Inspection on 14/06/07 for Colin Care Home

This inspection was carried out on 14th June 2007.

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

The inspector 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 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colin Care Home 16/05/08

Colin Care Home 11/01/07

Colin Care Home 03/08/06

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Colin Care Home 19 Garlies Road Forest Hill London SE23 2RU Lead Inspector Ornella Cavuoto Unannounced Inspection 14 &15th June 2007 10:00 th DS0000066922.V338955.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 DS0000066922.V338955.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. DS0000066922.V338955.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colin Care Home Address 19 Garlies Road Forest Hill London SE23 2RU 020 8699 5151 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) colincarese23@yahoo.co.uk Colin Limited Ms Vernett Brown Care Home 4 Category(ies) of Dementia (4), Mental disorder, excluding registration, with number learning disability or dementia (4) of places DS0000066922.V338955.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2007 Brief Description of the Service: Colin Care is a care home that provides long, medium and short term residential care to four men and women who have incurred a brain injury aged between 18-65. At the time the inspection was held there was one vacancy. The home is situated in a residential road close to good transport links to nearby Catford, Lewisham and Forest Hill areas. The home aims to work with service users to improve their overall quality of life and promote independence. The home is a large period property and has four large bedrooms two of which are en-suite and one bedroom is situated on the ground floor and three upstairs. There is no passenger lift within the home and so there is limited access for wheelchair users. Potential service users are given information about the service at the point when they have an initial visit to the home as part of the assessment process. Service users will be given a copy of reports issued by CSCI. Weekly fees vary from £875 - £1000. There are no additional charges. This information was provided to CSCI in August 2006. DS0000066922.V338955.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over a day and a half. Since the last inspection a new manager had been appointed. They had only been in post since 17th March 2007 at the time the inspection was held. The manager was present for the duration of the inspection and was helpful in facilitating the inspection process. The inspection involved speaking to three of the support workers, two of the residents and a relative. Other inspection methods included inspection of care records and a tour of the premises. The previous two inspections held at the home had identified concerns in a number of areas and this inspection was aimed at assessing any progress that had been made by the home in meeting previous requirements. The timescale for compliance for the majority of the requirements had not been exceeded at the time the inspection was held but progress had been made with eleven of the previous requirements having been met. The majority of the remaining requirements were assessed as partially met and three new requirements were specified. One area of concern around the knowledge and competency level of support staff although recognised by management requires further measures to be taken to ensure this area is addressed. What the service does well: What has improved since the last inspection? All residents living at the home had signed statement of terms and conditions outlining their stay within the home. DS0000066922.V338955.R01.S.doc Version 5.2 Page 6 Residents meetings had been regularly held to provide residents with an opportunity to give feedback and have an input in decisions about the running of the home. Improvements had been made to support residents to become involved in meaningful and valued activities and to look at ways they can access training and employment opportunities. Residents were more involved in the local community and making use of local facilities. Some improvements had been made in the opportunities provided to residents to become involved in leisure activities particularly outside of the home. The handling and administration of medication by staff had improved. All complaints were being logged and appropriately dealt with. Adaptations had been made to the home to help those residents with mobility problems to be more independent around the home. The home has started to organise training for staff and drawn up an annual training plan to ensure mandatory and specific training is completed. There had been improvements in the quality assurance systems of the home with the views of residents having been sought about the home. What they could do better: The home needs to ensure that information regarding fees payable and what is included in the charges made by the home for residents is included in the service user guide. The copy of the needs assessments obtained for individual residents prior to referral should be kept on service users’ personal files. Care plans that comprehensively address all residents personal support, social care and health care needs have to be drawn up and these should be regularly reviewed with any changes in support needs reflected. Detailed risk assessments need to be drawn up for all residents living at the home. All staff working at the home need to undertake risk assessment and risk management training. Staff still need to be clear about their responsibilities in respect to confidentiality and that the personal information of service users is handled appropriately. Records detailing individual and group activities that residents have been involved in need to be maintained. Staff need to be fully aware of their role and responsibilities as key workers to ensure residents needs are effectively met. Formal medication training needs to be organised for all staff working at the home. All staff need to receive formal accredited training around adult abuse and adult protection procedures and it needs to be ensured that staff have a comprehensive understanding of these issues so that residents are fully protected from abuse and harm. The home needs to ensure that the skill mix of staff is more balanced so that staff that are appropriately qualified and experienced are working at the home to meet the needs of residents and for the effective running of the home. DS0000066922.V338955.R01.S.doc Version 5.2 Page 7 There still needs to be improvements made in the home’s vetting procedures when recruiting new staff. All staff need to be provided with regular supervision. All aspects of health and safety must be addressed by the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000066922.V338955.R01.S.doc Version 5.2 Page 8 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 DS0000066922.V338955.