Inspection on 07/09/06 for Elm Tree House

This inspection was carried out on 7th September 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elm Tree House 31/07/07

Elm Tree House 25/10/05

Elm Tree House 27/04/05

Elm Tree House 19/10/04

Elm Tree House 13/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Elm Tree House 4 Kilkenny Avenue Taunton Somerset TA2 7PJ Lead Inspector John Hurley Key Unannounced Inspection 7 September 2006 09:30 th Elm Tree House DS0000016047.V304578.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 Elm Tree House DS0000016047.V304578.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. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Tree House Address 4 Kilkenny Avenue Taunton Somerset TA2 7PJ 01823 322408 01823 322408 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) Mr Philip Mark Coggins Mrs Elizabeth Anne Coggins Mrs Elizabeth Anne Coggins Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named resident over 65 years of age Date of last inspection 25th October 2005 Brief Description of the Service: Elm Tree House is registered with the Commission for Social Care Inspection to provide care to up to 9 people under the age of 65 who have mental health difficulties. The home itself is a large semi detached Victorian house which provides accommodation on three floors. There are seven single bedrooms and one double. One single bedroom is on the ground floor and all others can only be accessed by stairs and therefore people living at the home need to be physically able. All communal areas are located on the ground floor. The home is owned by Philip and Elizabeth Coggins, Elizabeth Coggins is the registered manager. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a 5 hour period. The inspection was carried out on an unannounced basis. There were 8 service users living at the home at the time of this inspection. The inspector was able to speak with service users and staff in private and in communal areas. The inspector also spoke with a visiting care manager and NVQ trainer. Both indicated that they had no concerns over the care provided, the care manager confirmed that their client was happy at the home. All records requested were made available and the inspector was given unrestricted access to all areas of the home with the permission of the service user. Prior to the inspection comment cards were sent to service users, their relatives where appropriate and other health care professionals. No adverse comments were received. The registered manager was available throughout the inspection. What the service does well: What has improved since the last inspection? There has been some improvements made with regards to the interior decoration of the home along with some of the soft furnishings. The registered manager has explored ways in which the service users can be more involved in the running of the home by the use of service user meetings. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 6 Since the last inspection the home has continued to make progress in addressing the shortfalls noted with regards to care plans. The registered manager demonstrated that they had been proactive in making the necessary changes by consulting with other professions. Staff meeting notes also demonstrated that the staff were being briefed about their roles and training needs. 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. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 The registered manager must ensure that an initial assessment of need is carried out and recorded prior to prospective service users taking up residence. Quality in this outcome area is judged to be adequate. This judgement has been made by evaluating the available evidence and conducting an unannounced visit to this service. EVIDENCE: The registered manager informed the inspector that one new service user had taken up residency since the last inspection. The information provided prior to admission by way of a service user guide and statement of purpose continues to meet the National Minimum Standards relating to standard one. The inspector sampled this service users file but could not find the initial assessment of need as carried out by the registered manager. The registered manager confirmed that this had not been carried out explaining in mitigation that the individual had transferred from another service provider and they had considered that the original assessment from that service was valid. The file did contain evidence that the service user had visited the home prior to taking up residency and that their suitability to live with the rest of the group who reside at the home had been evaluated. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The service users individual plans cover all of the areas required to meet the National Minimum Standards but would benefit from being clearly indexed for easy reference. Risk assessments acknowledge risks but do not state how to minimise risk. Quality in this outcome area is judged to be adequate. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: The inspector sampled a number of the care plans. The plans that were viewed contained information relating to the individuals likes and dislikes, physical health and well-being, abilities relating to personal care, communication, emotional wellbeing, relationships/lifestyle and financial considerations. The inspector also sampled some of the information relating to the mental health difficulties experienced by each service user and behavioural issues. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 10 A general review had been carried out on all of those that were sampled. This review formed a statement as to the recent history of the individual and a number of the individual’s needs and aspirations. Service users spoken to confirmed that they continued to make decisions about their day-to-day lives. They informed the inspector that they decide when they get up, when they go to bed and how they spend their day. The staff confirmed that they give options to individuals to enable them to control their lives, observations by the inspector confirmed this. Many of the service users living at the home access the local community unaccompanied. Although there are a number of risk assessments in place some risks are either not acknowledged or statements made as to how to minimise the risk recorded. The registered manager acknowledged this observation and agreed to review all assessments that had been made to ensure the standard continues to be fully met. Risks are acknowledged and recorded in the service user individual files. The selection that the inspector sampled whist describing situations that poised risk to the individual did not then state what should be done to reduce that risk. For example it may be stated that an individual may display challenging behaviour but then did not give clear instruction as to how to avoid the situation or some of the proven strategies in dealing with the behaviour should it become necessary. At previous inspections it has been noted that the service users files whilst containing all of the required information are hard to use due to the repetition of information, the amount of historical information contained on file and that information may be in stored in different areas. At the last inspection it was reported that the file system had improved. Whilst the inspector acknowledges this point they consider that it would be helpful if further improvements were made to the service users files to provide better navigation through the information held. The home has produced a policy statement that clearly sets out their position with regards to data protection and confidentiality. Service users are aware that they can access their files if they wish. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 The outcome for the service users is good in so much as their individual lifestyles are maintained at a good standard. Opportunities for individuals to participate in ordinary life activities are available for those who wish to take them up. Quality in this outcome area is judged to be good. This judgement has been made by evaluating the available evidence and conducting an unannounced visit to this service. EVIDENCE: All service users are able to lock their personal rooms and receive their mail unopened. People are free to spend time in their private rooms or in communal areas. Service users stated that their privacy is respected. Service users spoken to were happy with the level of activity in the home. Some service users have comprehensive activity programmes that are supported by staff on a one to one basis. These activities include shopping, cricket, walking and developing household skills. The staff the inspector spoke Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 12 with explained that the majority of service users continue to enjoy one to one activities but do not always enjoy structured group activities. Contact with family, friends and advocates are promoted which assists in the development of important relationships external to the home. Staff were observed as being respectful of the individuals right to make choices and only offer a differing perspective on issues raised in order to allow the individual to make a choice from a more informed perspective. Through discussion with the service users and by direct observation the inspector established that individuals rights to maintain and develop relationships are robustly upheld. As the residents are ambulant they can access the local town centre and surrounding attractions with ease. Service users confirmed that staff help them in the preparation of the daily meals. The menus reflect a degree of healthy eating options and a wideranging menu. Service user confirmed that they had been consulted with in relation to the setting of the menus. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Staff support service users in a consistent and professional manner. The recording of medication received for administration and rationales for medication administered via the PRN route need to be more robust. Quality in this outcome area is judged to be adequate. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: The health care needs of the service users are monitored. Care plans describe the support people need with personal and healthcare and how this would be offered. The staff team were able to explain the preference of the service users and were thus aware of their needs. Some service users are vocal and able to voice their wishes. Healthcare records provided evidence that individuals have access to other healthcare professionals and were supported when attending appointments. Service user records are kept on a weekly basis; a staff handover book carries forward important issues relating to the home the service is running and any changing needs that may have emerged on shift. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 14 The inspector viewed the storage arrangements for medication and found them to be suitable. An updated medication reference book is seen to be available. The inspector sampled the administration records and found that a number of handwritten entries were not double signed as is acknowledged as good practice. There are no service users who self medicate at present. The files sampled did not evidence that the individuals have signed to indicate that they do not wish to have the responsibility of looking after their medication. Although staff can give medication on a PRN basis there is no recorded rationale to guide and inform staff as to the safe and appropriate use of medication administered in this way. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The service views are listened to and acted upon. Their rights to self autonomy are upheld. Quality in this outcome area is judged to be good. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: A complaints procedure has been established by the home which specifies that all complaints would be responded to within 28 days, provides details of how to contact the Commission for Social Care Inspection and this could be at any stage, should the complainant wish to do so. The registered manager informed the inspector that no complaints had been made since the last inspection. Through sampling the service users files it is evident that the staff and service users have good professional relationships. The records indicate that on many occasions the staff have acted as advocates for the service user where appropriate. There is further evidence that staff have assisted individuals to source other outside bodies to act as advocates such as citizens’ advice. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,30 The environment is both clean comfortable and hygienic. A programme of refurbishment is underway to update all areas, which once complete will greatly enhance the homes ambience. The laundry room requires finishing so that the wall and floor coverings can easily be cleaned. Quality in this outcome area is judged to be adequate. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: The inspector was shown around the premises and some of the resident’s rooms with their permission. They found that the home had maintained many of its domestic features whilst appearing to meet the relevant guidelines. The inspector noted that the bedrooms appear to be suitably furnished with a range of fittings. The bedrooms have been personalised and appear to reflect the individuals interests and leisure activities. Service users expressed satisfaction with the facilities provided. