Inspection on 26/02/08 for Fallings Park Lodge

This inspection was carried out on 26th February 2008.

CSCI found this care home to be providing an Adequate service.

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

Fallings Park Lodge 04/12/07

Fallings Park Lodge 20/08/07

Fallings Park Lodge 20/06/07

Fallings Park Lodge 16/01/07

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Heathlands

Aston Court Nursing Home

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Ravenhurst

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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 Fallings Park Lodge 99A Old fallings Lane Fallings Park Wolverhampton West Midlands WV10 8BJ Lead Inspector Rosalind Dennis Unannounced Inspection 26th February 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fallings Park Lodge DS0000068603.V360167.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. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fallings Park Lodge Address 99A Old fallings Lane Fallings Park Wolverhampton West Midlands WV10 8BJ 01902 722700 01902 722700 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) Aplin Care Homes Ltd *Post vacant* Care Home 48 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (35) of places Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. In the OP category Females 60 years and above and males 65 years and above The home should only accommodate up to 13 service users with dementia. Up to seven service users aged 55 years plus, other service users must be over 60 years. The Second floor lounge and bedrooms are used for the thirteen service users with dementia. 4th December 2007 Date of last inspection Brief Description of the Service: Fallings Park Lodge is a purpose built care home situated in the residential area of Fallings Park and is close to local shops and amenities. The home has three floors with wheelchair and disabled access throughout. There are 48 bedrooms all of which have en-suite and a modern nurse call system. There are five communal lounges each incorporating dining facilities for the residents. The top floor has thirteen rooms, which are registered for use by people with dementia. The home has extensive gardens and grounds, with raised flowerbeds at the rear and there is car parking at the front of the building. At this inspection weekly fees are confirmed as £349-£400 per week. The reader is advised to contact the home to obtain up date information on the fees charged. People can obtain information about this service from the home’s Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by two inspectors over a period of around 6 hours. The purpose of this inspection was to look at what improvements had taken place since the last key inspection in December 2007 and to assess all ‘key’ standards -that is those areas of service delivery that are considered essential to the running of a care home. We, the commission used a range of evidence to make judgements about this service which included discussions with people living at the home, speaking with staff and observing them in their work, looking at care records and other documentation. We have closely monitored Fallings Park Lodge for sometime because of ongoing concerns regarding how the home was operating and a failure on the part of the provider to take action to improve the service, comply with requirements and protect the health and safety of people living at the home. This inspection finds that the home has made progress in achieving requirements made at previous inspections. Although some shortfalls are still evident these are much reduced and observations suggest that work is in progress by the new manager Ms Jackie Whatling to address shortfalls. The provider, manager and staff now need to demonstrate that improvements can be sustained with their own internal processes to ensure people receive a quality service within an environment which is safe and well-maintained. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: As at other inspections people spoke positively about how they are looked after by the care staff. People who weren’t able to give their views, appeared content, clean and comfortable and during the day staff were attentive, offering drinks, snacks and helping people Bedrooms are spacious and have the facility of an en-suite. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: We found that nine previously made requirements have been achieved or partially achieved, which shows that the home has improved many aspects of the service it provides to people. There are areas where the home still needs to make improvements, which includes: Observation of the records for the temperature of medication room shows that the temperature of the room remains too warm at times (an ongoing problem) and the provider needs to take action to address this. Since the last inspection a specific cupboard has been fitted to store ‘controlled’ medicines, however we observed that the fittings did not appear to be of the required standard. The home still needs to establish a quality assurance system to enable people who live or visit the home to provide their views on all aspects of the service such as through the provision of ‘satisfaction surveys’. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 7 We found that one set of bed rails had not been fitted correctly. The failure of the home to ensure bed rails are fitted correctly has been an ongoing concern and the home needs to take action to ensure that if people are assessed as needing bed rails then the bed rails must be assessed, fitted and maintained by a competent person in accordance with guidance. At this inspection we observed that the environment was generally safe but needed attention. What was positive at this inspection was that the manager had sought advice and obtained quotes for necessary work and we received further information after the inspection confirming that work was in progress to address some of these deficits. The provider needs to take action to develop an ongoing programme of maintenance and ensure that any repairs are dealt with promptly so that people’s comfort and safety is assured. 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. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 8 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 Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 9 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): 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has the processes in place to enable the successful admission of a person to Fallings Park Lodge. EVIDENCE: We looked at the care file for a person recently admitted to Fallings Park Lodge, this shows that the manager had conducted an assessment of the person’s needs and obtained information from other care professionals before the person was admitted to the home. This information was then used to develop a care plan and identify potential risks to the individual’s health, safety and welfare in the form of a risk assessment. We were not able to establish whether the person was satisfied with the admission process because of their illness, but the information documented within the care plan appeared to be an accurate reflection of this person’s needs. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 10 Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the care planning and risk assessment process means that staff are provided with the information they require to meet people’s needs. EVIDENCE: Time was spent on the Dementia care Unit observing staff interactions with people who live in this part of the home. The atmosphere was cheerful, people appeared content and well cared for and the staff group were responding to people appropriately and with kindness. Other people, who were more able to provide views of their care, spoke positively about the care they receive and the staff group. All people spoken with confirmed that their privacy is maintained and that staff respect them as individuals. This inspection finds that the new manager is improving how the home develops and writes care plans with people, this is work in progress as some Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 12 people still need their care records updating but the manager spoke of her intention to ensure everyone’s care records are reviewed. We looked at a selection of care files which have been updated by the manager and we found that information within care plans was clear and set out in detail how people want their needs met and the action needed by staff to meet their needs. We also found that the home is now identifying potential risks to the individual’s safety and these risks are documented in the form of a risk assessment, which clearly identify how the risk is to be managed. Care staff complete daily written records, these were detailed and gave a good account of how the person had spent the day and the care given. We looked at a selection of medication administration records (MAR) charts, these showed that medication had been recorded accurately with all medication signed and accounted for. Observation of the records for the temperature of medication room shows that the temperature of the room remains too warm at times (an ongoing problem) and the provider needs to take action to address this. Since the last inspection a specific cupboard has been fitted to store ‘controlled’ medicines, however the fittings did not appear to be of the required standard and the manager was informed of this. Information was available which confirms that staff who are involved in administration of medication have received specific training in ‘safe handling of medicines’. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Fallings Park Lodge are able to enjoy a range of activities, which are based on their capabilities and preference. Meals at the home are good, offering variety and catering for different nutritional needs. EVIDENCE: People spoke about different activities and events, which take place at the home including visits by entertainers, quizzes, visits to the shops, local day care centres. People confirmed that daily routines are flexible and the atmosphere throughout the day appeared relaxed with staff providing assistance to people as needed. Staff are now keeping good written records of individual attendance at activities, and observation of these records show that people are provided with a range of activities including specific activities for people who have memory related difficulties, such as dementia. We saw staff encouraging people to maintain their independence but providing Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 14 assistance when necessary, for example on the Dementia unit some people chose to wash up items of crockery, closely supervised by staff. As at other inspections the food served looked appetising and people confirmed that choices are offered at each meal. The home has introduced new menus and everyone spoken with appeared happy with the variety and choices offered. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensures that people have access to a clear complaints procedure, which enables concerns or complaints to be dealt with promptly and professionally. Staff are provided with training to equip them with the knowledge and skills to safeguard adults from the risk of abuse or neglect. EVIDENCE: The home has a complaints procedure, which is described in the statement of purpose and referred to in the service user guide. A copy of the complaints procedure is also available in the reception area of the home. The home has received one complaint since the last inspection. We looked at the method used to record and respond to this complaint and this shows that the manager has introduced a process of responding to complaints or minor concerns. We have not received any recent complaints in respect of the home. All people spoken with during the inspection confirmed they would feel comfortable in raising any concerns with either the manager or other staff at the home. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 16 Information was available to show that over half the staff have now received training in adult protection and abuse awareness, with further training planned for all other staff and the manager to attend. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Fallings Park Lodge provides a physical environment that meets the specific needs of the people who live there, however improvements are needed to ensure that people are provided with a home, which is well-maintained. EVIDENCE: The home offers spacious individual bedrooms, all of which have an en-suite facility and communal lounges provide people with a range of places to relax. Observation of a selection of individual bedrooms found them to be clean and decorated to a good standard. Staff have received training in infection control and during the day we observed staff wearing appropriate protective clothing. An ongoing concern with the home has been a lack of intervention to ensure the environment is consistently well maintained and safe. At this inspection we observed that the environment was generally safe but needed attention, Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 18 such as carpets were loose in areas, a downstairs toilet was missing a floor tile creating an uneven floor surface and there was a lack of hot water. Further detail regarding these issues is included in the management and administration section of this report. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home now provides a recruitment procedure, which complies with legislation and safeguards people from the risk of employment of inappropriate staff. Staff have been provided with training to equip them with the skills to care for people and staffing levels are currently sufficient to meet the needs of the people living at the home. EVIDENCE: People who were spoken with during the inspection feel that there is enough staff on each shift to meet their needs. Staff spoken with during the inspection felt that staffing levels are sufficient to meet the needs of the people currently living at the home. We observed staff working in different parts of the home and this indicated that sufficient care staff were on duty. The manager spoke of how she has looked at the allocation of staff at different times of day, and in particular ensuring sufficient staff are working on the Dementia care unit-staff on this unit spoke of improvements in staffing since the manager’s appointment. The manager is aware that staffing levels need to be kept under review according to the needs and number of people accommodated. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 20 We looked at six staff personnel files and this shows that the home has improved its recruitment procedure. Two staff appointed since the last inspection had all required pre-employment checks on their file. The files for four staff appointed last year without required pre-employment checks, have been audited by the home and information previously lacking has been obtained. We saw a list identifying which staff had received training in moving and handling, food hygiene, first aid and infection control in December 2007. Staff spoke of how the home is continuing to provide training opportunities, including training in dementia care and supporting staff to study for a nationally recognised qualification in care (NVQ). Evidence of induction was available within the files for two staff recently appointed and both the manager and deputy manager demonstrated their awareness of the comprehensive induction programme (Skills for Care). Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager Ms Jackie Whatling is improving and developing systems that monitor practice and compliance and is leading the staff team to ensure people are provided with the care they need. EVIDENCE: Since the inspection in December 2007 a new manager, Ms Jackie Whatling has been appointed by the home. It is clear that Ms Whatling has had a positive impact on the running of the home and is aware of where improvements still need to be made. Staff described how Ms Whatling is an ‘effective manager’ and staff commented that this has resulted in better teamwork and improved morale which has benefited people living at the Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 22 home. We spoke with the local District Nursing team before this inspection who provided us with positive feedback about how the service has improved since the appointment of Ms Whatling. Ms Whatling is aware that an application will need to be submitted to CSCI to enable the formal registration process with CSCI to commence-completion of this process is needed to become a Registered Manager. The home still needs to establish a quality assurance system to enable people who live or visit the home to provide their views on all aspects of the service such as through the provision of ‘satisfaction surveys’. A person has been nominated by the home to conduct unannounced visits and copies of the findings of these visits have been sent through to CSCI. One bed, which was seen had bed rails fitted, however these were not fitted according to relevant guidance and would put the person at risk of harm when they were in bed, a headboard was also not fitted to the person’s bed. The manager was informed of where to locate the guidance and of the need to ensure that staff who fit bed rails are fully competent in this procedure-the manager gave assurances that action would be taken immediately to ensure the bed rails were safe. An area which has been of concern at previous inspections has been an apparent failure of the provider to take action when there have been maintenance issues which need attention. There continues to be parts of the building which need improving, but at this inspection the manager provided examples of quotes which have been obtained and spoke of plans to initiate improvements. One example is the temperature of hot water; records show that the temperature is too low, the manager sought advice, which identified that an additional hot water cylinder is required. Carpets in parts of the home are loose and floor tiles were missing in one downstairs toilet. A copy of a recent Regulation 26 visit conducted by the company secretary shortly after our inspection provides written confirmation that quotes have been obtained for an extra hot water cylinder, new call bells are to be fitted in the lounge, head boards have been fitted to beds and a carpet fitter is due to visit. We checked the home’s fire safety log during the inspection which shows that regular checks of the fire alarm system are now conducted by the home. Observation of a selection of individual financial records demonstrates that the home has robust systems in place to safeguard people’s financial interests. Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13(2) Requirement Medication must be stored within the temperature range recommended by the manufacturer to ensure that medication does not lose potency or become contaminated. (26/02/08 -Compliance not achieved. Previous timescale of 10/12/07 and 20/07/07) Timescale for action 01/04/08 2. OP9 13(2) A Controlled Drugs cabinet must 01/05/08 be installed correctly in order to comply with new legislation and ensure that Controlled Drugs are stored safely (26/02/08- cupboard installed but needs correct fittings to fully comply with legislation. Previous timescale of 31/12/07) Bed rails must be assessed, fitted and maintained by a competent person in accordance with MHRA/HSE guidance. This is to protect the person from the risk of harm and promote their safety (26/02/08-non-compliance. Previous non-compliance at DS0000068603.V360167.R01.S.doc 3. OP38 13 (4) (c) 27/02/08 Fallings Park Lodge Version 5.2 Page 25 inspection on 29/03/07,20/06/07 and 04/12/07). 4 OP33 24 A system for evaluating the 01/04/08 quality of the services provided at this home must be implemented, which actively seeks the views of people using the service, their representatives and other stakeholders. The results should then be used to improve the home’s performance based on the feedback from others. (Assessed as work in progress on 20/08/07, little evidence of further action on 4/12/07 & 26/02/08. Previous timescale of 01/08/07) 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 OP19 Good Practice Recommendations All parts of the home, including bathrooms and toilets must be kept and in a good state of repair. This is to ensure that people are provided with a clean, homely and safe place to live and where their dignity is not compromised. The provider needs to take action to develop an ongoing programme of maintenance and ensure that any repairs are dealt with promptly so that people’s comfort and safety is assured. 2 OP19 Fallings Park Lodge DS0000068603.V360167.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Fallings Park Lodge DS0000068603.V360167.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!