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2&5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide had been revised to include information about the home that was up to date but information about fees for the service had still to be included in the service user guide. There had not been any new admissions to the home to be able to identify the residents’ needs would be fully assessed prior to their admission. Residents had been issued with a statement of terms and conditions that they or a relative on their behalf had signed. EVIDENCE: At the last inspection it was identified that the home had a statement of purpose and service user guide that generally included all the information required by regulation and National Minimum Standards (NMS). Yet, in respect to the statement of purpose it was noted that changes to do with staff specifically that a new manager was in post had not been addressed. Also, it was identified within the service user guide that certain information such as the complaints policy had been adopted from another service and still included the name of that service. Prior to the inspection being held an updated statement of purpose and service user guide had been sent to the Commission of Social Care Inspection (CSCI) in which both these matters had been addressed. However, a previous requirement that the service user guide must include information about the fees of the home had not been met. Although DS0000066922.V338955.R01.S.doc Version 5.2 Page 10 the manager reported that negotiations with placing authorities were still being undertaken in respect to fee levels for the new financial year details still need to be available to residents about the charges made by the home as specified within the regulations. A previous recommendation that the registered provider becomes familiar with the regulation pertaining to fees that came into force from September 2006 is also to remain in place (See Requirements and Recommendations). There have been inconsistencies in the home’s practice of ensuring that the needs of residents have been fully assessed prior to admission to ensure the home would be fully able to meet individual residents’ needs. At the home’s first inspection it was identified that three of the four residents only had their needs assessed by the respective placing authorities after the residents had already moved into the home. All the residents were moved from a supported housing project. At the last inspection there had not been any new admissions to the home so this standard could not be fully assessed although concerns were raised as copies of needs assessments for two residents were not in their personal files and could not be found. At this inspection, there had still not been any new admissions to the home to assess this standard despite the home having a vacancy. Therefore, the previous requirement specified in this area will remain in place. In respect to the needs assessments that were missing, the new manager reported that they had been unable to find copies of these documents but reviews with the placing authorities for the three remaining residents had been arranged to ensure there was updated information available on all the residents to identify progress they had made and any specific areas in which individual residents required continued support. At the time the inspection was held annual reviews had been held with two of the residents although notes on these meetings had still not been received by the home. The review with the other resident was to take place in the next couple of weeks (See Requirements). A previous requirement that all residents living at the home should be issued with a statement of terms and conditions that outlines their stay with the home and that this should be signed either by the resident or a relative or a representative where appropriate had been met. DS0000066922.V338955.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents did not have a comprehensive care plan in place that addressed in detail all their assessed needs and personal goals. Residents had been supported to make their own decisions. Comprehensive risk assessments were in place but had not been completed for all residents to support them to take risks as part of an independent lifestyle. There were still gaps in the knowledge of staff in relation to confidentiality for residents to feel confident that information about them would be handled appropriately. EVIDENCE: At the last inspection all the residents had a care plan in place that were comprehensively written that looked at areas relating to personal and social support and health care needs. Also, aggressive, self -harming behaviour and how specialist requirements were to be met had been addressed. Apart from one all the residents or a relative on their behalf had signed the care plans. However, despite their being evidence that the care plans had been regularly reviewed it was identified that changes in the needs of residents had not DS0000066922.V338955.R01.S.doc Version 5.2 Page 12 always been addressed in the care plans. Furthermore, the manager was taking sole responsibility for the care plans although there was some evidence that the manager at that time was beginning to work with staff to develop their understanding of their responsibilities as key workers and for them to have an input in the care planning process. At this inspection it was found that these care plans were no longer in use. Instead, each resident had a task plan in place. These provided some background information about residents and outlined in detail personal care needs, individual preferences and daily routines. The residents or a relative on their behalf had signed them to indicate their involvement and understanding of the content. Yet, only brief details were provided around other aspects of personal support and social care and health care needs, for example medication was included but only stated to be given as prescribed, in reference to daily activities it stated that the weekly plan should be looked at. The manager acknowledged that the task plans were not sufficiently detailed and that they had been trying to develop more detailed care plans with input from residents’ key workers. Evidence of a care plan that had been drawn up by one of the key workers was seen but this was not very comprehensive and the manager reported that this was an area in which the support workers needed further support. However, more detailed care plans for residents need to be drawn up that address all areas of need and these should be regularly reviewed with changes in need reflected (See Requirements). Evidence was identified at this inspection to indicate that residents’ rights to make their own decisions had generally been supported by the home with restrictions on their rights and choices having been addressed either within an individual agreement that they had signed or within risk assessments that had been completed. However, it was noted at the last inspection that residents’ meetings as an opportunity to allow residents to have an input into decisions about different aspects of living at the home had not been held. At this inspection, it was found that residents’ meetings had been held on a regular basis in which residents were asked about activities and general feedback about the home. They were also encouraged by staff to raise any complaints or concerns they may have about living in the home. Previous inspections had identified concerns about the lack of consistency in the way the home had addressed and managed