Inspection on 13/04/06 for Glendale

This inspection was carried out on 13th April 2006.

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

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

Other inspections for this house

Glendale 20/06/07

Glendale 05/03/07

Glendale 04/10/05

Glendale 10/05/05

Glendale 11/01/05

Glendale 06/08/04

Glendale 13/05/04

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

CARE HOMES FOR OLDER PEOPLE Glendale Ambleside Avenue Walton-on-Thames Surrey KT12 3LW Lead Inspector Damian Griffiths Unannounced Inspection 13th April 2006 09:30 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 Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glendale Address Ambleside Avenue Walton-on-Thames Surrey KT12 3LW 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) 01932 251980 01932 232593 sharon.blackwell@anchor.org Anchor Trust Lorraine Susan Hills-Avery Care Home 60 Category(ies) of Dementia - over 65 years of age (26), Learning registration, with number disability over 65 years of age (1), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (3), Old age, not falling within any other category (51), Physical disability over 65 years of age (8) Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the residents accommodated in the home up to 26 may fall within the category DE(E) and up to 8 may fall within the category PD(E). The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE. 1st February 2006 Date of last inspection Brief Description of the Service: Glendale is a purpose built care home for older people, situated in a quiet residential area in Walton-on-Thames. The home is approximately one mile from the town centre. Service provision affords permanent and respite care and includes care for service users with dementia and physical disability. Personal and communal accommodation is provided on three floors. There are five units, each with twelve beds, each self-contained, with assisted bathrooms, lounges, dining rooms, and kitchen facilities. All bedrooms are for single occupancy, with ensuite wash hand basins and WCs. There is a courtyard and enclosed landscape gardens. Glendale has off road parking facilities. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the Commission for Social Care Inspection year April 2006. It was an unannounced inspection and took place over a period of 7 ½ hours. Lead Inspector Damian Griffiths was accompanied by Geraldine Yates, CSCI Pharmacist and assisted throughout the visit by Mary Hunt the Manager, yet to be registered and representing the establishment. The inspector consulted seven residents, a relative and staff who contribute to the inspection report. The inspector sampled six residents care assessments and care plans to confirm whether standards were met. Other areas relating to the residents care needs that included a tour of the premises and inspection of staff rota and files was also conducted. The inspectors would like to extend thanks to the residents staff and management at Glendale for their assistance and hospitality. What the service does well: Glendale was comfortable, clean and homely the atmosphere was friendly and festive with preparations for the Easter celebrations. Resident’s bedrooms were personalised and well kept respecting individual lifestyle choices. Potential new residents have the opportunity to visit the home and experience short stays and there is information about the home readily available for enquirers. All residents files inspected contained contracts and information about their care needs and interests. Couples are also catered for providing they each occupy a single room however residents confirmed that their privacy and dignity was respected. Residents have the opportunity to have their say at regular monthly meetings. The new manager, yet to be registered, operates an open door policy for residents and staff and had ensured that guidelines for the complaints and comments procedures were correctly observed following complaints and incidences calling on the Surrey Multi-disciplinary procedure for the Protection of Vulnerable Adults. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The home needs to ensure that the residents assessed needs are recorded on a daily care plan and in particular residents with dementia need to have a sensitive and relevant activity programme. The home had recorded a lot of information about the residents but this was held in different places. Staff consulted were under pressure to inform new or agency staff what to do and new staff were not aware of information contained on existing care plans. Staff on the rota’s sampled did not have any recent training in dementia care and there was no guarantee of the quality of training received by the Anchor care bank staff. Comments received by residents and staff called into question the staff ratios on duty to meet the assessed needs of the residents from 9pm and 9am the next day. Staff training generally was good but in need of further improvements for staff to gain experience and confidence when working with residents with dementia care needs, activities and good mental health. The manager must register with CSCI. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 7 A quality assurance exercise was needed to assure, residents, relatives, staff, friends, and health and social care practitioners regarding the quality of service provided and residents suggested that they would like help to prepare agenda’s and questions for the residents meetings. 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. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, 4 and 5. Information about the home was available for residents and prospective residents to make informed choices. New residents received an adequate assessment prior to admission however there were gaps in staff ability to meet the specialist care needs of the residents. Pre-admission information was available to new residents. Intermediate care is not available at Glendale. EVIDENCE: Resident information packs about the home were evidenced in most of the resident’s rooms and each contained the last inspection report, which was also found on the notice board of each unit inspected. Six residents Assessments and Care plans were inspected each contained detailed information of their needs including resident’s contracts with the home. Since the last inspection a complaint had been made about the standard of the respite care service offered at the home. Areas of improvement related to assessment, care planning and staff response. Two recent assessments and care plans were sampled from residents receiving a respite service and each Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 10 had received a full assessment with corresponding care plans. The home was also updating its respite programme. Residents assessed as needing dementia care were not receiving a particularly specialised service although their basic care needs were being met. Staff had not received the training required to deliver this service more effectively. Please see the recommendations and requirements section of this report. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Care planning information and staff access to them including review of health care needs needed to improve. Medication administration had improved since the last inspection. Residents and couples at the home were afforded privacy and respect as appropriate. EVIDENCE: There was evidence that information recorded on the assessment document had not been followed up or recorded on the care plan. Residents consulted confirmed that religious needs were often not addressed and social and cultural needs such as visiting the pub and mixing with the locals was rarely open to them. Detailed care plans with photographs of each resident attached were available in files. Files however were stored in a different place to those used by staff on a daily basis. Staff found this information took time to find and was recorded on different forms and a variety of folders. Staff consulted understood the needs of the residents when questioned and confirmed that new staff and care bank had particular problems accessing information essential for understanding Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 12 the individual care needs of the resident. This often meant that experienced staff spent more time advising new staff of information that could be found in the care plans. Health care plans did not make clear what was currently being monitored in particular; recording of falls, action taken and prevention was not in evidence. One resident did not feel that staff had enough knowledge about her health needs. The manager agreed to reassess all residents with dementia needs. Medication administration had been a subject of concern to the Commission (CSCI) and an random inspection visit had showed that the home was experiencing problems with staff recording inconsistencies that had led to some residents not receiving the correct dosages of their prescribed medication and others not being referred for essential blood tests. The residents involved had not suffered any adverse affects and the home had informed CSCI of this problem. Staff involved were excluded from these duties and retrained as appropriate. The areas found to be at risk were inspected by the CSCI Pharmacist and included: drug disposal and recording, audit of drugs given daily (MAR), written notes, referral for blood tests and appointments, signatures, self medicating risk assessments, policy and procedures and training were some of the aspects inspected. The Pharmacist was able to confirm that the home had maintained consistency, good practice and correct procedures were in evidence. Staff were observed assisting residents with in their daily routine with sensitivity and politeness using residents preferred form of address. Residents consulted included couples confirmed that their privacy was respected at all times and that staff were generally sensitive to their needs however some care bank staff had said to be often unhelpful and rude. Please see the recommendations and requirements section of this report. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 15. Residents had a choice of the usual activities but generally low expectations were the norm and some residents felt they were unable to access local facilities. Family and friends were welcomed and encouraged to visit. Residents felt that the food was good but sometimes it to too long to serve. EVIDENCE: The residents were engaged in Easter celebrations that included preparation for a night’s entertainment including an Easter bonnet competition. The home has employed new activities organiser however she was without any specific training experience but was enthusiastic about her new post and had listed a programme of activities. Staff were expected to help and join in any activity and also be available to perform the daily tasks as required. Residents consulted did not feel that the activities were suitable and request for more evening events such as visiting the local pub ‘for a pint’ was not easy to achieve. Residents accepted this and did not expect much to change. Activities for male residents were not in evidence despite them being in a minority and therefore easier to arrange specific events such as visiting sports events trips out to the pub. This was also the case for residents with dementia care needs. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 14 Residents consulted about access to the electoral process and voting due on 4th May were going to use the postal system. The food at Glendale at the home was generally thought to be good but residents consulted stated that the food, despite being stored in heated trolleys was sometimes served cold due to the shortage of staff who were at times needed in other areas at short notice. Please see the recommendations and requirements section of this report. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Complaints had been managed with sensitivity and in keeping with the homes procedures including the Surrey’s Multi-Disciplinary Procedures for the Protection of Vulnerable Adults. EVIDENCE: The home had received three complaints and Vulnerable Adult issues since the last inspection. The complaints had been satisfactorily managed and resolved with actions and improvements noted. A complaint regarding the quality of the respite care received by one resident was considered to be unsatisfactory by the family and the home. A number of improvements had since been implemented to ensure the needs of the resident are met by staff. Social care teams and families had participated appropriately with vulnerable adult investigations. The home had acted immediately to allegations of staff misconduct and staff involved had been suspended. The manager has made additional adult protection training available for staff and staff facing disciplinary hearings were scheduled for completion within a week of this inspection. Service users consulted agreed that they felt safe and confident to make a complaint although some did not know whom the manager was. Comments regarding the standard of care ranged from: adequate to good with care bank staff being noted as offering a poor service and having a poor attitude. Please see the recommendations and requirements section of this report. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 16 Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The home was consistently clean and tidy throughout and the laundry services were very good however there was a need to invest further in this area to ensure the health and welfare of residents. EVIDENCE: A tour of the premises was conducted and the home provided a clean, homely and pleasant environment for residents. The garden was not in use at present but was due for attention. Residents consulted felt that the garden could be used more. Residents commented on the good quality of the laundering services available. The laundry rooms are situated on the ground and second floor the former being the largest. All rooms were in use and they were clean and tidy. Facilities for the efficient and hygienic laundering process were in place however the second floor area did not contain the same level of equipment. When the volume of laundry was great there was a need for staff to transfer it to the laundry room downstairs were it would intrude upon the residents using Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 18 the lift and corridors areas. Soiled laundry should not intrude on residents therefore additional washing capacity must be made available on the second floor. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30. The numbers and skill mix of staff was felt to be inadequate by some residents and staff consulted and further development of dementia care services was needed. EVIDENCE: Staff rota’s, for two days and training records were inspected to establish whether they linked well to provide the staff with the skills needed to care for the residents on their shift. Residents consulted said the breakfasts were left to get cold because staff were sometimes called away without being able to serve. Staff and residents consulted confirmed that the were at times only two staff were present however the rota’s inspected showed three staff available throughout the night on each unit and also on morning shifts although in the event of unexpected sickness this may happen. Five staff files of the staff providing care for the two nights appearing on the rotas were inspected. The training was generally good and contained: first aid, safe handling, food hygiene, fire safety and they majority of staff had attained level 2NVQ. Only one staff member was trained to dispense medication but no members of staff had received any training in dementia care. There was also room for improvement to ensure that staff were aware of the ageing issues facing the residents as was stated in a recent complaint about the staff lack of understanding the short term needs of a resident receiving respite care. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 20 It was not possible to confirm whether the level of ‘care bank’ training necessary for such challenging and varied work had been attained. The manager aware of this situation and was taking steps to rectify the shortfalls in staff training. Dementia care training had been approved but the time and content was still to be decided. Please see the recommendations and requirements section of this report. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 33. The manager has yet to registered with the Commission (CSCI) however the service users benefited from the management approach at the home providing an open, positive atmosphere. The home must conduct a quality assurance monitoring exercise to include relatives, health and social care practitioners. EVIDENCE: The manager had recently gained her Managers Award and confirmed that she will be applying for registration with the commission shortly. Staff and residents were satisfied with the style of management at the home however a few residents did not know who the manager was but did not appear to be overly concerned. Staff had no complaints about the management style and felt they were able to approach the manager if they had a problem. Residents have access to monthly residents meetings but were not sure about the usefulness of them. Resident’s consulted felt an overall dissatisfaction with Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 22 the outcome of these meetings and most residents consulted wanted to be more involved with the decision-making but found it difficult to present their concerns or ideas. Residents agreed that they would like some help prior to the meetings to ensure their points were understood and minuted. Other Issues described within this inspection report by residents have included: Problems with the food getting cold, staff shortage and alleged attitude and poor training of care bank staff, lack of any relevant activities for male residents or access to a local amenities including the pub. The manger agreed that a quality assurance monitoring exercise was due and will be reassessing residents with dementia needs to establish whether current staffing levels are adequate. Please see the recommendations and requirements section of this report. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 3 X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X X Glendale DS0000039536.V289922.R01.S.doc Version 5.1 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 OP4 Regulation 15(1) Requirement The assessment and the care plan must give sufficient detail about the service user to enable correct action to meet needs, in particular those residents with dementia needs and to review and implement the religious, cultural needs of residents. This was the second time this requirement has been made. A new timescale for completion has been agreed. The service must ensure that the assessment details are transferred adequately to the care plan in sufficient detail about the service user to enable correct action to be taken to meet the needs and is accessible and understandable to all staff, especially new and care bank staff. The service must ensure that the health care needs of residents are met i.e. psychological and mental health care needs and falls are being monitored and suitable action taken to reduce risk. DS0000039536.V289922.R01.S.doc Timescale for action 13/07/06 2. OP7 14(1) & 15 (1) 30/05/06 3. OP8 14(1)(2) & 15(1) 30/05/06 Glendale Version 5.1 Page 25 4. OP8 14(1)(2) & 15(1) 5. OP26 13(3) 16(2)(e) 6. OP27 14(1), 18(1) (A)(c) 7. OP30 14(1), 18(1) (a)(c) 8. OP27 14(1),18( 1) (a)(c) & 24(1)(a)( b)(2) 9(2)(a)(b) 24(1)(a)( b) 9 10. OP31 OP33 The service must ensure that care plans are accessible and understandable to all staff, especially new and care bank staff. The service must ensure that adequate laundering provision is made on the 2nd floor laundry area by the instillation of another washing machine. The service must ensure that residents assessed needs are met by an appropriately trained and experienced workforce that includes new and care bank staff. The service must ensure that residents assessed needs are met by an appropriately trained and experienced workforce that includes new (supervised) and care bank staff. The service must ensure that adequate and skilled staff are available to meet the assessed needs of the residents at all times but especially from 9pm and 9am the next day. The service must ensure that the manager is registered with CSCI. The service must conduct a Quality Assurance exercise with Residence, Relatives Staff, Friends and Health and Social Care practitioners regarding the quality of services provided. 30/05/06 30/05/06 30/05/06 30/05/06 30/05/06 30/05/06 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 26 1. OP30 2. OP5 It was recommended that the dementia care training that has already been identified be made a top priority and to include activities as directed by NAPA as was the intention of the service manager. It was recommended that the service record the issue of the Glendale information packs. Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Glendale DS0000039536.V289922.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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