Inspection on 30/08/07 for Fairfield Residential Care Home

This inspection was carried out on 30th August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fairfield Residential Care Home 09/02/09

Fairfield Residential Care Home 21/02/08

Fairfield Residential Care Home 18/12/06

Fairfield Residential Care Home 28/07/06

Fairfield Residential Care Home 15/11/05

Fairfield Residential Care Home 09/06/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Fairfield Residential Care Home 27 Old Warwick Road Olton Solihull West Midlands B92 7JQ Lead Inspector Sandra Wade Key Unannounced Inspection 08:00 30th August 2007 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 Fairfield Residential Care Home DS0000063831.V342457.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. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairfield Residential Care Home Address 27 Old Warwick Road Olton Solihull West Midlands B92 7JQ 0121 706 2909 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) Santok Mayariya Mr Dilip Mayariya ** Post Vacant *** Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The current registered double room is to remain as a permanent single room for as long as the existing service user chooses to remain in that room. During this period the effective capacity of the Home will be seventeen service users. Service users in the six upstairs bedrooms located in the original part of the house may continue to live there as long as their needs can be met. Until such time as the difficulty of split level floors is solved to the satisfaction of CSCI all future service users residing in this area must be ambulant. In the event of the Registered Manager leaving, a fulltime care practice consultant must be retained until such time as a replacement manager is actually registered. This arrangement to exist for a period of two years and applies to any reoccurrence of a registered manager leaving within that period. The current minimum staffing levels must be maintained until such time as agreement is reached with CSCI on the basis of service user needs, environmental factors and staff competency that these may be changed. 18 December 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Fairfield is a large extended detached house providing care for up to 18 older service users. The home is located in the Olton area of Solihull and is readily accessible to amenities such as shops, places of worship and public transport. The home comprises of 16 single bedrooms, thirteen of which have en-suite facilities and there is one double bedroom. Accommodation is provided on two floors and on the upper floor there are rooms which can only be accessed via a few stairs which means they would only be suitable for people who are fully mobile. There are two lounges separated by glass doors, which when opened creates one large lounge area, there is a television based in both areas. A dining room and conservatory are also provided. There is a shaft lift to the upper floor. There are attractive gardens to the rear of the property which are accessed via a ramp from the conservatory enabling access for service users in wheelchairs or with a disability. Handrails are also provided. Limited parking facilities are available at the front of the building, however onroad parking is readily available outside the home. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 5 The fee payable range from £355 to £360.00 per week. Additional charges are made for chiropody (£10.00) and hairdressing (from £6.00). Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This unannounced inspection took place from 8.40am to 9pm. Before the inspection the manager of the home was asked to complete an Annual Quality Assurance Assessment (AQAA) detailing information about the services, care and management of the home. Upon the receipt of this a number of questionnaires were sent out to service users and their families to ask their views about the home. Eight service user questionnaires were returned and three relative comment cards. Information contained within these plus the AQAA are detailed within this report where appropriate. Two people who were staying at the home were ‘case tracked’. This involves establishing an individual’s experience of staying at the home, meeting or observing them, discussing their care with staff and relatives (where possible), looking at their care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. Records examined during this inspection, in addition to care records, included staff training records, the Service User Guide, staff duty rotas, social activity records, kitchen records, accident records, financial records, health and safety records and medication records. A tour of the home was undertaken and the inspector spent time speaking with residents, visitors and staff within the home. What the service does well: The providers spend a lot of time in the home to help with supporting residents as well as the management of the home. One service user said “the owners are lovely people” The home always writes to service users following their assessment to confirm the home can meet their needs. Families are made welcome to the home; one relative stated, “Staff are usually friendly and caring. The home is always clean and tidy and residents always look cared for”. Another relative stated, “The home is welcoming and never has a bad smell. Residents are always clean and well dressed”. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 7 The majority of staff have completed training to achieve the National Vocational Qualification (NVQ) II in Care to help them provide more effective care to the residents. Training in the home is being addressed on an ongoing basis to ensure staff are competent in their roles in supporting residents. What has improved since the last inspection? What they could do better: Care plans need to clearly show all care needs of residents and the staff actions required for these to be met. Daily records also need to show the staff actions carried out so that it is clear the care needs of residents are being met. The personal care of residents needs to be fully demonstrated, this includes ensuring residents are assisted to the toilet when they need support. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 8 Care plan evaluations need to consistently identify changes in care needs and care records need to be updated accordingly to ensure staff know of any additional actions required to meet the care needs of the residents. Prompt actions are needed to address safe medication management in the home. Medications must be given as prescribed and sufficient records kept to confirm residents have received this as appropriate. Where risks associated with a residents care are identified such as falls, nutrition, pressure areas and the use of bedrails. Risk assessments need to clearly show what the risks are and how these risks are to be managed to ensure the resident can be cared for safely. Where residents have lost a significant amount of weight, records must demonstrate that sufficient actions have been taken to address this to maintain the health and wellbeing of the resident. The carpets in the home need a thorough clean to ensure residents are cared for in a clean and hygienic environment. Stocks of food in the home need to be increased so there is a sufficient variation of food including snacks that staff can access for residents. Although progress has been made in obtaining new laundry equipment, prompt action is now required to ensure there is a fully functioning laundry service available in the home for residents. Staffing arrangements in the home are in need of review to ensure residents receive an effective service and carers are available when required to meet their care needs. Prompt action is required to ensure the home has a registered manager. application should be made for this to be pursued as soon as possible. An Suitable actions need to be taken to ensure any bedroom doors, which need to be kept open, have suitable devices fitted linked to the fire alarm. This allows the doors to close in the event of a fire to protect the residents. Some attention in needed in regard to health and safety, this includes sufficient action to ensure fridges and freezers operate within the recommended guideline temperatures for food to be stored safely. Water temperatures also need attention to ensure the hot water is sufficiently warm enough for residents to wash in. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 9 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. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 10 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 Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 11 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): Standards 1 and 3 were assessed. Standard 6 is not applicable. Quality in this outcome area is adequate. Prospective service users receive some information about the home to allow them to make a decision about whether to stay at the home. Service users are assessed prior to their admission but it not clear this sufficiently comprehensive to identify all service user needs to ensure they can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Service User Guide was viewed. This did not contain a copy of the summary inspection report to enable prospective service users to have all the required information to make a decision whether to stay at the home. Since the last inspection, pre-assessment documentation has been devised which is in the format of a pre-printed document where staff record a persons needs as “good” or “poor” and there is a small area to record any additional needs not listed. This style of assessment prevents a clear picture of the service users individual needs being established so that it is clear where the Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 12 support of staff is needed. If this information is not clear there is a possibility specific needs will be overlooked and will not form part of the care plans where staff actions to meet a service user needs should be clearly documented. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 13 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): Standards 7,8,9 and 10 assessed. Quality in this outcome area is poor. It is not clear that the care needs of residents are being met consistently to support their health and wellbeing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the manager has taken steps to try and improve the care planning system within the home. Care plans were viewed for the two people who were case tracked as part of this inspection. Other records for residents were viewed to follow up specific issues as appropriate. It was evident that some of the records forming part of the care plans were not needed as they made reference to needs where no support was required. For example a care plan had been devised for communication and breathing when it was identified the resident had no problems in these areas. Care plans were lengthy and took a long time to read and it was difficult to easily establish a person’s current needs without reading all of the Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 14 documentation on the files. Care plans need to focus on specific care needs of each person and detail the staff support required to meet these needs. One person had diabetes – there was no specific care plan for the management of this which detailed the persons acceptable blood sugar levels, how often they should be taken, what staff should do if the blood sugar levels were too high or too low, what symptoms they should look out for and how staff should support the service user to inject their own insulin. There were references in the eating and drinking care plan in relation to diabetes and there was a sheet on the care plan file detailing the times and readings of the blood sugar levels. It was evident that the district nurse had been consulted on the monitoring of the blood sugar levels including how often this should be done. On viewing the records it was not evident staff were doing this as often as they should on Fridays. Another residents file was viewed and this showed they had lost a significant amount of weight over a short period of time. Care plan evaluations stated “no change” in regard to the persons needs and therefore did not identify any actions to address this weight loss. No nutritional risk assessment had been devised and no food or fluid intake charts were in use. Staff reported that the resident ate well although the resident did need some support and assistance at times. The resident said that they liked their food. The resident did look frail but did not look in ill health. The resident said they could not move their limbs very well down one side and had to ask staff to support them with this. This information was not reflected in the mobility care plan. The manager agreed to undertake a nutritional risk assessment and to review the weights of all residents to identify any who may need additional nutritional intake to maintain their health. One person in the home had developed a pressure area after their mobility had deteriorated. It was not evident the home had completed an appropriate pressure sore risk assessment to manage the risk of pressure areas developing and to identify actions to prevent these. Professional advice had been sought from the district nurse when staff identified this pressure area and actions had been detailed in the care plan how staff should manage this. It was evident from the care plan evaluations that the sore had healed and the district nurse was continuing to monitor the service user. A risk assessment had been completed for the