risks presented by individual residents. Also, at the last inspection concerns were raised about the manager’s knowledge base around risk assessment and management. As a result a requirement was specified that all staff should undertake risk assessment and management training. At this inspection the new manager who had since come into post demonstrated they did have an awareness around risk assessment and management. Yet, as previously required training to look at this area had been included in the home’s training plan for the manager the owner and one of the support staff to attend although all staff need to undertake this training. Comprehensive and detailed risk assessments DS0000066922.V338955.R01.S.doc Version 5.2 Page 13 had been completed for two of the three residents living at the home at the time the inspection was held that addressed individual risk factors presented by residents needs as well as environmental risks. Where risks had been identified risk management plans detailing control measures to reduce the level of risk had been drawn up that were signed by residents and reviewed regularly (See Requirements). It was identified at the last inspection that residents’ personal files were left on an open shelf in the office rather than being secured in a locked cabinet when not in use. Also, staff spoken to did not demonstrate a clear understanding in respect to the principles of confidentiality. At this inspection it was found that personal files of residents had been secured in a locked cabinet. However, in respect to support staffs’ knowledge about confidentiality it was evident from discussions with three staff members that they still did not have a full understanding of the principles of confidentiality despite the manager reporting they had all received training carried out internally in data protection awareness. Further attention in this area is required (See Requirements). DS0000066922.V338955.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16&17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents had been supported to look at and engage in meaningful and fulfilling activities. Residents had been provided with more opportunities to participate in the local community and to be involved in appropriate leisure activities although records of this had not been maintained. Residents’ family and personal relationships had been maintained with support from staff. Restrictions were in place that residents had to adhere to but overall their rights had been respected. Generally residents had received meals of their choice. EVIDENCE: Previous inspections had raised concerns that the home was not fully supporting residents to engage in valued and meaningful activities such as being supported to access training or education and that staff did not have sufficient information about resources and facilities to help residents look at different options available to them. Given that the home’s statement of DS0000066922.V338955.R01.S.doc Version 5.2 Page 15 purpose states the home aims to “promote their independence” and “rehabilitate individuals back into the community” this needed to be more effectively addressed by the home. At this inspection it was reported that links with the day centre, Headways where all the residents attend on a weekly basis, had been more established in this area and two of the residents had seen the employment adviser based there. As result, a recommendation had been made that these residents should attend another day centre where they would be involved in doing different types of work. However, funding for this was required from respective placing authorities and agreement for this had still not been confirmed. There was also evidence that a resident had registered with a volunteer centre and had recently done some gardening for some elderly people living in a sheltered accommodation scheme. In addition, they were enrolled with another volunteer gardening project although had not carried out any work with them recently. As identified at the last inspection another resident was attending computer classes at a local college. The manager reported that motivating residents and sustaining their interest was quite difficult but that the home was receiving advice and support from Headways to look at ways they could encourage and keep residents stimulated to become involved in different activities. It was evident from speaking to residents at previous inspections that they had received limited support to participate in the local community and to use facilities. Apart from all the residents attending a local day centre only one resident attended a gym regularly. Another resident had occasionally attended church, been to the hairdresser and had been accompanied a couple of times to the pub. At this inspection feedback from residents was much more positive in that it was reported that as well as using the local shops and those facilities mentioned previously they had been supported to go out regularly for meals locally and to go out more for walks. Another resident was also being supported to attend a gym. A previous requirement in respect to leisure activities that residents should be provided with opportunities to partake in activities inside and outside the house on an individual and also a group basis and that a record of activities that individual service users had been involved in should be maintained had been partially met. Yet, the timescale for compliance had not been fully exceeded at the time the inspection was held. There was evidence that weekly activities plans had been drawn up for each resident that they or a relative on their behalf had signed to indicate their agreement. These provided details on residents’ individual daily routines and some of the leisure activities specified included doing art and crafts, going to the gym, using the internet, movie nights, going for walks, going shopping. Others simply stated group activity or one to one session with staff. Residents spoken to confirmed they had been involved in some of the leisure activities specified within their activity plans as well as having been out for meals as mentioned previously. A barbecue had also been recently held in the home for residents to which family and friends had been invited and they stated that they were going on a trip to London Zoo DS0000066922.V338955.R01.S.doc Version 5.2 Page 16 the week after the inspection was held that they were looking forward to. Inside the house one of the residents confirmed they played board games with staff regularly such as scrabble. Two of the residents had “Time spent with” charts detailing interaction with staff. Overall, it was evident that there had been some improvement in leisure activities provided to residents although individual activity charts specifying precisely what residents had been involved in were still to be completed. Also, residents had still to be offered the option of an annual holiday of their choice and it is advised this is looked into by the home (See Requirements and Recommendations). Daily records indicated that residents had been supported to maintain contact with family, friends and develop personal relationships where appropriate. Also, residents spoken to confirmed this. One resident regularly spends weekends