Inspection on 14/07/05 for Edward House

This inspection was carried out on 14th July 2005.

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 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

Edward House 11/07/07

Edward House 27/06/06

Edward House 17/11/05

Edward House 24/03/05

Edward House 18/01/05

Edward House 18/02/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Edward House Matson Lane Matson Gloucester Glos GL4 6ED Lead Inspector Tanya Harding Unannounced 14 July 2005 10:00 th 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 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 Stationary 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. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Edward House Address Matson Lane Matson Gloucester Glos GL4 6ED 01452 307069 01452 311742 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Selwyn Care Limited Ms Tracy Nunes Care Home 9 Category(ies) of Learning Disability (9) registration, with number Physical Disability (9) of places Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Suitable dining arrangements must be put in place as agreed with the Responsible Individual and the Registered Manager. Condition to be reviewed by 31 March 2005. Two additional staff must be employed to cover daytime shifts to accommodate the increase in numbers (once the nineth person has been accommodated). Condition to be reviewed by 31 March 2006. Date of last inspection 24/03/05 Brief Description of the Service: Edward House is part of the care provision offered by Selwyn Care Limited. The home is situated on the outskirts of Gloucester in the Matson area. The organisation provides residential and day care services to adults with Autistic Spectrum disorders and associated behaviours. The home shares the site with the organisational office, another home and the day care facility. There are spacious grounds around the home, with a lake, garden, fields and a large car park. All communal and individual accommodation is on ground floor level. There are nine single bedrooms all with full en-suite facilities. There are two spacious communal lounges, one incorporating a dining / activities area, as well as an additional dining room accessed via the kitchen. Just outside the main building there is a laundry area and an additional room, which is used for art and craft activities by the residents. The laundry and the art room have stepped access. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 10 am on 14th July 2005 and a subsequent visit to the home was made on 25th July 2005. The inspection lasted some five hours and was supported by the second inspector, Tim Cotterell. There has been a change of management since the last inspection and the new acting manager as well as the previous manager helped with the inspection. The main purpose of the inspection was to investigate issues raised in a complaint received from relatives of one service user and the report presents the findings and recommendations resulting from this. Compliance with some of the requirements made during the last inspection was not checked and will be followed up at the next visit. During the inspection a variety of records containing information about service users was examined. There were discussions with the acting manager and three of the staff. All of the service users were in the home and the inspectors met and greeted almost all of them. As a result of the investigation the Commission has required the home to take immediate corrective action to improve staffing levels in Edward House and agreed a system of monitoring staff levels on a weekly basis. What the service does well: What has improved since the last inspection? What they could do better: Care plans and support guidance need to revised to make them more detailed and person centred. Service users must be protected from physical abuse. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 6 Sufficient staff numbers must be maintained at all times and systems must be in place to provide cover for sickness and holidays. The home must be reviewing the needs of the service users if it is unable to meet the contractual arrangements agreed with the placing authorities. Lines of responsibility within the management of the home and the organisation more generally should be revisited to determine the level of authority and accountability given to the registered manager and senior staff. Quality assurance systems based on regular and detailed audit of all of the aspects of service provided in the home must be developed and implemented. 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. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. EVIDENCE: There have been no new admissions to the home since the last visit. One bedroom remains vacant. The Organisation has acknowledged that until staffing shortages are rectified no new service users will be placed at Edward House. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 Some care plans do not clearly and adequately reflect and meet the needs of service users. EVIDENCE: Care plans for one person were examined in detail. Information was provided about several assessed needs for the person and some guidance was given about how the support should be provided. However, there was evidence that the assessed needs may not always be met. The service user requires one to one staffing at all times during the day and this is not always available. The care plan seen was revised in January 2004 and contained several handwritten amendments and some of the information was simply crossed out. The amendments were not signed or dated and this made it impossible to determine how current the changes are. The care plan was not in a person centred format and some of the guidance given was limited in detail. For example there was no detail about the function of the one to one staff support and how the person’s privacy will be promoted in view of the constant supervision they require. Other shortfalls are identified further in the report. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 10 The above evidence suggests that the home has not met the requirement made in the last report to review care plans and information on service users’ files within set timescales. This has been a long-standing requirement and must be addressed. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The standards in this section were not assessed on this occasion. EVIDENCE: Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, Shortfalls in guidance and care planning for delivering personal care to service users may mean that there is an increased potential for inconsistent practice. EVIDENCE: Care plan for one service user was examined in detail. The quality of guidance about the person’s needs with regards to personal care was vague. For example where it talks about the continence needs, there is no guidance about how this should be done. Similarly, the guidance about how to support the person when they have a seizure is very limited. It makes reference to the protocol for rectal valium but nothing about what staff should do in the event of the person suffering a seizure. The care plan has not been updated following the medication review with the consultant which took place in February 2005 and staff spoken with were not aware of the recommendations made following this review. There are procedures in place for recording seizures. