users by the care staff in the privacy of their bedroom or in the bathroom as appropriate. The service users receive all the community and specialist medical care and support that they need, including visits from a Community Psychiatric Nurse. Records are held of these visits, but proved difficult to find due to the disorganisation within the files. Staff spoken to during the inspection were able to demonstrate that they were fully aware of each service users needs and of the specific care and support required. Neither of the service users is able to administer their own medications. Records relating to the administration of medications were up to date and each medication is counted and recorded regularly. On inspection, four tablets could not be accounted for and the number held did not relate to the recorded amount on the Medication Administration Record sheet. This would indicate that staff are not counting the number of tablets held, but are just reducing Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 14 the number in the records according to the number of tablets administered. The company is currently investigating this discrepancy. In order to ensure that medications held in the home are accurate, a full audit of medications should be undertaken at the beginning of each medication cycle and a signed record held of the findings. Medications are securely held within the home but are in two separate locations. This has the potential for not identifying and recording those medications held in the main storage area. Excessive medications should not be held in the home and should be returned to the pharmacist for disposal. Information could not be found regarding information relating to medications which are to be administered on an ‘as and when necessary’ basis. Specific information should be recorded to ensure that staff have full information regarding the signs that indicate that these medications should be given, the minimum time between doses of the medication and the maximum amount that can be given within any twenty-four hour period. At the previous inspection, the home was advised to follow advice detailed in the Royal Pharmaceutical Society’s publication ‘the Administration and Control of Medicines in Care Homes and Children’s Services’. At this inspection, it was found that the home had failed to obtain a copy of this document. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies and procedures have been prepared to ensure the protection of service users but it is necessary that the reporting procedure is appropriately followed. EVIDENCE: The owners have prepared a detailed policy and procedure for complaints and information on how to make a complaint is displayed in the home. The staff records show that staff have been given training on adult protection and staff spoken to during the inspection were able to demonstrate that they were knowledgeable about the various types of abuse and of the action to be taken in the event of abuse being suspected. Unfortunately, a recent incident in the home was not dealt with appropriately at the time, nor was it reported in accordance with the home’s policy and procedure. A full investigation is being undertaken by the owners and CSCI will be advised of the findings and action taken. The home does not have a copy of ‘No Secrets’ and it is strongly recommended that a copy is obtained and read by all staff. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements continue to be made within the home to meet the needs of the service users. EVIDENCE: Chelwood Avenue is a domestic semi detached house within a residential community. The home provides two single bedrooms for service users and a third bedroom for the member of staff on sleep in duty. It is evident that staff have strived to provide a homely environment for the service users within a risk management strategy. Furnishings are of domestic style and the majority of floors have been fitted with laminate surfaces. Since the last inspection, a considerable number of new furnishings have been provided. New tables and chairs have been provided in the dining room, new sideboards and a leather settee. The television has been fitted into a cabinet to prevent damage. Plans are in place to make the garden more suitable for service users, although this work will not take place until early 2007. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 17 Service users are free to use all areas of the home. The safety of the kitchen is currently under review by the home to ensure that service users are not placed at risk whilst meals are being prepared. The office is located off the kitchen and a full risk management plan needs to be prepared to ensure that access to the office is available to staff without compromising the safety of the service users. A risk assessment has been undertaken with regard to the safety gate at the top of the stairs. This gate is closed at night to prevent one service user using the stairs during the night. The gate is left open during the day. The service users bedrooms are spacious, furnished to a high standard and are personalised as much as possible to reflect the service users lifestyle and preferences. A new bath had been fitted in the bathroom in the week prior to the inspection and arrangements are in place for the damaged décor to be attended to. The home was clean and fresh throughout. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recent management changes has resulted in low staff morale which has the potential for impacting on service users. EVIDENCE: The day to day management of the home is unstable as the acting manager is currently absent. Arrangements are in place for this to be rectified, however, staff morale has been affected due to this. The owners are currently reviewing the staffing within the home and are using bank staff to cover for sickness, annual leave and other shortfalls. The home’s own staff are given the opportunity to work additional hours, if they wish, to ensure continuity of care for the service users to avoid the over use of bank staff. The bank staff are employed by CIC and are knowledgeable of the service users care needs. The staff rotas provide evidence that all shifts are covered. All shifts within the home are being covered with the exception of the management. This position is currently being covered on a peripatetic basis although arrangements are being made for another experienced manager to take responsibility for the home on a full time basis. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 19 Staff spoken to during the inspection were fully aware of their role and it was evident that team working takes place. The staff are responsible for care, domestic and catering duties and a work schedule provides evidence that all tasks are completed effectively. Discussion with staff identified that there was an element of uncertainty within the team due to the lack of a manager, a recent incident within the home and the information recorded in the communications book which some staff felt were confidential. Training has been given to all staff and the home now employs 70 of staff with NVQ qualifications. One member of staff is currently working towards NVQ at level 3 and it may benefit other staff to undertake this training. Staff records were organised and contain details of all checks made on staff including references and evidence of CRB clearance. Evidence is held of training courses undertaken by the staff. Supervision has been given to staff on a regular basis and will be continued by the new manager in accordance with the owner’s policy and procedure. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42, 43 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home remains unstable and requires that a consistent leadership approach be provided to promote service users best interests. EVIDENCE: Due to the absence of the acting manager, the staff have been ultimately responsible for ensuring that the home runs in the best interests of the service user. They have worked well under the supervision of one of the company’s managers who has overseen the home during this time. It is essential that the management issues be resolved as quickly to ensure that staff morale is improved and service users protected. An application to register the acting manager has been submitted to CSCI and is being processed. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 21 The service users do not have verbal communication skills and so it was not possible during the inspection to ascertain their views of the home or whether they considered that their individual needs are being met. The health and well being of service users is protected through multi disciplinary interventions to support the work undertaken by staff. Service users are involved in the day to day running of the home as much as they are able and their families are consulted where appropriate. Policies and procedures are reviewed and updated as necessary both corporately and in house for those are specific for the service. Safety checks are made on fire detection equipment and on the premises and records maintained as required. All safety records were up to date and well maintained. Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 1 1 3 X X 1 1 Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 YA18 Regulation 15 Requirement The Registered Person must ensure that outdated records are archived and only relevant information held in care files. The Registered Person must arrange for the appointment of a permanent manager who will apply to be registered by the Commission for Social Care Inspection The Registered Person must ensure that accurate records are maintained of medications held in the home. The Registered Person must ensure that service users are protected from abuse in accordance with written policies. Timescale for action 31/01/07 2. YA37 YA38 YA43 8 31/01/07 3. YA20 13(2) 08/12/06 4. YA23 YA42 13(6) 08/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 24 Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Chelwood Avenue (7) DS0000025236.V303809.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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