with their family and was due to go away on holiday with them. Another resident had been supported to maintain a relationship and their partner regularly visited the home. Although residents living at the home were subject to restrictions as mentioned in relation to Standard 7 there was evidence to indicate that generally their rights and choices had been respected. Also, the daily routines of the house had promoted independence. All the residents had to take responsibility for tidying their own rooms and to do their own laundry. Staff supervision and support was provided where required. Individual residents could also cook for themselves. Responsibilities for housekeeping tasks had been addressed in the home’s service user guide. Each resident had an individual nutrition chart in the daily files maintained by staff where meals eaten by service users had been recorded. The home had developed a four- week rolling menu since the last inspection, which one of the residents confirmed they had been consulted about. Records indicated that meals cooked were generally varied and balanced although there was a little repetition. Residents’ specific cultural needs had also been catered to. However, the menu had not always been adhered to and it is advised this is followed to try to prevent meals being repeated. Concerns were also raised about the diet of one of the residents that was quite poor consisting mainly of snacks. However, the manager reported that staff at the home and other professionals involved in their care were aware of this and it was noted in their daily task plan that they should be encouraged where possible to eat a main meal (See Recommendations) DS0000066922.V338955.R01.S.doc Version 5.2 Page 17 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. 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. Residents were generally more satisfied about the level of support received from support staff but measures were still needed to ensure that all staff were fully aware of their key working responsibilities. Physical and emotional needs had been met by the home. The home had changed the medication system, which had been effective in protecting residents but all staff still needed to receive training in medication. EVIDENCE: Residents at the home are generally able to carry out their personal care and only require minimal support and encouragement from support staff. Residents were observed at the inspection as being well - dressed and groomed. In terms of general day- to -day support the home operates a key worker system to try to ensure consistency. However, at the last inspection, feedback about the support received from staff varied in that individual residents commented on how they were not aware of who their key worker was and how some days staff would not interact with them at all. At this inspection residents spoken to were generally more satisfied with the level of support received from support staff. One of the residents stated that their key worker “Spends a lot of time DS0000066922.V338955.R01.S.doc Version 5.2 Page 18 with me”. Yet, in respect to support staff being clear about their key working responsibilities it was evident in speaking to one of them that although they did have some knowledge about what this involved, overall their awareness of their responsibilities was limited. The manager acknowledged that staff had received very little input on key working and that this was an area they were yet to fully address with them. In terms of a previous recommendation that the home should aim to recruit some male workers to balance the staff team, which consisted of female staff only, to provide a choice to residents of staff who they would prefer to work with them, this had partly been addressed. A male support worker had been recruited to work at the home since the last inspection although it is advised the home continue to look at ways of balancing the staff team when recruiting staff in the future (See Requirements and Recommendations). It was evident from the daily files used by staff that residents’ health and emotional needs had been met. As previously recommended each resident had an individual record of medical appointments that they had attended. This demonstrated that there had been liaison with a range of health professionals including GPs, dentists, opticians, chiropodists/foot services, psychologists, neurologists and neuro psychiatrists and specialist alcohol services. Where required residents had been supported to maintain a reduction in their alcohol use and evidence of records to monitor this were in place. Also, for those suffering from epilepsy monitoring charts had been put in place and regularly completed by support staff. The last inspection identified that although there had been improvements in the recording of the administration of medication by support staff a previous requirement that all support staff should receive training on medication had not been met. Also, despite weekly stock checks being carried out, a number of discrepancies were found in that stocks of tablets did not correspond with medication that had been signed as having been administered. However, since the last inspection a blister pack system had been introduced. As a result audits of the medication were more easily carried out and stocks of tablets could be accurately monitored. A sample of medication records was checked and these were generally accurate apart from a couple of minor errors. All staff had received training on the new medication system from the supplying pharmacist. In respect to more formal medication training some of the support staff were in the process of completing a long distant course in medication arranged by John Ruskin College. However, all staff need to undertake medication training. In addition, the temperature of the room where medication was kept had not been checked daily to ensure it was maintained at the recommended level of 25c. The home did not have any medication requiring cold storage (See Requirements). DS0000066922.V338955.R01.S.doc Version 5.2 Page 19 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. 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. Residents considered their views would be listened to and acted upon. Measures had been taken by the home to ensure that residents were protected from abuse but despite this staff spoken to were still not all clear about procedures to be taken in respect to adult protection. EVIDENCE: The home had a complaints policy and procedure that met with NMS and set out the stages and timescales for the process. A copy of the complaints policy that had been written in a simpler format was also included in the service user guide and provided information about local advocacy services where residents could seek independent advice and representation if required. Subject to a previous requirement that the home must include the new address and contact number of the new local office for CSCI in the policy, this had been addressed. Concerns were identified at the last inspection, as residents spoken to although aware of the home’s policy had not felt that their views had been listened to. It was also identified that in respect to informal complaints these had not all been recorded in the complaints