use of bedrails but the risks of using these were not fully acknowledged with sufficient actions to prevent injuries to the service user. A risk assessment for falls had not been fully completed because it had been photocopied and half of the scoring section had been chopped off so staff had not completed it. This resulted in the risk assessment for the resident being Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 15 scored as low. It was identified that this resident had fallen in the home and was also prone to dizzy spells and stumbling. The care plan for mobility did not identify any actions to prevent further falls. Personal care plans were in place but these were not always specific about exactly what the staff were required to do. It was not clear how often a resident was to have a bath, shower or strip wash. The care plan stated “may now require assistance of two carers at times”. A care plan for continence said that supervision was required but did not say how often and whether this was just prompting or assistance of staff. A care plan for oral health was viewed and this identified a resident had lost a tooth and the dentist was to be called. This was dated February 2007 but records indicated the resident did not see the dentist until the end of June 2007. This would suggest that specialist support is not being effectively accessed by the home to maintain the health and wellbeing of the resident. Daily records were being completed by staff for each resident but these were not linked to individual care needs so that it was clear residents were receiving the support they needed from staff. Staff were also not using the care plans when writing the daily reports to ensure they were confirming that actions detailed in care plans were being carried out. Nighttime reports for all residents were on one sheet as opposed to being written into each individual care plan to confirm specific care needs were being met and to meet with the protection of personal information as required by the Data Protection Act. Service user comment cards received by us showed that three service users felt they “always” received the care and support they needed and five felt they “usually” did. Two service users commented that they had to wait too long to be assisted to the toilet. During the inspection a service user spoken to also confirmed this. There are systems in place to support the privacy and dignity of residents, which include a curtain around the beds in the double room, and two sets of furniture, detailing on care plans how residents like to be addressed and for some, how they like their daily routine to be managed. It was observed that some staff do not always talk to residents when they are carrying out their duties. For example one resident was assisted to move from the dining room into the lounge with no discussion so the resident would not have necessarily known where the carer was going to take them. A review of medications was carried out. Since the last inspection a controlled drugs register has been obtained and is now being completed. It was however evident that this had not been completed correctly. Staff had not Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 16 appropriately counted down the number of patches used for one resident and has crossed out one of the totals so it was not clear how they had arrived at the figure indicating the number of patches that were available. Staff advised that some had been returned and this was why the totals in the book appeared to look incorrect. The returns book showed that two patches had been returned, staff felt that this meant the total available was therefore correct. The Medication Administration Records (MAR) were checked against the Controlled Drugs Register to try and confirm the number of patches given and number remaining. It was evident that the dates on the MAR did not consistently correspond with the dates in the controlled drugs register. Concern was expressed that the prescribing instructions for a patch to be given every four days did not appear to be adhered to. The MAR chart indicated that in some instances a patch had been given on the second day and fifth day. The manager agreed to investigate the discrepancies as indicated above and write to us to confirm the number of patches available are correct. The manager will also need to take appropriate actions to ensure staff are fully competent in administering medications safely. One person was noted to be self-medicating. It was noted that this resident was taking numerous medications but there was no formal assessment carried out by staff to confirm the resident was capable of doing this safely and independently. It was established that the resident was unable to independently push tablets out of the packets and relied on staff to do this for them. It was not evident that the home had a ‘self medication’ policy to ensure residents could be supported to manage their medications safely. Paracetamol had been prescribed for one resident “one or two to be given” and staff were writing on the MAR whether one or two had been given within the boxes. This resulted in the MAR being difficult to read. The home should devise a protocol to agree how this can be managed effectively so that the MAR remains legible. Folic acid in use in the home had passed it ‘use by’ date and had been used for three days beyond the date it should have been. Once this was highlighted to the manager, it was removed. The MAR indicated that a resident had been prescribed 500ml of Ferrous Fumorate Syrup but it was not clear this amount had been received or that this amount was available. Two medications on the MAR had no signatures against them to confirm they had been given. The manager said they had been stopped but this was not Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 17 clearly indicated on the MAR to make sure staff giving out medication knew this. Co-codamol tablets for one person had the nighttime dosages crossed out and an entry made that they could be given four times a day. It was established that actually the person could have them four times a day and at night. A gap was noted on one MAR for Senna tablets so it was not clear if the resident had received them. A gap was also noted for eye drops and lactulose. The lactulose stated to be given twice a day but it was only being offered once a day at 9am. For one resident, Omeprazole had been prescribed, four had been signed for on the MAR but only three had been given suggesting staff had signed the records when one tablet had not been given. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 18 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): Standards 12,13,14 and 15 were assessed. Quality in this outcome area is adequate. Service users have access to some activities to satisfy their social interests but have limited choices in regard to the food provided and do not always receive an appealing diet to maintain their health and wellbeing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident care plans showed that each residents wishes in regard to their daily routine had been documented such as times they like to get up, times they would like breakfast and what drinks they would like and when they want to go to bed. Residents also are asked to complete and sign a “Charter of Rights” form; this lists questions such as “Is your dignity respected?”; “Can you lock your own room?” and “Do you know about the complaints procedure?” A residents file viewed showed that the resident had answered “yes” to all of these questions. The same resident had also completed a form to confirm whether they agreed to have a carer of the opposite gender provide care for them. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 19 Since the last inspection actions have been taken to implement activities within the home and to record activities undertaken with specific residents. It was evident from discussions with staff, residents and relatives that staff time available for activities varies. Both residents and relatives acknowledge in comment cards received by us that there could be more done to improve the provision of activities in the home. A comment card received from a resident stated in response to the question “are there activities arranged by the home you can take part in” “because of staff shortages although willing, there often too busy” A comment card from a relative stated, “lounge supervision is sometimes lacking and residents entertainment/occupation is rather haphazard”. A comment was also made there could be more activities provided to exercise the mind as opposed to physical exercises. During the inspection a member of staff did play a board game with a resident in the lounge and an outside entertainer came into the home to do physical exercises to music, which the residents seemed to enjoy. The manager advised that a service user meeting had been held where social activities were discussed. It was acknowledged that residents felt these could be improved and suggestions had been put forward which the manager was in the process of addressing. The manager said that birthdays are celebrated with a birthday tea, hat and cake. She also said that there was a good choice of old time music and old films for residents to enjoy. Staff said that they try to do at least one activity a day and sometimes there can be two if they are not too busy. They had recently had an outing to a “50s” lunch which had proved very successful. Pictures were available in the home of residents enjoying themselves at the lunch. It was noted that at the service user meeting, the mealtimes were discussed and residents said they wanted breakfast earlier. The manager confirmed that the times staff worked in the kitchen had been changed so that residents could have breakfast from 7am. A certificate in the home showed that they had been awarded the “Safer Food Better Business Award” in March 2007. The dining areas had tables with patterned plastic coated tablecloths, serviettes and cutlery, it was noted that one of the tablecloths was ripped. At breakfast, residents were observed to have cereals and toast. It was not evident that a cooked breakfast is offered or provided. The manager said that Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 20 they used to provide a cooked breakfast but they had not provided these recently. At lunchtime residents were all given lamb casserole with potatoes and mixed vegetables followed by rice pudding. There did not appear to be a second choice offered or made available. Staff were observed to pour the same squash into beakers on each table, no choice of other drinks was offered. The meal on the day of inspection was not the meal on the menu, the manager said that staff had forgot to get the meat out of the freezer earlier in the week and this had meant the menus had changed around. On viewing the records of meals provided over a period of time it was evident that only one main meal was being provided at lunchtime, it was not evident any alternatives had been offered or cooked. It was not evident that the menus in place were always being followed. Some residents in the home were identified to be diabetic; staff said they used alternative sugar products when preparing puddings for them. It was not evident from records in place that the diabetic residents were receiving anything different from the other residents to ensure their blood sugar levels were maintained appropriately. It was identified during the inspection that one diabetic person had fluctuating blood sugar levels. Those residents who experienced difficulty in eating had been provided with adapted cutlery and plate guards to help support them to eat independently. Staff finished serving all residents before they assisted those residents who needed support to eat. Some residents just needed prompting and others needed assistance to eat. Staff assisting did not sit with the residents throughout their meals to give support; they were up and down from their chairs or standing to give spoonfuls of food in between doing other things in the dining areas. It is clear that some of the resident’s food would have been cold by the time the residents would have finished it. Residents who took extra time to eat their meals were left at the tables to finish their meals at their own pace. All residents were seen to eat their meals as if they were hungry, one person who finished their meal quickly was asked if they would like more and received a second plate of food. At teatime sandwiches were provided, these were all made with white sliced bread with the crusts cut off. A choice of fillings had been offered and these included, ham, cheese, corned beef, lemon curd and tuna. For pudding there was rice pudding or fruit cocktail. The manager confirmed that on some days there are hot choices offered at teatime but care staff are required to prepare the meals at teatime so these are usually snack meals. There were no Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 21 additional snacks such as salad, pork pie, pickles etc provided with the sandwiches. There is no snack meal offered in the evenings although the manager said these could be provided. On viewing the food store, there were minimal supplies of tinned, dried food or fresh food. There were also limited supplies of snack foods to prepare for residents. A member of staff said that the provider usually did some food shopping each day and this was observed during the inspection. The cupboards were viewed after the food items had been placed in them. A staff questionnaire carried out by the home showed that a member of staff had requested the home “provide enough basic food commodities in food cupboard”, another comment was made in regard to the “quantity of food” available. A resident comment card received by us stated, “meals are well prepared but inclined to be monotonous”. Another resident stated “no variety in the meals, no nice things to eat”. A relative commented “X likes breakfast, lunch X is not too keen with”. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 22 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): Standards 16 and 18 were assessed. Quality in this outcome area is good. Systems are in place to manage complaints and abuse to help maintain the safety and protection of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A clear complaints procedure is in place and this is detailed in the service user guide, which is provided to each resident upon their admission. Copies of these are also kept on service user care plan files. Comment cards received by us showed that some residents knew how to make a formal complaint and some did not. Since the last inspection the home has received two complaints, one from a member of staff and one from a relative about a missing item belonging to them. The manager had taken actions to address both of these complaints within suitable timescales. There have been no allegations of abuse since the last inspection. Concerns raised regarding staff attitude prior to the last inspection resulted in the manager agreeing to regular supervision for these staff. It was not evident that the frequency of the supervision agreed had been carried out. The manager said that she had not received any further concerns about these staff and had not identified any concerns herself from discussions with other staff and residents. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 23 Since the last inspection staff have commenced training on abuse and those staff spoken to were able to give examples of abuse and knew what their responsibilities were in terms of reporting this. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 24 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): Standards 19,21,25 and 26 were assessed. Quality in this outcome area is adequate. There are areas of the home, which require attention to allow residents to be cared for in a homely, safe, clean and pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are two communal lounges, which are split by glass doors, which are usually open to form a large lounge area. There is a conservatory off the lounge which overlooks the garden and which contains cane type furniture. Due to the low level of this furniture, this could be difficult for some residents to use. There is an attractive garden, which has a patio area with seating as well as a grassed area so that residents can sit out in the warmer weather. The garden can be accessed from the conservatory and there is a ramp to assist those with mobility difficulties or in wheelchairs. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 25 There is a dedicated dining room, which since the last inspection has been fitted with a new wood-panelling floor. Since the last inspection, the shower room has been painted and new items purchased including a shower curtain and blind to make it look more homely. This was bright and clean with the exception that the grouting on the washhand basin was black and in need of replacement. The shower room has a shower chair to support service users to have a shower but there was no toilet raiser on the toilet. The manager said it was planned to purchase some more. The bathroom is limited in space particularly if the hoist is needed; the manager reported on the Annual Quality Assurance Assessment that this is to be “re done”. One bedroom had been fitted with wood panelled flooring, which the manager said the service user agreed they wanted. The manager confirmed that other items addressed since the last inspection included: • The fitting of a fly screen in the kitchen to prevent flys etc getting into the kitchen when the windows are open, which could contaminate food. • Replacement of the kitchen work surface, which was burnt. • Replacement of the rusty shower chair to prevent cross infection. • Cleaning of the extractor over the cooker. • Repair of the lock on the toilet door to ensure service users dignity. • The removal of communal towels from communal bathroom and showers rooms to prevent cross infection. • The replacement of bins in the kitchen to the pedal bin type to prevent cross infection. During the tour of the home, carpets in several areas of the home were noted to be in need of a deep clean due to staining and marks. This included the lounges, conservatory and various bedrooms. It was not evident that there is a regular cleaning routine for carpets, cleaning staff only hoover the carpets. The domestic in the home advised that the handyman usually cleaned the carpets when needed. There were areas around the home, which appeared cluttered; this included the conservatory, which contained wheelchairs, a hoist, and a laundry drier with tea towels on it, laundry basket, basket of coat hangers and an iron. The manager said that the laundry items were being stored in the conservatory while the laundry was being refurbished due to a flood. Bedrooms seen had been personalised and on the whole were clean and suitably decorated. Some of the wallpaper borders in bedrooms were coming off the wall or were ripped. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 26 Many of the towels observed in the home were fraying on the edges and were greying in appearance suggesting they were need of replacement. Many of the taps did not have the “hot” or “cold” tab on the top so that it was clear to residents, which was which. A soap dish in one of the bedrooms was not clean and contained debris. Hot water tested in many of the rooms was not sufficiently warm enough for residents to wash in. On checking the temperature records for the home it was evident many of the hot taps were operating at temperatures in the 30’s as opposed to the 43.5°C recommended. The hot taps in the sluice and laundry areas were also operating below the recommended temperatures to kill bacteria and clean items appropriately. The manager agreed to address this. Radiators were not in use on the day of inspection as it was sufficiently warm without them. The manager will need to ensure when in use these are suitably risk assessed and suitable actions taken to safeguard residents from the risk of burns. There were no unpleasant odours in the communal areas of the home or in the majority of bedrooms. In one bedroom there was a strong unpleasant odour despite the windows being fully open. This was discussed with the manager who advised some actions had already been taken to eradicate this. The manager acknowledged that further actions were needed to ensure this unpleasant odour was fully removed. On the day of inspection new washing machines and driers had been delivered to the home and were in the process of being fitted. The laundry has been out of action for several weeks due to being flooded. Staff stated that the provider had been taking the laundry out of the home to get cleaned and this was being returned the next day so this did not affect residents. Due to the refurbishment of the laundry area it was not possible to confirm appropriate procedures are being followed. It was however evident there are dedicated trolleys for dirty washing and staff have access to a hand wash sink to wash their hands to maintain good hygiene. During the inspection staff were observed to use both blue and white plastic aprons to carry out ‘clean’ and ‘dirty’ tasks within the home to maintain effective infection control practices. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 27 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): Standards 27,28,29 and 30 were assessed. Quality in this outcome area is adequate. Staffing in the home is not consistent to ensure the needs of residents are always met effectively. Staff training is ongoing to ensure staff are suitably competent to care for residents safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All care staff working in the home, work part time hours, which can impact on the consistently in care as well as the effective management of the home due to the constant changeover of staff. Of the eight comment cards received from service users, four stated that staff are “always” available when they need them, three stated they “usually” are and one stated they “never” are. Residents spoken to said that sometimes they had to wait to go to the toilet because staff were busy. One person said that staff would usually say, “Ill be back in a minute” but then not return. A comment card received by us from a service user stated “There has been times when due to staff shortages …. things get over looked”. In response to the question “Do staff listen to what you say”? One resident responded “yes but not always”. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 28 Of the three relative comment cards received, two stated they felt that staff “usually” had the right skills and experience to look after people properly and one did not respond. Relatives spoken to confirmed that care staff are always busy and don’t always have the time they would like to spend with the residents. A relative comment card states “Sometimes staffing problems mean that people with low skill levels are utilised putting more pressure on few staff to provide care”. Another relative comment states “staff change quite often, staff are usually friendly and caring. The home is always clean and tidy and residents always look cared for”. During the inspection the owners of the home were seen to spend time with the residents and the residents seemed to enjoy their company. One person said, “the owners are lovely people”. The manager said that they aim to have three care staff on duty during the day and two waking night staff. The manager said she was working in a supernumerary capacity although her hours are not indicated on duty rotas to demonstrate this. Duty rotas do not show that the proposed staffing levels for the home are being maintained consistently. On some days there are two staff for periods during the day as opposed to three. Duty rotas show there are always two night staff on duty. Duty rotas do not show staff designations or their second names so that there is a clear audit trail and the home can demonstrate sufficient staff hours are provided for care and services provided to the residents. It is not consistently clear from duty rotas, who is doing the cooking. The cook for the home is indicated as “sick” so care staff are covering these shifts. Care staff confirmed there is no person employed to carry out the laundry and they have to do this as part of their duties. They also confirmed that a carer is allocated to help with kitchen duties each day. Allocating carers to undertake non-caring duties can take them away from providing care to the residents. Carers confirmed that sometimes it was difficult to get all the laundry done as well as give the time and attention needed for some of the residents. It was established that night staff have a cleaning rota, which lists numerous tasks including to empty bins, wipe down skirting boards, disinfect toilets and sink basins. These are classed as “dirty” tasks. It is poor infection control practice for staff to undertake these tasks when also dealing with residents as Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 29 this could compromise effective infection control practices in the home. The providers will need to review this matter accordingly. Duty rotas show that although there are two cleaners for the home there is usually one rostered to work each day but there are days when there are no domestics to clean the home. It is not clear from rotas, who carried out their duties in their absence. The manager confirmed there is 23 care staff working in the home and all but three have achieved the NVQ II in Care. This exceeds the care standard for 50 of staff to achieve this and is to be commended. A training schedule is in place to show training completed by staff and to indicate those staff that need to complete training. It was evident that most staff had completed manual-handling training but there were staff who needed to update their food hygiene and infection control training. Some staff had completed training in dementia, violence and aggression and health and safety. Some staff still needed to complete fire training and first aid training. Some staff had completed training in regard to medication in 2006 or prior to this, it was evident from this inspection that further consideration will need to be given to more comprehensive training in this area. Induction training is carried out which complies with the Skills for Care Council Common Induction Standards. This training is completed over a number of weeks and allows staff to build up their competencies to be able to care for residents safely. A review of staff files was undertaken, it was evident that new staff employed had two written references and had completed an application form indicating their past employment and education. Action had been taken to apply for Protection of Vulnerable Adult (POVA) checks before staff were allowed to work in the home to ensure they were safe to work with the residents. Criminal Record Bureau checks were also available. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 30 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): Standards 31,33,35 and 38 were assessed. Quality in this outcome area is adequate. The manager of the home aims to ensure the home is run in the best interests of the service users but this is not happening consistently. Some attention is required to maintain the health and safety of the home to protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home was employed as Acting Manager on 23 October 2006. She previously worked in another care home as Assistant Manager and Trainer but then had a 2-year break where she did not work. The manager has attained a National Vocational Qualification (NVQ) II and III in Care and has almost completed the training required to attain Registered Managers Award. The manager has continued to attend other training Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 31 including infection control, adult protection, health and safety, dementia awareness etc and also has attained the D32/33 Assessors Award. The manager is keen to make improvements for the benefit of service users and since the last inspection has taken actions to address many issues raised in the last report. She is aware there is further work to be done to fully complete these. Staff spoken to said they felt well supported by the manager and owners of the home. The owners were in the home on the day of inspection and were supporting the manager in her role. It was not evident that the provider has fully complied with their Conditions of Registration. One of these conditions states that:“In the event of the Registered Manager leaving, a fulltime care practice consultant must be retained until such time as a replacement manager is actually registered. This arrangement to exist for a period of two years and applies to any reoccurrence of a registered manager leaving within that period”. At the time of this inspection no application had been made to us for a manager to become registered. The provider was made aware of this. The manager advised that staff meetings are held three monthly and it was evident these had been held in May and July 2007. A service user meeting was last held in April 2007 and a number of issues were raised by service users for attention including comments on food, staff confidentiality of resident information, activities and the use of equipment in the home. The manager reported that relative meetings are held six monthly and relatives had communicated they were happy with this frequency. The manager had implemented several audits to help identify that staff were completing their role effectively. This included audits on bedrooms, medication, supervision and water temperatures. It was evident the manager had implemented some changes to address problems identified such as a schedule to allow supervisions to be carried out by senior staff more frequently. It was not evident that these audits were effective in identifying problems in other areas such as medication and water temperatures. Although it was evident supervisions are now being carried out more frequently, it was not evident that the monthly supervisions for staff previously suspended from the home had been completed as required. The manager Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 32 reported there had been no concerns in relation to these staff and she had established this from talking with other staff and residents. Quality satisfaction surveys had been completed by relatives of service users and positive comments were made about the home including “it is a pleasure to visit your home and chat to your clients”, and “I am made extremely welcome” and “we feel mum is in good hands and well looked after”. The manager is aware that she will need to do an outcome report of the results and planned actions in relation to the responses made and make this report available to residents and other interested parties. One service user comment card received by us completed by a relative on behalf of a service user stated, “X is comfortable with the home and care standard. X says it’s very nice and clean and never have to moan”. A resident comment card stated, “the home is welcoming and never has a bad smell. Residents are always clean and well dressed”. The manager said they do not deal directly with service users finances and relatives do this. The financial records relating to service user personal monies held in the home were reviewed. It was evident that the money held by the home was correct in relation to the records in place. Records gave full details of expenditure and balance transfers and receipts were in place, which were numbered for adequate auditing purposes. A review of health and safety checks was carried out to confirm the home is operating safely. The gas safety check was last carried out in December 2006 and the five-year electrical wiring checks in December 2005. Electrical portable appliances had been checked and approved in June 2007 and hoists and bath chairs checked in June 2007. Records of the fridges and freezers showed these were not consistently operating at the recommended guidelines. The fridge temperatures were reading 10°C, which is above the recommended guidelines, and the freezers on the day of inspection were reading -10°C and -15°C, which is higher than the recommended range to store food safely. A packet of cooked ham in the fridge had been opened but not sealed, there was an open box of biscuit cereals in the kitchen cupboard that had not been sealed or placed in a sealed container to keep them fresh. It was established that some of the service user bedroom doors are held open at night but these do not have door retainers linked to the fire alarm so that in Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 33 the event of a fire the doors would automatically close to safeguard the residents. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 34 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 2 X 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X X 2 2 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 35 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement Care plans need to be person centred and clearly reflect care needs and how these are to be met. This includes specific care plans on how personal care needs are to be met as well as specialist care needs such as diabetes. Records must demonstrate that the staff actions required to meet care needs are being carried out. 2. OP7 12 (1) Personal care needs must be met. This includes ensuring residents are toileted when needed and receive any specialist treatment needed such as dental treatment promptly. Staff must ensure that evaluations of care needs consistently identify any changes in the person’s health as well as any additional support required to monitor or provide additional care. Timescale of 28.2.07 not met Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 36 Timescale for action 31/10/07 30/09/07 3. OP7 15(2) 31/10/07 4. OP8 13 (4) Risk Assessments must be developed with clear actions on how risks are to be managed where appropriate. This includes appropriate risk assessments for pressure areas, bedrails, nutrition and falls. Where it is evident that a service user has lost weight appropriate care and consultation must take place and records must reflect this. Timescale of 22.11.06 not met. 31/10/07 5. OP8 12 (1) 31/10/07 6. OP9 13 (2) Medications must be managed effectively in the home records must demonstrate these have been given as prescribed. This includes: • Appropriate and safe management of controlled drugs. The appropriate completion of a controlled drugs register and MAR chart. The implementation of an appropriate self medicating policy and procedure. Ensuring any homely remedies are appropriately audited. Ensuring no medications are used after their “use by” date. Ensuring all medications given are signed for or coded appropriately on the MAR if not taken. 