Inspection on 31/05/05 for George Mason Lodge

This inspection was carried out on 31st May 2005.

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

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

Other inspections for this house

George Mason Lodge 18/04/06

George Mason Lodge 27/10/05

George Mason Lodge 26/01/05

George Mason Lodge 19/08/04

George Mason Lodge 16/03/04

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

CARE HOMES FOR OLDER PEOPLE George Mason Lodge Chelmsford Road Leytonstone London E11 1BS Lead Inspector Rob Cole Announced Inspection 31 May 2005 at 10:00am st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service George Mason Lodge Address Chelmsford Road, Leytonstone, London, E11 1BS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8496 3000 London Borough of Waltham Forest Mr Peter Kenneth Stanley Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26th January 2005 Brief Description of the Service: George Mason Lodge is a registered care home for elders situated in the Leytonstone area of the London Borough of Waltham Forest. The home is run by the Local Authority. The home also includes the provision of a nine bedded intermediate care facility that was set up in March 2003 to provide a period of short term rehabilitation, using specialist occupational and physiotherapy interventions to a similar group pf service users. It is a joint health and social services undertaking with the overall managerial responsibility vested in the registered care manager. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 31/5/05 and was announced. The inspector had the opportunity of speaking with service users, relatives, staff and the homes manager was present throughout the inspection. The inspector believes that this is a well run home, and that service users receive a high level of care and support. Service users spoken to all said that they are happy living at the home, and are treated with respect by the staff. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 6 by contacting your local CSCI office. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 7 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 Standards Statutory Requirements Identified During the Inspection George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 and 6 The inspector was satisfied that service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and the chance to visit the home. However, the inspector has concerns that the home is taking on service users for whom they are unable to meet all their assessed needs. EVIDENCE: The home has both a Statement of Purpose and Service User Guide in place. Both documents are clear and comprehensive. The Statement includes details of the organisation and management, the aims and objectives of the home and all information required by Schedule 1 of the Care Homes Regulations 2001. The Statement also includes a section on the homes Intermediate Care Unit (ICU). The Service User Guide includes details of the physical environment and the homes complaints procedure. All service users are provided with a statement of terms and conditions, which includes fees payable and what they cover, accommodation provided and the care and services which the home offers. These statements are signed either by the service user, or their representative as appropriate. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 9 Pre admissions assessments are carried out on all service users. For those service users in the residential unit these were seen to be of a high standard, clearly setting out the assessed needs of service users. However, as at the previous inspection, the assessments for service users admitted to the ICU were not sufficiently detailed, in that they concentrated on the persons therapeutic needs, and there was very little information on how the home could meet their other needs. The inspector spoke with the homes manager and with the therapy team leader, both of whom said that the home was in the process of developing pre admission assessments for the ICU. The homes admissions procedure states that service users are able to visit the home for a trial visit, including overnight stays, before making any decision as to move in or not. Service users spoken to confirmed that this was the case. The home has a designated nine bed ICU Unit. The Unit was well maintained and decorated to a high standard, and all service users have their own ensuite bedroom. The home also has a therapy room for service users in this unit. The unit is staffed by a therapy team consisting of physiotherapists, rehab assistants and occupational therapists and care staff. Service users in the ICU unit said they were generally satisfied with the level of care and support provided. Through observation and discussion there was evidence that the home is generally able to meet the individual and collective needs of service users. However, there were two service users in the home whose needs were not being satisfactorily met, both of whom are recent admissions. One service user has dementia, the manager informed the inspector that they were not able to meet this persons needs, and indeed the home is not registered to provide support to people with dementia. Another service user has been verbally and physically aggressive to staff, and caused distress to service users. The inspector considers this person to be placed inappropriately, as the home is not able to meet their needs, and their placement at the home is having a detrimental impact on other service users. It is required that the home only provides accommodation to service users if it is able to meet all their assessed needs. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 and 11 Generally the inspector was satisfied that the home is able to meet the personal and health care needs of service users. High standards of care planning and a sensitive approach by staff help this. However, the home must ensure that service users have access to all health care professionals as appropriate. EVIDENCE: All service users have a care plan in place. Care plans in the residential unit were clear and comprehensive, and regularly reviewed. Plans covered medical needs, mobility and health. Service users in the ICU also have care plans. These have been updated since the last inspection and now contain details of how the home can meet service users social and leisure needs, and were of a satisfactory standard. Service users also have risk assessments in place. Likewise, these are regularly reviewed, and included assessments on the risk of falling and risks associated with medical conditions. All service users are registered with a GP, and there was evidence of the involvement of other health professionals including physiotherapists and chiropodists. Records are maintained of medical appointments including any follow up action required. However, not all service users have had access to