log or addressed whilst details regarding formal complaints were not available for inspection. At this inspection, residents spoken to were more confident that if they raised concerns that these would be acted upon. As mentioned in respect to Standard 7 there was also evidence within residents’ meetings that they had been encouraged by staff to raise any issues or matters they were unhappy about living in the home. The complaints log was inspected and there had been two complaints made since the last DS0000066922.V338955.R01.S.doc Version 5.2 Page 20 inspection. One complaint was in respect to support staff using their mobile phones and speaking in their own language whilst accompanying residents to the day centre. This had been investigated and appropriate action had been taken. Another complaint had only very recently been made and was yet to be looked into by the manager. This involved an incident whereby one of the residents who was displaying challenging behaviour had stated that one of the support staff had addressed them inappropriately in an exchange of words. As a result of action being taken to ensure complaints had been recorded and acted upon the previous requirement in this area is deemed met. In respect to adult protection the home had a policy that met with NMS. However, where incidents had occurred that potentially could require further investigation under adult protection procedures, these had not always been immediately referred to social services or to CSCI as required under regulation 37 of the Care Standards Act 2000. As a result, an immediate requirement was issued to the home prior to the last inspection that all incidents regardless of severity needed to be reported to CSCI until further notice. This had been addressed by the home in that incidents had been appropriately reported to CSCI meeting this requirement. Furthermore, an adult protection investigation that was undertaken in relation to the home prior to the last inspection following an incident in which a resident self- harmed by setting themselves alight in November 2006, identified that there were gaps in staffs’ knowledge in respect to them being able to manage residents’ needs, which were complex and challenging and also to manage difficult/emergency situations (For further details see Standard 33 & Standard 35). Support staff spoken to at previous inspections did have some knowledge of adult abuse and what action to take if abuse was suspected or identified. Yet, there was only evidence that two of the staff team had completed training on adult abuse and protection although the manager reported at the last inspection that all staff had looked at adult abuse as part of an induction programme that met with Skills for Care specifications. However, due to the poor reporting of incidents and to ensure that all support staff had a clear understanding of the issues involved in adult abuse and adult protection procedures a requirement was specified that formal external training should be undertaken by the staff team. At this inspection, evidence was in place that demonstrated that all staff had been inducted on the local Borough’s adult protection procedures and there was evidence they had signed a form to state they understood the procedures and were clear about what action to take in the event they identified abuse or suspected it was occurring within the home. In addition, the manager had applied for places on training courses provided externally by Lewisham Partnership of which there was evidence. At the point the inspection was held three support staff had completed this training and three were due to attend in July 2007. However, although the three support staff that were spoken to at the inspection were aware of the different types of abuse, two were still not clear about action to be taken in respect to adult protection procedures. Given DS0000066922.V338955.R01.S.doc Version 5.2 Page 21 the input that staff had received on this topic this was concerning and needs further attention by the manager (See Requirements). DS0000066922.V338955.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was homely, comfortable and well maintained. Residents’ bedrooms met their needs. There were adequate communal spaces that supplemented residents’ individual rooms. Measures had been taken by the home to put in appropriate aids and make adaptations to maximise the independence of individual residents and ensure they had access to all parts of the home. The home was clean and hygienic. EVIDENCE: The home was a large period property that had been decorated to a good standard with neutral colours being used throughout and there was laminate flooring all the way through the home making it bright and airy. Furnishings were domestic in nature making the home comfortable and homely and it had access to local amenities, local transport and relevant support services to suit the personal and lifestyle needs of the residents. Overall, it was suitable for its stated purpose with measures having been taken to ensure that residents with DS0000066922.V338955.R01.S.doc Version 5.2 Page 23 mobility difficulties could access all parts of the home (For details see Standard 29). Residents’ bedrooms were all large and spacious and contained all the required items of furniture. Two of the bedrooms had en-suite facilities that included a shower and a toilet. All the bedrooms had been suitably personalised. In relation to communal spaces the home had a spacious lounge. There are French doors with steps leading to the garden, which is well maintained. There was also a separate dining room and a kitchen that was domestic in nature. Concerns were raised at the last two inspections about the physical environment of the home and its suitability to meet the needs of two of the residents who had mobility difficulties. One of the residents who had a room upstairs stated they had difficulties managing the stairs and would have preferred a ground floor room but one was not available. Another resident had difficulty accessing the garden without staff support. As a result a requirement was specified that each resident should have an occupational therapy (OT) assessment to determine if any further aids or adaptations were required to help maximise their independence and ensure their safety. At this inspection, the resident with mobility problems whose room was upstairs was no longer living at the home having been moved to an alternative placement. In respect to the other resident although there was no evidence of a report the manager reported that the community OT who had been working with the resident did carry out an assessment and as a result grab rails had been placed by the French doors and also outside by the kitchen door where there were steps leading down to the garden. A grab rail had also been placed in the resident’s en-suite shower as an added safety measure. As a result of the aids the resident was able to access the garden independently and they expressed that they did help them to feel safer. Additional rails had also been placed along the walls up the stairs. The home was clean and hygienic on the day the inspection was held. There are adequate laundry facilities sited away from the preparation of food. DS0000066922.V338955.