30/09/07 • • • • • Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 37 • 7. OP15 16(2) Ensuring the frequencies of medication are adhered to. 12/09/07 There must be sufficient supplies of food in the home to ensure residents are able to receive a varied, wholesome and sufficient diet to support their health. This includes the provision of sufficient snacks during the day and evening in accordance with residents needs. The home must be maintained in a clean condition. This in particular applies to ensuring carpets in the home are clean and removing any unpleasant odours. Prompt action must be taken to complete works in the laundry so the home has a fully functioning laundry service to meet the laundry demands of the home. Staffing arrangements within the home require further review to ensure residents care needs are met and they receive an effective service. This includes taking appropriate action to ensure care staff do not compromise the infection control procedures within the home by completing laundry and cleaning tasks whilst also caring for residents. The manager must be qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. An application form for registration is to be pursued. (Timescale of 28.2.07 part met) 8. OP26 16(2) 30/09/07 9. OP26 16(2) 31/10/07 10. OP27 18(1) 31/10/07 11. OP31 8(1) 31/10/07 Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 38 12. OP38 13 (4) (c) Suitable actions must be taken to ensure any bedroom doors which need to be kept open have suitable devices fitted which are linked to the fire alarm to safeguard residents in the event of a fire. Risk Assessments are to be developed accordingly. Fridges and freezers in the home must operate at temperatures within the recommended guidelines to ensure food is stored safely and is safe for residents to eat. Opened packets of food must also be appropriately sealed to ensure they are pest proof and do not deteriorate. 30/11/07 13. OP38 13(4)(c) 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The Service User Guide should be reviewed to ensure this contains the summary inspection report for the home to help prospective service users make an informed choice on whether to stay at the home. The pre-assessment record used by the home should be reviewed to ensure needs of service users are person centred and clearly identified so that staff are clear on the arrangements required to meet these needs. For those residents self medicating, there should be an assessment procedure in place which periodically allows staff to check service users can safely administer their own medications as prescribed. DS0000063831.V342457.R01.S.doc Version 5.2 Page 39 2. OP3 3. OP9 Fairfield Residential Care Home 4. OP10 Service users must be treated with respect at all times. Staff communication with residents needs to be clear and supportive where appropriate so that residents are aware at all times what staff intentions are and feel confident in receiving staff assistance. A further review of activities should be undertaken to ensure all residents in the home can benefit from social stimulation. This includes both physical and mental stimulation. The home should be conduced so as to maximise service users’ capacity to exercise personal autonomy and choice. This in particular applies to choices made in relation to drinks and meals. Meals as indicated on the menus should be available to allow resident choice. (issue relating to resident choices outstanding from previous inspection) A review of the dining facilities should be undertaken to ensure tablecloths are in good repair and residents have access to condiments and any other items they may need to make the dining experience more pleasurable. Sufficient records should be maintained to confirm residents are receiving a sufficient and varied diet to maintain their health. This includes records of any special dietary needs catered for. 5. OP12 6. OP14 7. OP15 8. OP19 Consideration should be given to whether all residents are able to access the low level cane seating in the conservatory. Alternative seating should be considered for those residents who may be unable to use this. A review of the homes storage facilities should be undertaken to ensure areas of the home do not become cluttered with inappropriate items. The wallpaper borders in some of the bedrooms require attention so they are not ripped or damaged. The greying and frayed towels in the home are in need of replacement so that residents have suitable towels to use. Hot water temperatures need to be sufficiently warm enough for residents to wash in and sufficiently hot enough in the sluice to effectively kill bacteria. 9. 10. OP19 OP25 Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 40 11. OP27 Duty rotas need to clearly show full names of staff, their designations and clearly indicate any carer hours allocated to non caring duties in the home so that it is clear there are sufficient hours being allocated both to caring and services provided in the home. Suitable actions need to be taken to review current audits carried out by the manager to ensure these are suitably comprehensive and clearly identify discrepancies and actions required to address them. This includes audits on water temperatures and medication. Where actions are identified following protection of vulnerable adult investigations, the manager must ensure these are carried out consistently as required. 12. OP31 13. OP33 The manager is to ensure that the results from quality surveys are collated and detailed in a report which is made available to service users and their representatives. Actions to address comments made must be clearly demonstrated to show the home commitments to improving the ongoing quality of care and services provided. Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 41 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham West Midlands B2 4UZ 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 Fairfield Residential Care Home DS0000063831.V342457.R01.S.doc Version 5.2 Page 42 - 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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