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The Organisation invites an open dialogue from relatives and outside professionals who may have concerns about the care provided in the home. However, arrangements for protecting service users are not satisfactory, putting them at risk of harm and abuse. EVIDENCE: The Commission has received a complaint from relatives of one of the service users at Edward House. The relatives were given the information about this process by the Organisation. The complainants were concerned about the frequency of physical attacks on their relative and the ability of staff to manage aggressive behaviours. A particular concern was raised about a specific incident when the service user acquired a number of injuries. The family also queried the provision of one to one support and compatibility of the residents in the home. As part of the investigation the placing authority were asked to carry out urgent placement reviews for the relevant service users. The Commission has investigated the specific incident and other aspects of the complaint. A summary of the findings is as follows: 1. There has been a number of physical attacks in the past few months aimed primarily at one service user. Examination of the incident records provided evidence that some attacks could have been prevented if the staff levels and appropriate supervision were maintained. There was evidence that the person needed to be supervised at all times. However, this has not always been possible due to staff shortages. This part of the complaint has been substantiated. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 14 2. The specific incident was investigated and no assault could be evidenced. There was evidence to suggest that the person suffered injuries as a result of an epileptic fit. This part of the complaint is not substantiated. 3. Concerns about the ability of staff to manage aggressive behaviours. Discussions with care staff and the management of the home provided evidence that staff receive training and guidance in dealing with aggression. Staff are instructed to use diversion and de-escalation. They are taught to use Studio III restraint methods as a last resort. Incident records were examined and showed that on the whole staff do take the necessary preventative actions wherever possible. This part of the complaint is partially substantiated, on the basis that staff may not always have had the resources to prevent the physical attacks. Overall conclusions reached by the Commission for Social Care Inspection following the investigation into the above complaint are that there is sufficient evidence to suggest that the home has failed to fully meet its’ duty of care to the service users. A number of requirements are made under the staffing and the management of the home standards to ensure that such grave deficiencies in the service provision are not allowed to develop again. Concerns about staffing levels have been identified at previous inspections. The home must evidence that sufficient staff are available consistently and failure to comply with these requirements may lead to the Commission taking enforcement action against the Registered Provider. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The standards in this section were not inspected on this occasion. EVIDENCE: The home provides a spacious purpose build accommodation for the service users. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Service users health and welfare are being seriously compromised by shortfalls in staff cover. EVIDENCE: During the investigation a number of shortfalls in provision of correct staffing levels have been identified by the inspectors as follows. Night cover: There should be a waking night staff and a sleeping in staff member during the night. This has not always been adhered to. Staff said that when no waking staff are present, two staff are asked to sleep in. This has become a regular occurrence since October 2004. Staff also said that the requirement for the waking staff member was to provide close observation and ongoing supervision for service users who have epilepsy and voiced concerns about not having the waking staff member on duty. The current and previous managers of Edward House at the time of the investigation both felt that lack of waking night cover compromises the safety and well being of the service users and that they had voiced their concerns to the Group Care Director. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 17 Day cover: The inspectors were informed by the manager of the home that there are five service users in Edward House who require one to one support during the day (at all times). For one person this was to be reviewed with the likelihood that one to one would no longer be required. This service user has been living in the home since January 2005. A sample of daily shift forms were examined and provided evidence that for service users who require and are funded for one to one, this has not always been available. On some occasions one staff member would be expected to provide one to one support to two service users. Staff confirmed that staff shortages have been a regular occurrence and the required staffing ratios have not always been maintained. Rotas for May 05, June 05 and July 05 were examined. A significant number of shifts were covered by just three staff, the majority of shifts were covered by four staff and some shifts showed just two staff working. These numbers are well below the agreed minimum level. Staff commented that there are suppose to be at least 6 staff on shift (this applies to the home running with eight service users). There was evidence that staff shortages may have compromised the safety and wellbeing of the service users. For example there were a number of violent incidents on 2nd July 2005 when only three staff were on duty. A serious incident took place on 5thh July 2005, when just three staff were on duty. It was also found that the relevant placing authorities have not been kept informed of the shortfalls in staffing for the respective residents even though there may be contractual agreements in place to provide certain staffing and supervision. The inspectors tried to determine what systems were in place to ensure that there are sufficient staff in the home. At the time of the investigation there were no arrangements for accessing agency staff to support the home. The responsibility for accessing staff cover at short notice was with the team leader running the shift, or in the absence of the team leader, the next senior person on duty. Staff could be called from a sister home on site or asked to do overtime. Where these requests were not successful, shifts would run at an unsafe level. An immediate requirement was issued to the home to ensure that sufficient staff are present in the home at all times. The Organisation was asked to supply a weekly staffing rota (of shifts actually worked) so that the Commission can monitor the staffing levels. A meeting has been arranged with the Providers and home management in September to discuss recent events, findings of the investigation and future improvement strategy. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 43 Poor monitoring and lack of robust quality assurance systems have significantly compromised the service provided in the home. EVIDENCE: Selwyn Care has grown significantly as an Organisation during the last 12 months. Two new homes have been opened in another county and this has meant that the efforts of the Directors and Responsible Individuals have been directed away from the provision in Gloucester for part of the time. The Commission has been in liaison with the Selwyn Care during this period of growth and has made requirements to improve management arrangements for the homes in Gloucester. This has now been achieved through management restructuring within Selwyn Care and a new manager was appointed and registered for Edward House in May / June 2005. The Commission has met with the Registered providers and the management of the home in June 2005 to discuss a number of concerns about the service. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 19 During this meeting assurances were given to the Commission of the intent to improve and to meet the National Minimum Standards and Care Home Regulations. During the investigation into the complaint which prompted this inspection, the Commission has found a significant number of shortcomings. This report identifies critical areas where the Organisation is failing to meet the National Minimum Standards. It was also concerning to find that shortfalls in staffing for example, were known for a considerable amount of time by the management of the home but not addressed in a satisfactory manner. It is possible that there have been miscommunications between the home management and the Care Director and lack of clarity as to the legal responsibilities of providing agreed staffing ratios. This lack of corrective action could be attributed to poor monitoring and poor quality assurance systems employed by the company. For example, although Regulation 26 visits are now taking place, the quality of the information provided in the resulting reports demonstrates lack of understanding of the process and provides little useful information about the quality of life for service users. As a tool for self-regulation, this is not being applied effectively or critically to identify the necessary improvements. These must be improved to ensure there are clear lines of responsibility for monitoring each aspect of the service with robust procedures for identifying and responding to shortfalls in provision. Another meeting has been arranged with the Registered Persons to discuss improvement strategies. Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 2 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 1 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Edward House Score 2 x x x Standard No 37 38 39 40 41 42 43 Score 2 x 1 x x x 2 D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 15 (2) Requirement Timescale for action 31st December 2005 31st December 2005 2. 6 3. 18 4. 5. 6. 23 23 23 Care plans must be reviewed regularly and updated with the necessary changes. Timescale of 30th June 2005 not met 14 (2), 15 Review current care planning (1) and systems and develop service 12 user plans about all aspects of (1)(2)(3)( their lives. Information on 4),and 17. personal files must be dated and signed. Any undated information must be reviewed to establish whether it is still applicable and revised as necessary in consultation with the service users and their representatives. Timescale of 30th June 2005 not meet. 12(1)(2)( Care plans must provide detailed 4) and 15 guidance on how service users (1) want to be supported with personal and other aspects of their care in the way which meets their needs and protects their privacy and dignity. 12(1) and The home must ensure that 13 (3)(6)( service users are not subjected to physical assaults. 13(6) Where service users require one to one supervision this must be observed at all times 13(6) Establish a formal process by D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc 31st December 2005 14th July 2005 14th July 2005 31st Page 22 Edward House Version 1.40 7. 33 18(1) 8. 33 12(1) and 18 (1) 9. 10. 33 33 18(1) 18 (1) and 37 11. 39 24 12. 39 26 which the placing athourities are notified of any breaches in agreed staffing arrangements. The home must ensure that minimum agreed levels of staff are maintained at all times. This is currently a minimum of six staff during the day (five providing one to one support and at least one additional staff member for three remaining service users), the arangements for the night duty are to be two staff, with at least one waking night. There must be a regular review of the staffing complement in the home to ensure that this is appropriate to the needs of the service users as well as to the number of service users in the home. Evidence of such reviews must be available for inspection. There must be clear protocols in place for accessing additional staff to cover absense. The Commission must be informed of any shortfalls in agreed staffing numbers at the earliest possible opportunity. Reasons for shortages and action taken to rectify the situation must be recoded and made available for inspection on request. A robust and effective system for monitoring the quality of care provided in the home must be developed Visits carried out under Regulation 26 must provide evidence of critical appraisal of each aspect of the service, identify areas for improvement and follow up, clearly stating who is responsible for taking corrective action. There must be evidence of feedback being October 2005 14/07/05 31st October 2005 31st October 2005 30th September 2005 31st December 2005 30th September 2005 Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 23 sought from staff and service users / their representatives, as appropriate in order to gage a better overview as to the standard of care provided. 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. Refer to Standard Good Practice Recommendations Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 24 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Edward House D51_D03_S30393_EdwardHouse_V241364_140705_Stage4_U.doc Version 1.40 Page 25 - 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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