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 &36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Evidence was made available that the majority of the support staff working at the home had obtained or were in the process of completing a relevant qualification. There were sufficient staff on duty but staff did not clearly demonstrate they had the necessary skills and knowledge to be able to effectively meet residents’ needs and be responsible for the daily running of the home. Generally recruitment practices had protected residents but some improvements in vetting procedures were still required. The home had a training plan in place although the home needs to ensure all staff completes an induction that meets with Skills for Care specifications. Staff had still not received regular supervision. EVIDENCE: At the last inspection evidence was identified that two of the support staff had achieved qualifications abroad, one in nursing and the other had a Bachelor degree in medicine. The staff member whose background was in nursing reported they were undertaking a National Vocational Qualification (NVQ) Level 4 in Health and Social Care. In respect to the other support workers it was DS0000066922.V338955.R01.S.doc Version 5.2 Page 25 reported they were all in the process of completing a NVQ Level 2. However, the home was not supporting staff with obtaining these qualifications and as a result it was required that evidence should be obtained confirming the information that had been provided by staff. At this inspection, of the eight support workers presently employed by the home there was only evidence for one of them that had been recruited since the last inspection that they were in the process of studying for a BTEC Diploma in Care which would be completed in June 2008. There was also a lack of clarity and at times conflicting information provided by the manager and individual support staff about qualifications they had completed and those that they were in the process of undertaking. However, following the inspection evidence was sent to CSCI for all the remaining staff working at the home apart from one, of qualifications they had completed, were in the process of doing and also that they were due to commence (See Requirements). A previous requirement that the home must ensure that there is an accurate rota in place that reflects staff working in the home at all times and where changes are made in staffing arrangements these are noted on the rota accordingly, this had been addressed. There was evidence that a rota was drawn up on a weekly basis and on both days that the inspection was held sufficient staff were observed to be working at the home. However, in terms of the skills level of staff to ensure the efficient and effective day to day running of the home, management of emergencies and to meet the individual and collective needs of residents it was evident in speaking to individual support staff that there were gaps in their knowledge and a lack of awareness to ensure the overall safety of residents and of the home (For further details see Standards 6,10 & 23). The manager reported that all the support staff were presently under probation due to concerns about performance and efforts had been made to provide training to staff to improve their knowledge base in specific areas (For details see Standard 35). Yet, it was evident that further measures needed to be taken to ensure the skill mix of staff was more balanced for the effective day- to- day running of the home and to support residents assessed needs at all times. In respect to a previous recommendation that the home should consider the employment of bank staff to alleviate the pressure of covering shifts by permanent staff this had not been addressed although the manager reported there were plans for this to be organised (See Requirements and Recommendations). Two support staff had been recruited since the last inspection. The staff records for these staff members were checked along with all other support staff. All the records looked at were found to include the necessary documents required by regulation including Enhanced Criminal Record Bureau (ECRB) checks, two references and appropriate identification. In respect to a previous requirement that the vetting procedures used by the home needed to be improved the timescale for compliance had not been exceeded at the time the inspection was held but was identified as having been partially met. The application form used by the home had been changed to ensure a more DS0000066922.V338955.R01.S.doc Version 5.2 Page 26 detailed employment history was provided although gaps in employment were identified for one of the new staff members recruited and there was no evidence that this had been addressed with them and reasons for the gaps noted. Also, as previously required there was evidence of interview questions that had been used as part of the recruitment process that addressed areas such as risk assessment, challenging behaviour care planning and adult protection. However, rather than the questions being asked the staff members had written answers to the questions themselves and the interviewer had then written comments. It was evident from these documents that improvements in the vetting of staff were still required. The present manager was not involved in the recent recruitment of staff but concerns were raised with them about the quality of some of the answers provided and the eligibility criteria used by the home to assess suitability of applicants. As a result it is advised as part of equal opportunities that a more formal interviewing process is used by the home at which at least two people should be involved (See Requirements and Recommendations). Prior to the inspection the home had provided CSCI with a training plan that clearly outlined training to be completed by all support staff including both mandatory training and specific training such as an introduction to mental health and introduction to brain injury to be provided by Headways. At the inspection staff records included evidence that applications for courses included in the training plan had been submitted to Lewisham Partnership and these indicated as mentioned in respect to Standard 23 that some of the support staff had at the time the inspection was held completed external training on adult protection as well as food hygiene and infection control whilst one of them had completed first aid training and food safety in catering. In addition, the manager reported that as part of ensuring support staff were fully inducted they had completed training internally with all of them apart from one on a range of topics including as mentioned in relation to Standard 10 and Standard 23 data protection awareness and adult protection procedures and also challenging behaviour, epilepsy, personal care amongst others. However, as previously discussed in the report, in talking to the support staff it was evident that despite having received this training they still had gaps in their knowledge and they could not fully demonstrate that they had a comprehensive understanding and awareness of issues in relation to the management of difficult behaviour, confidentiality and adult protection. Concerns about this were raised with the manager