Inspection on 24/09/07 for Combe House

This inspection was carried out on 24th September 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Combe House 02/06/08

Combe House 29/01/08

Combe House 08/05/06

Combe House 13/10/05

Combe House 09/05/05

Combe House 15/11/04

Combe House 14/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Combe House Central Drive Walney Island Barrow in Furness Cumbria LA14 3HY Lead Inspector Ray Mowat Unannounced Inspection 24th September 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Combe House Address Central Drive Walney Island Barrow in Furness Cumbria LA14 3HY 01229 473617 01229 476336 combe.house@cumbriacc.gov.uk www.cumbriacare.org.uk Cumbria Care 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) Mrs Melanie Louise Williamson Care Home 40 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (40) of places Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Code PC, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Dementia over 65 years of age: Code DE(E) (maximum number of places: 12). Old age, not falling within any other category: Code OP (maximum number of places: 40). The maximum number of people who can be accommodated is: 40. Date of last inspection 8th May 2006 Brief Description of the Service: Combe House is a purpose built residential care home, which is owned by Cumbria County Council and operated by Cumbria Care, an internal business unit of the Councils Contract services group. The home is registered to accommodate forty people over sixty-five years of age, including up to ten people with dementia and a person with a mental disorder. The home is single storey and divided into four distinct living units, with all the units being fully accessible. They each contain ten bedrooms, bathrooms, toilets, a good size lounge with kitchenette and dining area. It is situated on Walney Island near the town of Barrow-in-Furness. It is in a residential area of the island and is on a main bus route and close to local amenities. The home has been designed and equipped to meet the needs of the residents. It is in its own grounds with gardens to the front and rear and off road parking is available. The monthly fees range from £363 per week to £422 per week with additional charges for personal sundry expenses. The service user guide and statement of purpose are made available to prospective new residents and previous inspection reports are displayed on the notice board in the foyer. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit took place between 9am and 6pm to enable me to see the daytime and early evening routines of the home. During the visit I met with people living in the home, visitors and relatives and spent time with the manager and supervisors on duty. I also spoke to staff as they went about their duties. Prior to the visit the manager completed a self-assessment questionnaire called an Annual Quality Assurance Assessment. This provided me with information about how the home is run and the manager’s views on what the home does well and where they need to improve. There is also information about people living in the home and the staff. The views of people living in the home, their relatives, staff and other professionals were used to formulate the judgements made in this report. I also examined records relating to the running of the home as required by legislation, including personal care plan files, about the people living there. These provide staff with information about what is important to a person and how they like to live their lives. I also examined staff files and records relating to the maintenance and safety of the home. What the service does well: People living in the home feel “safe and well cared for”. Regular meetings are being held so that people can make their views known and express personal preferences about how the home is run and improvements they would like to see. An annual questionnaire is also sent out to them and their relatives to get their views about all aspects of the home. Information about the home is accessible to people and some of it is supplied in an audio format to make it easier to understand. All staff receive regular support and supervision including annual appraisals to agree development targets and training needs. Good training is provided to staff to make sure they have the skills and knowledge to support people. The home is clean and hygienic, safe and well maintained. People are able to choose what furniture they have in their room and colour schemes when they are decorated. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure ensures people are given suitable information about how the home is run and their needs are fully assessed. EVIDENCE: When a person makes an initial enquiry about the home they are provided with a service user guide and statement of purpose, which provides them with detailed information about all aspects of home life and how the home is run. These are updated at least annually or as changes occur. I examined several care plan files, which on the whole were up to date and accurate with appropriate assessments completed and contracts of terms and conditions signed and agreed by both parties. However one file of someone who had recently moved into the home did not contain a contract. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 9 Detailed needs assessments are now being completed containing relevant information about a person’s personal and healthcare needs, some files also contained informative personal profiles. These gave an insight to how people like to live their lives such as daily routines and other things that are important to them. This type of information is invaluable to staff in gaining a better understanding about the person and their individual needs and preferences. Plans are in place to develop the assessments further ensuring a holistic ‘person centred assessment’ is completed on all the people in the home. Nutritional assessments have been developed, which guide staff in meeting people’s dietary requirements. This could include healthy eating plans, weight loss and gain or specialist dietary needs such as Diabetes. The home also works closely with other agencies taking account of any specialist assessments or services people require. I talked to several people about their experiences when moving into or choosing the home. Some of them had visited the home prior to choosing to move in, either on respite care or a planned visit. They really valued this and found it made the process easier to accept as they “knew what to expect”. One person told me that they were having their room decorated and would be “moving their own furniture in and making it more like my own home”. Through an annual audit of staff training the manager ensures the staff team are suitably trained and experienced to provide appropriate support to people including any specialist needs they may have. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The content of care plans are inconsistent and lack sufficient detail to support a person centred approach. EVIDENCE: Based on the pre-admission assessment and any other specialist assessments care plans have been developed for each person. There was evidence the content of these care plans and assessments have improved. They are agreed and signed by the person or their representative. They are kept under review with any changes to the plan recorded, signed and dated. However the content of care plans was inconsistent, with some not having a personal profile completed. The personal profile when completed provides a valuable insight to how a person likes to live their lives from daily routines to what they like and what is important to them such as social, cultural and religious needs. Care plans also contained ‘stock phrases’ to describe someone’s needs and how they should be met. These need to be more person centred and reflect the needs and preferences of the individual. The manager did say that plans were in Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 11 place to develop more person centred care plans with training for staff also planned, which will guide their practice. Daily records are completed at the end of each shift that record what personal care and support has been provided and any significant issues that need to be passed onto the supervisor or the next shift. This may include any health related issues that require a referral to another agency. The staff also work closely with the District Nurse from the local GP practice who I spoke to as part of this inspection. They confirmed that the staff are “aware of people’s needs and make appropriate referrals for advice and treatment”. They have a good awareness of pressure care needs and monitor people closely working proactively with the other services such as Continence advisors, Occupational Therapists and Dieticians. I checked the contents of the medication cabinet against the medical records held by the home. These were found to be up to date and in order. All prescribed medicines were held securely with appropriate amounts available. PRN (as and when required medication) were recorded with clear protocols developed for staff based on the advice of the GP. This ensures staff administer medication consistently. All staff who administer or check medication have received suitable training for their role. There have been several medication errors since my last visit to the home. These were fully investigated by the manager and appropriate action taken with the people involved to prevent a reoccurrence. The manager is now monitoring the competence of staff on an ongoing basis. It was evident throughout the inspection that staff have developed good relationships with people and respect their privacy and dignity as they support them. Doors were closed when providing personal care and staff routinely knock on doors before entering a room. Staff offered choices to people and respected their wishes such as what time to get up, what they wanted to eat and where they wanted to eat it. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The range of activities provided both in the home and in the local community has increased, with plans in place to provide more opportunities for people based on their personal preferences. EVIDENCE: There was evidence significant improvements have been made in developing a more varied programme of activities. A series of planned outings took place during the summer months, which was enjoyed by the people I spoke to. A nearby home has a function room which was used to provide an entertainments evening, which was also well received. Staff have been holding fund raising events to help pay for some or all of the activities from the home’s amenity fund. Regular meetings are being held to discuss people’s preferences, which is good practice. As a result of the last meeting a trip to the local Pantomime has been planned and the bingo session held in the home has been increased to twice weekly. Plans are also in place to arrange a monthly shopping trip again based on feedback from people living in the home. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 13 There is a relaxed atmosphere in the home with people moving freely between the separate units to visit friends and socialise. People can spend time in their own rooms where many of them have their own television or radio or enjoy reading a book or daily newspaper. Others prefer the company of one of the communal lounges where activities take place. The manager is currently developing a selection of resources to increase the type of in-house activity the home can provide. People said their visitors and relatives are always made welcome and that they were able to meet with them in private. During the inspection there were several visitors to the home. The introduction of Nutritional assessments has improved the level of information staff have about people’s dietary needs and their personal preferences with regard food. On the whole the majority of the people I met with were complimentary about the choice and quality of food. Menus had been discussed at a ‘residents meeting’, which resulted in changes being made to the planned menus. Each of the units has a kitchen dining area where food is served and snacks can be made, alternatively some people choose to take their meals in their own rooms. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures in place in the home ensure people are safeguarded and their complaints and concerns are heard and responded to. EVIDENCE: Since the last inspection visit two complaints have been received by the home, one has just been received and is currently being investigated with appropriate referrals being made to the local authority. The other complaint was fully investigated and the complainant responded to. The home’s policy and procedures are made available to people and are displayed in the home. They are also supplied in an audio format to make them easier to understand, which is good practice. The home is operated by Cumbria Care, which is part of the County Council and therefore have adopted the Council’s safeguarding Adults practice guidelines and policy. These ensure vulnerable people are safeguarded and staff are clear what their role and responsibilities are. Training has taken place for the majority of staff, with a further course planned for the remaining staff. Based on discussions with care staff and supervisors they had a sound understanding about identifying and responding to actual or suspected abuse. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Combe House provides a safe, clean and comfortable environment that is well maintained and decorated to a good standard. EVIDENCE: During the inspection I spent time in the communal areas of the home and also visited some individual bedrooms. All areas of the home were clean and hygienic with dedicated Domestic staff in place to maintain the cleanliness throughout the home. There were no obvious hazards noted with the home having their own internal system to monitor and maintain a safe and comfortable living environment. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 16 There were various aids and adaptations in place around the home to support and promote people’s independence and maintain their safety and the safety of staff. Annual condition surveys are completed to identify planned maintenance and repairs. The manager explained the programme in place for the coming year including the decoration of one of the communal lounges and 9 bedrooms, for which people have been involved in choosing colour schemes. Four rooms are being re-carpeted and eight double glazed units are being replaced. Remedial work is also required on the panelling behind the toilets as paint has peeled that makes the surface porous and difficult to clean. These should be repainted as planned. Gazebos were purchased in the summer enabling people to shelter from the sun and stay out in the garden and “enjoy the flowers and birds”, another said how they sit and “enjoy the view up to Black Combe”. Access to the garden is one level making it accessible to people who use a wheelchair or walking aid. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home felt “well looked after”, however staff shortages have resulted in an inconsistent quality of service. EVIDENCE: The staff rotas showed that the home has been operating with two vacant posts (52 hours) each week. In addition to this staff sickness and staff leaving has put pressure on the permanent staff team to cover all shifts, resulting in periodic staff shortages. Several people who live in the home mentioned the staff shortages to me during the day. One of the vacant posts has now been filled and adverts are out for the remaining position. At present the home does not advertise individually for staff vacancies, a pooled advert with other Cumbria Care homes is used, with managers jointly interviewing people and identifying them for positions. It is not clear how effective this has been in ensuring the appropriate numbers and skill mix of staff is maintained in the home. The recruitment policies and procedures are robust and in line with good practice and equal opportunities guidelines. Appropriate checks are completed with CRB disclosures in place for all staff. All new staff have completed a thorough induction training programme as well as shadowing experienced staff until they are familiar with the people living in the home and the daily routines. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 18 However a relief supervisor on duty over the weekend had not been inducted to that role so was not familiar with some systems, which had been problematical. It is recommended all relief staff be inducted to the home and the role they are to undertake, prior to working shifts there. Despite the staff shortages mentioned previously people did speak positively about the contribution staff make. When I asked one person what makes it a good home they said “it’s the staff who make it for me, we have got a good lot”, another said “they are pleasant, helpful and respect our opinions”. There was evidence the level of training has improved with staff commenting on this. An audit of staff training needs was completed that is used to identify and plan the training courses required. New staff had all received formal induction training and refresher training was taking place as well as training in more specialist areas. In addition over 60 of staff have already completed or are working toward their NVQ qualifications. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Combe House is being effectively managed in the best interest of the people living there. EVIDENCE: The new manager Mrs Melanie Williamson has settled into her role and made good progress in meeting the shortfalls identified at previous inspections. New systems to improve aspects of the service have been implemented and she is aware of areas for development. A good example of one of the improvements is staff supervision. A planned programme is now in place and staff are receiving regular formal supervision from one of the supervisory team. Annual appraisals are also taking place that identify personal targets and training and development needs, which is good practice and something that is valued by the staff team. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 20 As well as supervision the manager has introduced regular staff meetings that are scheduled on a monthly basis. This now includes the night staff, which is another positive development. Based on my discussions with staff they feel “well supported” and able to “raise any issues or concerns as they arise”. An annual quality assurance survey is issued to people living in the home and their relatives. The results of the surveys are issued and included in the statement of purpose and service user guide. The results are also used to shape the home’s annual development plans. Several changes have taken place in the home as a result of feedback from people through the surveys and meetings. This has included an increase in the number of trips, changes to menus, purchasing of Gazebos for the garden and blinds for the lounge windows. On the whole the records and procedures I examined as part of this inspection were up to date and safeguarded people living and working in the home. Records were securely stored whether in paper format or electronic. At present the home is retaining CRB disclosures for staff. This is contrary to Data Protection good practice guidelines. There are sound procedures in place to ensure the equipment and environment is well maintained so that people are safe at all times. Accidents are recorded and investigated to prevent a reoccurrence and to make sure there were no contributing factors. Risk assessments are completed when risks are identified, which are kept under review. Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18(1) a Requirement There must be appropriate numbers and skill mix of staff on duty at all times. Timescale for action 01/11/07 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. Refer to Standard OP7 OP19 OP30 Good Practice Recommendations Care plans should be sufficiently detailed to enable staff to provide more person centred care. Wooden panels behind the toilets should be repainted to enable them to be cleaned effectively. All relief staff should be inducted to the routines of the home and the role they are to undertake prior to working shifts there. All staff CRB disclosures should be retained in line with Data Protection good practice guidelines. 4. OP37 Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Combe House DS0000036531.V348096.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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