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Inspection on 27/06/05 for Great Western Road, Flat 3, 22-24

Also see our care home review for Great Western Road, Flat 3, 22-24 for more information

This inspection was carried out on 27th June 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a comfortable, homely and safe environment for service users. Service users are supported to make their own choices and are supported to maintain a full programme of activities and to take part in the local community. The service users plans are of a high standard and person centred The staff team understand the needs of the current service users and are managed by an experienced service manager.

What has improved since the last inspection?

There have been a number of improvements to the service since the last inspection, with nine requirements set at the last inspection being fully met. Service users` risk assessments have been reviewed and updated and the wishes and feelings of service users regarding death and funeral arrangements are now recorded. Personal files are now securely stored to maintain service users` confidentiality. The condition of the environment has improved since the last inspection. The source of the water damage has been identified, and major building work has been completed to rectify the cause. New Carpets have also been fitted to the main hallways. A computer has been installed in the home since the last inspection, which has enabled staff to update service users` personal plans and risk assessments and other documentation.

What the care home could do better:

There is a need for staff to be up to date with training in safe working practices to ensure that service users` health and safety is protected and promoted. Staff must ensure that the date of opening medication is recorded to ensure that medication is not used past their expiry date. Consideration should be given into making the service users` personal plans and contracts more accessible to service users.