as the home needs to ensure that staff working at the home are at a competent level to ensure the needs of the residents can be effectively met at all times. Furthermore, although the previous manager at the last inspection reported that staff had completed an induction that met with Skills for Care specifications there was no evidence of this available. At this inspection there was still no evidence to indicate an induction meeting these specifications had been completed with staff. This needs to be addressed (See Requirements). DS0000066922.V338955.R01.S.doc Version 5.2 Page 27 There was limited evidence that support staff had received formal supervision. Records available indicated that only two support staff had each received a supervision session. Given that there were concerns about staffs’ performance and that they had all been placed on probation it is essential that they all receive regular supervision to monitor progress and to highlight areas of concerns (See Requirements). DS0000066922.V338955.R01.S.doc Version 5.2 Page 28 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39&42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There had been improvements in the overall running of the home although additional administrative support is required to ensure that the home can be effectively managed. Service users and relatives views had been sought as part of self- monitoring although further measures in respect to quality assurance still need to be taken. The health, safety and welfare of residents had not been fully protected. EVIDENCE: The present manager had been in post for approximately three months the time the inspection was held having commenced working at the home March 17th 2007. They had previously worked as a registered manager for a domiciliary care agency. They had completed the NVQ Level 3 and were in the process of undertaking the Registered Manager’s Award NVQ Level 4. An application to become the registered manager had already been submitted to DS0000066922.V338955.R01.S.doc Version 5.2 Page 29 CSCI. It was evident in discussions with the manager that they had the relevant experience and knowledge to ensure the home was well run and from the inspection it was evident that they had already begun to make some improvements. However, given some of the issues that need to be addressed particularly in relation to staffs’ performance it was also clear that for these to be effectively addressed that the manager required additional support. As a result it is advised that the owner of the home look into the possibility of providing some support in respect to tackling administrative duties to enable the manager to have the time to focus on other issues in relation to the management of the home (See Recommendations). The timescale for a previous requirement that the home develop an effective quality assurance systems in which residents’ views are regularly sought as part of self -monitoring had not fully exceeded at the time inspection was held but was identified as having been partially met. There was evidence that a customer satisfaction survey had been carried out with two of the residents living at the home and also relatives. However, a report outlining the results of the surveys, which should be made accessible to residents, relatives and also to CSCI had not been completed and neither had a development plan in which aims and outcomes for residents based on the results of the surveys should be addressed. It is also advised that as part of future surveys the views of professionals involved in the home are sought. In respect to a requirement that monthly provider reports should be completed and copies of these sent to CSCI this had been met (See Requirements and Recommendations). As mentioned in respect to Standard 23 the home had met an immediate requirement to report all incidents as required under regulation 37 of the Care Standards Act 2000. However, a previous requirement to address other aspects of residents’ health and safety had been found to have been partially met in that although the home had recorded water temperatures regularly to prevent scalding the fire risk assessment had only been partially completed and was in need of being reviewed. In respect to a building risk assessment, environmental risks had been addressed as part of residents’ individual risk assessments but a more general risk assessment that also addresses risks to staff working at the home should be drawn up. There was evidence of up to date maintenance certificates for gas safety, electrical wiring and fire equipment but it was identified that fire alarm call points had not been tested weekly with the last test having been performed on 16/05/07 (See Requirements). DS0000066922.V338955.R01.S.doc Version 5.2 Page 30 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 2 2 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 1 33 1 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 1 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 X X 2 X DS0000066922.V338955.R01.S.doc Version 5.2 Page 31 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 YA1 Regulation 2(3) Requirement Timescale for action 31/08/07 2. YA2 14(1) The registered provider must ensure that the service user guide includes information about the fees charged by the home and what is included in the total fees payable. (Previous timescale of 31/05/07 not met). 30/09/07 The registered provider must ensure that prior to any service user moving into the home that a full needs assessment has been carried out by the relevant local authority and a copy of this is obtained to ensure that the home is fully able to meet the needs of the service user. A copy of the assessment should be kept on the service user’s file. (Previous timescale of 30/03/07 not exceeded and timescale of 31/05/07 not met. Requirement DS0000066922.V338955.R01.S.doc Version 5.2 Page 32 3. YA6 15 4. YA6 15(2) 5. YA9 13 (4) (a) &(b) could not be fully assessed at both inspections as no new admissions have occurred. The registered provider must ensure that a comprehensive care plan is drawn up in consultation with all service users, their relatives or a representative where appropriate and the service user indicating their involvement signs this. (Previous timescales of 31/01/07 & 31/07/07 not exceeded -partially met at time of inspections) The registered provider must ensure that following reviews or reassessment of service users’ needs that any changes in support are reflected within their individual care plans so that progress can be monitored and evaluated. (Previous timescale of 31/07/07 not exceeded but not met at time of inspection) The registered provider must ensure that all service users have a comprehensive risk assessment in place that addresses all identified risks presented by individual service users and control measure/ action is specified on how risks/hazards are to be reduced. 