George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 11 health care professionals as appropriate. For example one service users records indicated that they had not had access to any dental or eye care in the past three years, and this must be addressed. The inspector was informed that service users are able to see visiting health professionals in private. The home has a clear and comprehensive policy on medication, and all staff receive training before they are able to administer medications. The supplying pharmacist inspects the homes medication during monthly visits, they spoke with the inspector on the day of inspection and said that they were satisfied that medication in the home was stored, recorded and administered appropriately. MAR charts checked by the inspector were clear and up to date, although it is a repeat requirement that all hand written entries on MAR charts are signed. Since the last inspection the home now has guidelines in place for the administration of medications prescribed on a PRN basis. Through observation and discussion there was evidence that service users privacy and dignity is respected. The laundry system helps ensure that service users only wear their own clothes, and were appropriately dressed on the day of inspection. Screening is provided in shared bedrooms, and staff were seen to knock and wait before entering bedrooms. The home seeks and records the wishes of service users on arrangements to be made in the event of their death, and the manager informed the inspector that service users are able to remain in the home with a terminal illness, as long as the home can meet their medical needs. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 In the view of the inspector service users are supported to live fulfilling daily lives. Contact with family is encouraged, and service users are supported with a variety of social and leisure activities. EVIDENCE: Service users have access to a variety of social and leisure activities. There was a notice displayed in the home advertising the weekly activities programme, this included bingo and an exercise class. The manager informed the inspector that the home has set up a group to look into how the activities programme can be broadened, and the inspector was pleased to note that service users are involved and able to take the lead in this group. Service users access the local community, including going to pubs and shops, and day trips, for instance to Southend. A local church comes once a week to give a service in the home. Service users are able to see visiting family and friends in private. The inspector spoke with relatives of service users who were visiting on the day of inspection. They informed the inspector that they were able to visit when they liked, and were always made welcome by the home. The home maintains records of menus, these indicated that service users are offered a varied, balanced and nutritious diet. On the day of inspection service users were offered a choice of meals, and the food appeared to be healthy and appetizing. Individual needs are catered for, for example one service user was George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 13 allergic to tomatoes, and they had a meal cooked separately for them. The kitchen was clean and tidy and food was stored appropriately. All kitchen staff have received training in food hygiene. Records are kept of fridge and freezer temperatures. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18 The inspector was satisfied that the home has taken reasonable steps to help ensure service users are not at risk from abuse, and to enable service users and others to make a complaint if they so wish. EVIDENCE: The home maintains a complaints log, this evidenced that complaints have been appropriately recorded and dealt with. There is also a complaints log, which was on display within the home. This included contact details of the CSCI and timescales for responding to any complaints. The home is run by the Local Authority, and has a copy of their adult protection procedure. All staff have received training in adult protection issues, including the ICU’s therapy staff. Knowledge of adult protection issues has been built into all staff annual appraisal, and staff spoken to by the inspector demonstrated a good understanding of their roles and responsibilities with regard to adult protection. The home was able to evidence that any suspicions of abuse have been appropriately dealt with. All service users are on the electoral register, and able to vote in elections. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25 and 26 The inspector believes that physically the home is suitable to meet its stated purpose. Service users have adequate communal and private space, and the home was generally well maintained and domestic in character. EVIDENCE: The home is situated in the Leytonstone area of the London Borough of Waltham Forest, close to shops, transport networks and other local amenities. The home is built over three floors; service users are accommodated on all three floors. The home was generally well maintained. Some work has been done to address rotting window frames since the last inspection, but more still needs to be done. The manager informed the inspector that hopefully this work will be done within this year. The home provides adequate communal sitting and recreational space for service users, consisting of sitting rooms, dinning areas and a well maintained garden with appropriate garden furniture. The home has a designated smoking area. The home was generally clean and tidy, and furniture was well maintained and domestic in character. The home has suitable bathing and toilet facilities to meet service users needs. These are George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 16 situated throughout the home with locks fitted. Many of the baths are adapted to make them accessible to service users. On the day of inspection bathrooms and toilets were clean, tidy and free from offensive odour. All bedrooms in the ICU are ensuite. At the last inspection one bathroom had tiles missing from the wall, and these have been replaced. One toilet was found to be unmarked, and it is recommended that all toilets and bathrooms are clearly marked. The inspector checked several service users bedrooms, all of which were clean, tidy and free from offensive odours. Bedrooms were decorated to service users personal tastes, with family photographs much in evidence. Rooms had adequate furniture, including wardrobes and chest of draws. Bedding, carpets and curtains were well maintained and domestic in character. Ten bedrooms have been decorated since the last inspection. Bedrooms meet National Minimum Standards on size requirements. All bedrooms have central heating, and radiators all have appropriate protective covering. Lighting in rooms is domestic in character, and there is emergency lighting situated throughout the home. Bedrooms have adequate natural light and ventilation. The home has a policy in place on infection control. There are sluice rooms on all floors, and used continence products are disposed of in a macerator. Protective clothing such as gloves and aprons are available for staff. The home employs designated laundry staff, and the laundry room was well maintained, with an impermeable floor. Hand washing facilities are situated within the laundry room, and throughout the home. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The inspector believes that the home has sufficient staff on duty to effectively meet service users needs. Further, staff appeared to be competent and motivated, with a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24 hour staff support, with an emergency on call procedure. The home produces a staffing rota, and on the day of inspection this accurately reflected the actual staffing situation. As well as care staff the home employs cooking staff, cleaning staff, laundry staff, administrative staff and therapeutic staff who work specifically in the ICU. The home has policies in place on equal opportunities and recruitment and selection. Regular staff meetings are held, these are minuted, and all staff are able to contribute items to the agenda. All staff receive a structured induction . Training is on going, and records are maintained of staff training. These evidenced that staff have recently received training in manual handling, computers, fire safety, first aid and food hygiene. The inspector was informed that ten of the twelve care staff employed at the home either have or are currently working towards a relevant NVQ qualification, and that it is hoped that the other two will have the opportunity of doing an NVQ in the near future. All staff are given a copy of their job description. Staff spoken to by the inspector demonstrated a good understanding of their roles and responsibilities, and were observed to interact with service users in a friendly and supportive manner. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 18 George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 and 38 The inspector was satisfied that overall George Mason Lodge is a well run and well managed home. The manager is sufficiently qualified and experienced to carry out their roles and responsibilities effectively. EVIDENCE: The home has a manager, deputy manager and acting senior residential social worker in place. The manager has twenty one years experience of working in residential care, including seventeen years in a managerial capacity. They have a qualification in social work, and NVQ Level 4 in management. Service users spoken to informed the inspector that they found the manager to be approachable and accessible, and staff were observed to interact with the manager in a relaxed manner on the day of inspection. All staff receive formal supervision. Supervision duties are shared between the three senior staff. Minutes are maintained of supervision, and staff get their own copy of the minutes. Supervisions included discussions on service user issues, performance George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 20 and training needs. However, supervisions need to take place more regularly, for instance records indicated that some staff have had just two formal supervisions in the past year, and it is required that all staff receive formal supervision at least six times a year. All staff receive an annual appraisal. Care plan reviews, service user meetings and staff meetings all contribute to the quality assurance within the home. There was evidence of monthly Regulation 26 visits taking place, and copies of previous inspection reports were available to view at the home. The home issues regular questionnaires to service users and staff to gain their feedback on the running of the home. Those seen by the inspector evidenced generally positive feedback. All confidential records are stored securely, and staff and service users have access to them as appropriate. The inspector checked several policies at random, including adult protection and complaints, and all appeared to be satisfactory. The home has various health and safety policies in place, and staff receive health and safety training, including food hygiene and moving and handling. Fire fighting equipment was situated throughout the home, and fire exits were clearly signed and free from obstruction. Various routine health and safety checks are carried out, for example hot water temperatures and fire alarms are regularly checked. COSHH products were stored appropriately, and the home now has safe drinking water since the last inspection. The home has had recent satisfactory checks on Portable Appliances and the electrical installation. However, the home could not evidence that it has had a landlord’s gas safety check within the past twelve months, and this must be addressed. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 2 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 3 3 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 Standard No 16 17 18 Score 3 3 3 3 3 3 x x 2 3 2 George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 22 YES 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 OP19 Regulation 23 Requirement The registered person must ensure that the rotting window frames are repaired or replaced. (Timescale 30/4/05 not met) The registered person must ensure that thorough preadmission assessments are carried out on all service users prior to them been admitted to the home, to ensure the home can meet all the assessed needs of service users. (Timescale 30/4/05 not met) The registered person must ensure that all hand written entries entered on MAR chats are signed for. (Timescale 30/4/05 not met) The registered person must ensure that the home undergoes an appropriate gas safety check at least once every twelve months. (Timescale 30/4/05 not met) The registered person must ensure that the home only admits service users if they are satisfied that the home can meet all their assessed needs. The registered person must ensure that service users have G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Timescale for action 30/9/05 2. OP3 14 30/9/05 3. OP9 13 30/9/05 4. OP38 13 30/9/05 5. OP4 14 30/9/05 6. OP8 13 30/9/05 Page 23 George Mason Lodge Version 1.20 7. OP36 18 access to all health care as appropriate, including dental and eye care. The registered person must ensure that all staff recieve regular formal supervision at least six times a year. 30/9/05 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 OP21 Good Practice Recommendations It is recommended that all toilets and bathrooms in the home are clearly marked. George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI George Mason Lodge G56 G06 S36539 George Mason Lodge V216559 310505 Stage 4.doc Version 1.20 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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