Inspection on 03/04/07 for Fengates (1)

This inspection was carried out on 3rd April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fengates (1) 03/04/09

Fengates (1) 08/12/05

Fengates (1) 25/07/05

Fengates (1) 01/12/04

Fengates (1) 05/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Fengates (1) 1 Fengates Redhill Surrey RH1 6AH Lead Inspector Lisa Johnson Unannounced Inspection 3rd April 2007 09:40 Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fengates (1) Address 1 Fengates Redhill Surrey RH1 6AH 01737 778811 01737 789608 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) CMG Homes Ltd Miss Kate Charlotte Webber Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (2) of places Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home may accommodate up to 2 residents with both LD and MD within the total number of residents accommodated The age/age range of the persons to be accommodated will be 19 TO 45 YEARS 8th December 2005 Date of last inspection Brief Description of the Service: 1 Fengates is owned by Care Management Group. The home is a detached property providing accommodation to six adults who have learning disabilities. The home is located in Redhill, Surrey. The home is accessible to local shops and public transport. Redhill town centre is close by. The accommodation is provided over two floors. All bedrooms are single with en-suite showers. There is a comfortable lounge, separate dining room and a large kitchen. There is a patio area and a small garden that is laid with lawn to the rear of the house. Parking is available at the front of the house. The weekly charges range from £1,000- £1, 800. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over six and half hours commencing at nine forty am and finishing at four twenty pm. The visit was carried out by Mrs. L Johnson Regulation Inspector. The inspector spoke with three service users to gain their views on the care provided A full tour of the premises took place. Information was received from the registered manager who provided a pre- inspection questionnaire. Care plans, staff training records and policies and procedures were sampled. The inspector spoke to three members of staff. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: The home provides a high standard of accommodation, which provides a homely, and welcoming feel. Detailed and comprehensive care plans have been completed involving service users to make decisions and choices about their lives and includes their preferences, likes and dislikes. One Individual said, “Staff ask me what I would like to do”. The home has also completed health action plans and detailed risk assessments for all service users”. Service users are supported in accessing a range of activities, which meets their needs and preferences. One individual said, “I go to College”. Service users are fully involved in activities in the home and one individual was observed to be doing her laundry. Service users participate in cooking their meals and one individual said, “I like baking” and another individual said, “I get help with choosing my meals and I go food shopping”. Good relationships were observed between service users and staff who had a good knowledge and understanding of service users needs. The manager and her staff team were observed to be committed to ensuring that service users have a good quality life. Service users spoken with said that they were happy Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 6 living in the home. One individual said, “the staff are very nice and it is friendly here”. What has improved since the last inspection? What they could do better: It was recommended that the home complete a pre- admission assessment for all future service users admitted to the home, as this had not been completed for one individual. The recording practice observed on one medication administration record required improvement and the manager took prompt action during this visit ensuring that this matter was attended to. It was also recommended that where staff transcribe medication on to the record two members of staff check that this One individual receives leave medication that is secondary dispensed from the original container into another container. It was required that this matter is discussed with the local pharmacist and that the current risk assessment be reviewed to ensure that service users are protected by the homes medication policies and practices. During this visit it was observed that radiator covers were not supplied throughout home and it was required that a risk assessment is completed in respect of this matter to ensure the health, welfare and safety of service users. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 7 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. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with the information needed to choose the home, which will meet their needs. The needs of service users are assessed prior to admission to the home. EVIDENCE: The Statement of Purpose and service user guide were informative and gave accurate descriptions of the service provided. Service users views have been included in the document. The documents have been formulated in large print and pictures The registered manager stated that initial referrals are received by the company who have an assessment team with the manager being provided with the opportunity to carry out their own assessment. Evidence sampled indicated that one service user had a pre- admission assessment on their file, which was detailed and included culture and diversity issues. The second individual had been admitted to the home as an emergency. A community care assessment was available but a pre- admission assessment had not been completed by the home. Therefore it was recommended that the company undertake their own pre- admission assessments to ensure that the needs of service users can be met. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are provided with an individual care plan, which records their individual needs and goals. Service users are supported to make decisions about their lives with assistance and are supported to take risks as part of an independent lifestyle. EVIDENCE: The home has developed a good standard of care plans which has been based on a full needs assessment including personal health, emotional, social, self help, daily living skills, culture and friendships. Individual plans were detailed and structured with clear objectives and goals. It was evident that plans were regularly reviewed in consultation with service users, which were agreed and signed by them. Three service users spoken with said that they are involved in their meetings and one individual said, “staff ask me what I would like to do. Two members of staff spoken with who act as key workers confirmed that they were aware of service users individual plans and are involved in carrying out reviews. The home is currently further developing person centred planning and Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 11 one individual showed their plan to the inspector, which she had been involved with completing. Service users are consulted and supported to make decisions about their lives and are supported to manage their own finances but where support is required this was recorded in the care plan. Service users have their own keys to access both the house and their bedrooms rooms. Individual risk assessments were sampled which were detailed and comprehensive with clear strategies in place. Plans observed included community awareness, aggression, and managing emotions and daily living skills. Plans had been agreed and signed by service users and were reviewed on a monthly basis. All plans have been signed by staff to confirm that they have read and are aware of individual risk plans. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are provided with a range of appropriate activities and engage in a range of leisure activities. Service uses are supported to take part in the local community and the rights and responsibilities of service users are respected. The home is able to demonstrate that service users are provided with a wellbalanced and nutritious diet. EVIDENCE: Service users were supported to attend appropriate recreational and social activities. On individual said, “ I go to pottery, I clean my room and I do my laundry which was observed during this visit. Another individual works at a riding stable. One person said she goes out independently and goes shopping. Some individuals go the local gym, visit the cinema, attend relaxation, go swimming and receive aromatherapy. Service users help cook the evening meal and one individual said, “I like baking”. One service user told the inspector about her planned holiday for this year. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 13 A number of service users maintain links with their families and visit them at home. One individual says she has a mobile phone and a pay phone is available for service uses to access. One individual has an advocate it was evident that staff support service users with building relationships. One individual said she visits a friend and is supported by staff to maintain contact. One individual said that she can choose her food and goes to Sainsbury’s to purchase this. Service users are able to access all areas of the home with no restrictions. Staff were observed to talk to service. Menus are arranged on weekly basis, which is based on individual preferences. The main meal is provided in the evening. Service users spoken with stated that they were happy with the meals provided. Copies of menus were provided with the Pre-inspection questionnaire and were seen to be varied and well balanced. One service user spoken with prefers a vegetarian diet and said that her preference to have this diet is accommodated with staff providing support with her menu. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users receive personal support in the way they prefer. Service users physical and health needs are met and they are in the main protected by the homes medication administration procedures with one matter identified needing attention. EVIDENCE: The strengths and needs of each individual were identified in their care plan stating their preferred preferences about their daily lives. One individual’s plan identified that this person likes to see their General Practitioner independently and will ask staff if they require further support. Service users preferred ways of receiving medication was also recorded. The home has implemented health action plans, which had been completed in consultation with service users. Plans sampled were detailed and included all identified health care such as epilepsy, mental health issues, diet and exercise with detailed support plans documented. Records were maintained of health screen checks and visits to health care professionals including psychiatry, community, nurses, chiropody, GP and dentist. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 15 The homes medication policies and practices were examined. Photographs of service users were maintained with their records. A list of staff that are trained and authorized to administer medication was available. The home has a medication procedure in place. All medication administered was signed for. Staff receive training from Boots chemist and the company also conduct training. The manager stated that internal assessments are regularly carried out to ensure competency. Two matters were identified that required attention. The author had not signed one medication administration record that had been hand, transcribed by staff. It was also recommended that where medication is transcribed by staff this should be checked by two members of staff. The manager responded promptly to this matter, which was completed during this visit. One individual takes medication home and a risk assessment was in place. However this medication was secondary dispensed from the original container into an alternative container. A requirement was made that this matter is reviewed and discussed with the local pharmacist and that the risk assessment is reviewed to ensure that the health, welfare and safety of service users is protected. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of service users are listened to and acted upon. Service users are protected from abuse. EVIDENCE: There is a complaints procedure in place which the registered manager has adapted in large print and pictures to ensure it is accessible to service users. The manager has received three complaints since the previous visit, which had been appropriately investigated and followed up by the manager with detailed records and outcomes documented. Three-service users spoken with said that they were happy living in the home and said that that they would speak to the manager if they were unhappy. One individual said, “staff are nice and it is friendly”. The local authority multi- agency safeguarding adults from abuse procedure was available and the home has a whistle blowing policy. The manager has attended the local authority-safeguarding adult from abuse training. Training records were sampled for three members of staff, which indicated that two members of staff have completed appropriate training and arrangements are in place for a new member of staff to attend training. Two members of staff spoken with were aware of the procedures and were clear in their responses as to the action that they would take if they witnessed any abuse taking place. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users in the live in a homely, comfortable safe and clean environment. EVIDENCE: The home is situated in close to Redhill Town centre and there are local shops and amenities close by. The service provides a homely feel was maintained to a high standard and is well decorated and furnished. There is a comfortable sitting room, which has a fish tank for service users to enjoy. Since the previous visit a new kitchen has been installed and some carpets replaced. There is an accessible garden to the rear of the house, which was well maintained and is provided with garden furniture and bird tables. Bedrooms were viewed as comfortable and personalised with service users interests and personal effects. Service users are provided with the opportunity to choose the colour schemes in their bedrooms, which was confirmed by one individual spoken with who had recently had her bedroom repainted. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 18 The home was cleaned to a high standard and was hygienic. Suitable hand washing facilities were available and separate laundry facilities were provided to the rear of the house. Staff are provided with infection control training The inspector was informed that service users have also received information and guidance in infection control and food hygiene which was seen in records of service users meetings. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to meet the needs of service users. Service users are in the safe hands of the staff that were competent and trained to do their jobs and are protected by the homes recruitment policies and practices. EVIDENCE: During this visit there was two members of staff on duty. The rota was examined which concluded those two members of staff work during the day and two waking staff are provided at nighttime. Extra staff is provided to accommodate activities and one individual requires one to one support when accessing the community. The home is currently recruiting to a staff vacancy and the manager said that service users have the opportunity to meet candidates when they visit the home. The staff team are of mixed gender and the company has an equal opportunities policy in place. There is an overall company-training plan. The training records for three members of staff were sampled which indicated that staff receive mandatory training in first aid, fire awareness, health and safety infection control, safeguarding adults from abuse and food hygiene. Staff also recieve other training that supports the current needs of service users Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 20 including dignified management of aggressive behaviours, mental health, health action and person centred planning. One individual has been recently diagnosed with autism and the manager stated that she is in the process of arranging to attend autism specific training and then will conduct training with staff in the home. New staff receive induction based on the Skills for Care Standards. One new member of staff spoken with confirmed that she had received induction and had received training in fire awareness, health and safety, food hygiene and dignified management of aggressive behaviours. The pre- inspection questionnaire provided evidence that fifty percent of staff have obtained National Vocational Qualifications (level 2) or above. The deputy manager is in the process of completing National Vocational Qualification (Level 4) Three staff personal files were sampled which were maintained to a good standard and contained the required information. POVA first checks are carried out and enhanced police checks are completed with appropriate records maintained. Copies of the General Social Care of Conduct are made available to staff were present on individuals files. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that service users benefit from a well run home which is in run in their best interests. The health, welfare and safety of residents is protected with one matter identified needing attention. EVIDENCE: The registered manager has experience of working with people with learning disabilities and has completed the Registered Managers Award. It was evident that the manager undertakes training and development. The manager said that the company has been carrying out a detailed training programme for managers, which she has attended. There was an open atmosphere in the home and two members staff spoken to state that they felt supported by the management structure. One member of staff described the teamwork as Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 22 “brilliant”. During this visit the manager was observed to be accessible to both service users and staff. The home conducts quality assurance surveys, which have been updated. Questionnaires are also sent to relatives and other stakeholders. The responsible individual conducts monthly quality visits. The company holds an annual service users forum where there is an opportunity for service users to discuss their views and opinions in relation to subjects chosen by service users and issues raised by the feedback questionnaires. The manager has introduced a range of quality assurance systems in the home. Records are maintained of improvements and achievements for both service users and staff The manager has introduced quality assurance standards in respect of infection control and food hygiene and standards to support service users with a good quality life, which includes decision-making, activities, respect making choices and assisting service users with gaining new experiences. Health and safety records were sampled including fire records, which indicated that fire alarms are regularly checked and fire drills are up to date. Water temperature records were maintained and monthly health and safety checks are conducted. Accident records were sampled and were appropriately maintained. One requirement was made in respect of radiator covers that were not covered and a risk assessment must be carried out to ensure the health, safety and wellbeing of service users. Fengates (1) DS0000013437.V333189.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 X 4 X 4 X X 2 X Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement The registered person must review the practice of secondary dispensing for one individuals leave medication. The registered person must ensure that a risk assessment is completed in respect of the need to supply radiator covers. Timescale for action 03/05/07 2 YA42 13(4)(c) 03/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA2 YA20 Good Practice Recommendations It is recommended that the home carry out their own preadmission assessment prior to service users moving into the home. It is recommended that where medication is transcribed by staff on to the medication administration record this should be checked by two members of staff. Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Burgner House, 4630 Kingsgate Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Fengates (1) DS0000013437.V333189.R01.S.doc Version 5.2 Page 26 - 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!