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 17 The registered manager informed the inspector that a rolling programme of redecoration and refit is underway. The main communal lounge has been redecorated and new furniture provided as has some of the service users rooms, this represents progress. The main entrance hall does require redecoration, which is planned for the near future. The registered manager explained the difficulties in carrying out this work as the service users do go in and out of this entrance through out the day. Therefore this work is being carried out through the evenings. The home was found to be clean and hygienic with no malodours. The inspector noted that the laundry area required finishing following its recent refit. The registered manager acknowledged that the walls and flooring do not currently have an impermeable finish and agreed to make this a priority. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 The registered manager continues to ensure that training and individual learning guides and informs care practice. Recruitment procedures need to reflect current good practice. Quality in this outcome area is judged to be adequate. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: Staff confirmed to the inspector that vacant posts are advertised in the local job centre. Some staff have also been introduced to the service by word of mouth. The inspector looked at the application forms for the most recent staff. They found that in general the statutory requirements were being met. The inspector noted two points, one being that where a telephone reference had been given this was not followed up with a formal written request and that the application form only requested the employment history for the last ten years and not the required full employment history. The registered manager acknowledged these points and agreed to amend both practice and documentation. The home has a comprehensive induction programme covering all statutory requirements. Staff have a range of qualifications and experience of working in Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 19 a social care setting. The staff records set out their training needs. These range from industry standards such as health and safety and manual handling through to more targeted training such as dealing with aggressive behaviour and mental health issues. The staff impressed as knowledgeable with regards to the service users needs and how these should be met. The inspector spoke with staff that confirmed that they had both formal and informal supervision. They further confirmed that they felt well supported by the homes management. The registered manager informed the inspector that the night care staff attend regular training and that they supervise them on an ongoing basis. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42,43 The registered manager must ensure that all of the services recording systems are robust. Quality in this outcome area is judged to be adequate. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 21 The staff the inspector spoke with said that the manager was approachable and fair, often working with them and the service users. The records observed evidence that staff are being supervised on a formal basis. Through general discussions with the staff and service users the inspector considers that many efforts are made by management to replicate the positive aspects of communal living. This is evidenced in many ways such as house meetings, which appear to be managed to ensure that those who do not come forward to share their views are consulted. On a practical level there appeared to be good working relationships and a shared willingness to respond flexibly to meeting the needs of the service users. The registered manager informed the inspector that the home only holds money on behalf of one service user. The inspector checked the record relating to the deposit and withdraws of cash by this individual. They found that there was a discrepancy in the records that showed that the service user should have less than was available. The inspector made an immediate requirement requiring the registered manager to carry out an investigation and to submit a written report to the commission within five working days. The records the inspector sampled evidenced that staff members are inducted in health and safety and there was ongoing training in this area. Staff members are also trained in first aid and food hygiene. Substances hazardous to health were locked away when not in use. Risk assessments are in place but do not clearly demonstrate the action that need to be taken to minimise risk. The service has recently carried out a quality assurance programme that sought the views of all the interested parties. It would be helpful if the outcome of the quality assurance audit is circulated to all interested parties and where appropriate some of the findings could be incorporated into the homes development plan. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 2 Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 24 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 YA41 Regulation 17 Requirement The registered person must ensure that records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. (i.e. monitoring system with regards to the service users money and that all monies held can be accounted for) The registered manager must ensure that a full initial assessment of need is carried out prior to admission and a statement recorded that the service can meet the assessed need. The registered person must ensure all environmental and personal risk assessments are reviewed a minimum of once every twelve months or earlier if the risk has changed. The risk assessments must have a written statement, which states how the risks will be reduced. The registered person must ensure that the laundry room is finisheed so that the wall and floor coverings can easily be cleaned. Timescale for action 07/09/06 2 YA2 14 Scd 3(1)(a) 01/10/06 3 YA9 13(4) 01/10/06 4 YA30 16(2)(j) 21/11/06 5 YA35 19 5 YA20 13(2) Elm Tree House The registered person must 07/09/06 ensure that the correct recruitment procedure is followed at all times. 07/09/06 The registered manager must ensure that all medicines administered via the PRN route DS0000016047.V304578.R01.S.doc Version 5.2 Page 25 are done so in line with the homes policies and procedures and a rationale for giving medication via this route RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA20 YA41 Good Practice Recommendations All hand transcribed entries on Medication Administration Records should be signed and witnessed. The registered manager should consider reorganising the service users files so that all relevant and current information is contained in one colleted file. Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Elm Tree House DS0000016047.V304578.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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