30/09/07 30/09/07 30/09/07 DS0000066922.V338955.R01.S.doc Version 5.2 Page 33 6. YA9 18(1)(c)(i) 7. YA10 12(4) (a) 8. YA14 16(2)(n) (Previous timescale of 31/01/07 not exceeded -partially met at time of inspection. Timescale of 31/05/07 partially met) The registered provider 30/11/07 must ensure all staff working at the home receives training around risk assessment and management. (Previous timescale of 31/07/07 not exceeded but partially met at time of inspection) The registered provider 30/09/07 must ensure that all staff are aware of their responsibilities around maintaining confidentiality and also circumstances / situations when confidentiality needs to be breached. Also, that the personal files of service users should be kept in a locked cabinet when not in use. (Previous timescale of 31/07/07 not exceeded but partially met at time of inspection) The registered provider 30/09/07 must ensure that service users are provided with an activities programme that involves them partaking in activities both inside and outside the house on an individual and also a group basis and a record of activities that individual service users are involved in is maintained. DS0000066922.V338955.R01.S.doc Version 5.2 Page 34 9. YA18 12 10. YA20 13(2) 11. YA20 13(2) (Previous timescale of 31/03/07 not exceeded -not met at time of inspection. Timescale of 31/07/07 not exceeded but partially met at time of inspection) The registered provider 30/09/07 must ensure that all staff provides a consistent level of support to all service users and that they are all clear about their role as a key worker and the responsibilities this involves. (Previous timescale of 31/07/07 not exceeded but partially met at time of inspection). 30/11/07 The registered provider must ensure that all staff receives training around medication that meets with the specifications of standard 20:10 within the national minimum standards and in future all new staff must receive this training prior to being allowed to administer medication. (Previous timescale of 31/03/07 not exceeded-not met at time of inspection. Timescale of 31/07/07 not exceeded partially met at time of inspection). The registered provider 30/09/07 must ensure that the room temperature where medication is stored is monitored daily and recorded to ensure it does DS0000066922.V338955.R01.S.doc Version 5.2 Page 35 12. YA23 13(6) 13. YA32 18(1) 14. YA33 18(1)(a) 15. YA34 19 & Sched 2 not exceed the recommended level of 25c. The registered provider must ensure all staff working at the home receives formal accredited training on adult abuse and adult protection to ensure they are fully aware of reporting procedures. (Previous timescale of 31/07/07 not exceeded but partially met at time the inspection was held). The registered provider must ensure that evidence is obtained of all staff who are presently undertaking National Vocational Qualifications (NVQ) and when the courses have been completed a copy of the certificate is obtained and kept on individual staff files. (Previous timescale of 31/07/07 not exceeded but was partially met at time inspection was held. The registered provider must ensure that the skill mix of staff is more balanced to ensure there are a sufficient number of suitably qualified and experienced staff working at the home at all times to ensure the needs of residents can be effectively met and for the effective day to day running of the home. The registered provider must ensure that DS0000066922.V338955.R01.S.doc 30/11/07 31/08/07 30/11/07 30/09/07 Version 5.2 Page 36 16. YA35 18(1) 17. YA36 18 (2) adequate vetting procedures are used when recruiting staff to work in the home specifically that a full employment history is obtained and any gaps in employment are explored and accounted for. Also, that a record of the interview process carried out with staff is maintained. (Previous timescale of 31/07/07 not exceeded but partially met at the time of the inspection) The registered provider 30/11/07 must ensure that all staff working at the home have their individual training needs assessed and that a training plan is drawn up that outlines all training to be undertaken by staff which must include updating all mandatory training such as manual handling and also specific training to ensure the individual and collective needs of service users can be met effectively. (Previous timescale of 31/05/07 not exceeded and partially met) 30/11/07 The registered provider must ensure all individual staff receives at least six supervision sessions annually and records of the sessions are maintained. (Previous timescale of 31/07/07 not exceeded but not met at the time of DS0000066922.V338955.R01.S.doc Version 5.2 Page 37 inspection). 18. YA39 The registered provider 30/09/07 must ensure that the quality assurance systems for the home are developed. An effective system where service users ‘ views underpin all selfmonitoring, reviews and development of the home. (Previous timescale of 31/05/07 not exceeded-not met at time of inspection. Timescale of 31/07/07 not exceeded but partially met at time of the inspection) 31/08/07 13(4)(a)&(c)&23(4) The registered provider (c)&37 must ensure that all aspects of health and safety are addressed: _That when incidents occur in the home that a Regulation 37 report must be sent to CSCI as soon as possible. (Immediate Requirement issued 27/11/06 to remain in place till further notice) - A building risk assessment is completed. - A fire risk assessment is completed and fire equipment is maintained. - Water temperatures are checked and recorded. (Previous timescale of 31/07/07 not exceeded but partially met at time of inspection- Immediate Requirement had been met. Maintenance of fire equipment met and water temperatures DS0000066922.V338955.R01.S.doc Version 5.2 Page 38 24 19. YA42 recorded). 20. YA42 23(4)(c)(v) The registered provider must ensure that fire alarm call points are tested weekly to ensure the health and safety of residents is maintained. 30/09/07 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. 4. 5. 6. 7. 8. 9. Refer to Standard YA1 YA6 YA14 YA17 YA18 YA33 YA34 YA37 YA39 Good Practice Recommendations The registered provider should try to ensure they are fully familiar with the new regulation regarding information about fees being provided to service users. The registered provider should try to develop the role of the key worker further to involve them in the drawing up and reviewing of care plans. The registered provider should try to ensure that residents are offered an annual holiday of their choice. The registered provider should try to ensure that the menu plan is followed to avoid any repetition of meals. The registered provider should try to look at ways of recruiting male staff to give service users a choice of who works with them. The registered provider should consider the employment of bank staff to alleviate the pressure from the permanent staff to provide cover for annual leave and sickness. The registered provider should try to adhere to equal opportunities procedures and make sure that at least two people are present when interviewing applicants. The registered provider should try to ensure that the manager is provided with administrative support to support them with the effective running of he home. The registered provider should try to ensure that when completing customer satisfaction surveys professionals who are involved in the home are included. DS0000066922.V338955.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000066922.V338955.R01.S.doc Version 5.2 Page 40 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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