CARE HOME ADULTS 18-65 FLAT 3, GREAT WESTERN ROAD (22-24) FLAT 3 22 - 24 Great Western Road LONDON W9 3NN Lead Inspector Ffion Simmons Unannounced 27 June 2005 & 10.30 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Flat 3, Great Western Road (22-24) Address Flat 3, 22 - 24 Great Western Road 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 7289 5041 020 8964 5507 The Westminster Society for People with Learning Disabilities Christine Quantock Care Home 6 Category(ies) of Learning Disability (6) registration, with number of places FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No Date of last inspection 19 November 2005 Brief Description of the Service: Flat 3 is a purpose-built, wheelchair accessible, first floor flat providing accommodation for six service users of either gender with a learning disability. The property is owned and maintained by Paddington Church Housing Association, and the care is provided by the Westminster Society for People with Learning Disability, a voluntary organisation. The home is located in a residential area of Westbourne Grove, close to shops and transport links. The home is part of a small residential block that includes a second registered care home and six flats for people with a learning disability who are living independently. Each person living in the home has their own bedroom. Communal areas, bathrooms and toilets are shared. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place between 10.30 and 16.45 on the 27th June 2005. The inspector spent time observing care practices, talking to service users, staff and checking records and documentation. Comment cards were also sent out as part of the inspection process to gain feedback from service users, relatives and health care professionals. A total of seven comment cards were completed and sent to the CSCI. Some comments from these have been incorporated into the body of the report. What the service does well: What has improved since the last inspection? There have been a number of improvements to the service since the last inspection, with nine requirements set at the last inspection being fully met. Service users’ risk assessments have been reviewed and updated and the wishes and feelings of service users regarding death and funeral arrangements are now recorded. Personal files are now securely stored to maintain service users’ confidentiality. The condition of the environment has improved since the last inspection. The source of the water damage has been identified, and major building work has been completed to rectify the cause. New Carpets have also been fitted to the main hallways. A computer has been installed in the home since the last inspection, which has enabled staff to update service users’ personal plans and risk assessments and other documentation. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 6 What they could do better: 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. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 4 & 5 Full information is available on service users prior to them moving in, to enable their needs to be met. Service users have the opportunity to visit the home prior to moving into the home, to get to know staff, service users and to get familiar with the environment. EVIDENCE: A new service user moved into the home from another of the Westminster Society’s projects, two weeks prior to the inspection. Full information was available on file for the service user and an individual plan of care and risk assessments were in place. The service user is well known to the service users and staff at Flat 3 and is a close friend of one of the service users in flat 3. They visited the home on a number of occasions prior to moving in. This gave them the opportunity to get to know the staff and feel familiar with the environment before moving in. Individual contracts are available for each service user. The document includes pictures and symbols attempting to make the document more accessible to service users. Since the last inspection, staff have sought the input of an independent advocate to assist with supporting service users to understand the content of the contract. Staff during the inspection also had good idea s of how to make the document more accessible using multi-media. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 & 10 The service users plans are of a high standard, are person centred and reflect that service users are involved in decisions about their lives. Consideration should be given for making the care plans more accessible to service users. Thorough risk assessments are in place for identifying risks and minimising these risks and for promoting service users’ safety. EVIDENCE: The inspector viewed the personal files of three service users. Personal information relating to each service user is stored in a locked store cupboard within the home. Each service user has a very detailed individual plan, which outlines their main care needs. Goals of how the needs are to be met are also identified and regularly assessed. A daily log is completed, which was evidence that staff are supporting service users to meet their goals. The plans are person centred and reflect that service users’ wishes have been taken into account and that service users are involved as far as possible in the decisions about their lives. The assistant service manager shared some excellent ideas for making the care plans more accessible to service users and these should be considered and implemented. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 10 Risk taking policies are available for each service user, highlighting potential risks and strategies for minimising these risks. The risk assessments have been updated since the last inspection. Staff have worked very well with the input of the Psychologist and Challenging Needs Nurse to identify triggers to one service user’s challenging behaviour and have developed a “distracter list” and a list of signs/cues to behaviour. Staff were seen to be engaging well with the service user during the inspection and quickly identified changes in the service user’s behaviour and supported them to go for a walk to the local café for a coffee as a method for distracting the service user. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 & 17 Service users are well supported to access their programme of activities and to take part in the local community. Staff rotas are prepared to ensure that there are sufficient staff on duty for facilitating this. EVIDENCE: Service users living at flat three have a full programme of activities. On the day of the inspection, one of the service users told the inspector that they attend the day service every Monday. Another service user talked about going to their club on Monday evenings and Friday evenings. One service user had been to the day centre and was later getting ready to go to their dance class. The home’s house rules are displayed in the small lounge in pictorial format. Service users’ individual abilities and housekeeping responsibilities are highlighted in individual plans. Service users are supported with tasks such as preparing meals and staff were offering service users with a choice of what they would like to eat. One service user has a pictorial menu to enable them to choose their meals. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 12 One of the service users spoke openly about their sister and that she visits on Tuesday nights. Thee relatives who commented in the comment cards confirmed that they can visit their relative in private and are satisfied with the overall care. The following positive comments were received “Very pleased with the home and the care my relative is getting.” FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Service users’ personal care, physical and emotional needs are well documented and staff have a good understanding of these needs and promote service users’ independence. There was also evidence of good multi disciplinary working. The system for managing the medication is good but staff must record the date of opening on bottles of medication to ensure that they are not used past their expiry date. EVIDENCE: The service users’ personal care support needs are highlighted in their individual plans and include service users’ preferences. Service users’ abilities and ways for maximising their independence are also noted. Checking personal records was evidence that service users’ healthcare needs are well recorded and that they have access to the input of the multi disciplinary team. The team have recently been working very closely and successfully with the multi-disciplinary team in supporting one of the service users who had challenging needs. On the day of the inspection, one service user was being supported to attend a medical appointment in the morning and another was being supported to attend a hospital appointment in the afternoon. A comment card was received from a health and social care professional and contained the following comments “This home has a high FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 14 standard of care for the service users. They always invite us, other health and social care professionals when the clients ’reviews are carried out.” Medications are received mainly in blister packs, and are securely stored in a metal cabinet. The medication records were all well completed. It remains a requirement that staff record the date of opening on bottles of medication. Some work has been completed since the last inspection, to note the wishes and feelings of service users concerning death and funeral arrangements. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home’s complaints system is good and there is evidence that service users’ views are listened to. Systems are in place for protecting service users from abuse. EVIDENCE: The complaint records were checked which was evidence that service users views are listened to, the complaint recorded and acted upon where possible. Service users are also encouraged to view their concerns during residents’ meetings. A policy is available for the protection of vulnerable adults and all the staff have recently received training for managing challenging behaviour. The assistant service manager confirmed that a copy of the society’s policy on physical intervention and restraint has been obtained and is available in the home for staff reference. Lone working risk assessments are also in place. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 The home’s environment has been enhanced since the last inspection and is very homely, clean, comfortable and safe. The home is well located to enable service users to access the local amenities. EVIDENCE: Flat 3 is a purpose-built, wheelchair accessible, first floor flat providing accommodation for six service users. There is an entry phone system fitted to the main front door. CCTV cameras have been installed to monitor the main entrance only. The home is well located, close to shops and transport links and provides a comfortable and homely environment. Since the last inspection, the cause of the water damage seen at the last inspection has been identified and major building work has been completed to rectify the cause. A new suspended ceiling has been put in place and a new carpet has been fitted in the main hallways. Service users commented positively on the work completed to their home, which has enhanced the environment. The broken toilet chair in the separate toilet room has also been repaired since the last inspection. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 17 There is a separate laundry room in the home, which is fitted with two washing machines and two dryers. The home was clean and hygienic at the time of the inspection. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 The current staff team have a very good understanding of the service users’ needs and work hard to meet these needs sometimes under very difficult circumstances. Good training opportunities are available for staff to develop their skills and knowledge. All staff however need to be up-to-date with their training in safe working practices to ensure that service users’ health and safety is promoted. EVIDENCE: There is a full and permanent staff team currently working at the home providing service users with continuation of care. Some of the staff team have been working with the current service users for a number of years and so have a very good understanding of their needs. Staff rotas were checked and discussed with the assistant service manager. The staff rotas are prepared with the needs of the service users in mind. The assistant service manager explained that particularly on Mondays, consideration has to be given for ensuring sufficient staffing levels for supporting the service users to attend their social and health activities which includes dance classes and attending a session at the hydro pool. Training records were checked, which provided the evidence that there are a number of training opportunities available. One staff member had completed a number of training sessions including foundation, protection and values FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 19 training, mental health issues, MAKATON, foundation communication, epilepsy awareness and Learning Disability Awareness. All the staff team have recently had training in managing challenging behaviour and worked very well to develop a tool for managing some challenging behaviours recently displayed by one of their service users. Not all staff were up-to-date with their training is safe working practices and this is a requirement. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 42 The home is currently well run by an experienced service manager but she has recently resigned. Arrangements must be made for a suitable replacement. There has been an improvement in the health and safety monitoring in the home. Staff need to be up-to-date with their training in safe working practices to ensure that the health and safety of service users are promoted and protected. EVIDENCE: The service manager for flat 3 has resigned from her post and will be leaving the home in August 2005. The Manager is very experienced and has worked closely with the service users and some members of the staff team for a number of years. The Society must formally notify the commission of this change and must outline the arrangements that have been made, or are proposed to be made, for appointing another appropriate person to manage the home. The Society must also ensure that the newly appointed person completes a registered manager’s application with the CSCI’s Central Registrations Team. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 21 The inspector noticed an improvement in the health and safety monitoring in the home. Fire alarms are now tested weekly as per the regulations and water temperatures are also tested and recorded weekly. Fire drills are performed and the fire equipment is tested. Door guards have been fitted to fire doors throughout the home. COSHH assessments are also in place for the products used in the home. Staff training records were checked and this provided the inspector with the evidence that not all staff are up-to-date with their training in safe working practices including infection control, fire, health and safety, food hygiene and manual handling. Staff must be fully updated to ensure that service users’ health and safety is maintained. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 FLAT 3, GREAT WESTERN ROAD (22-24) Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 23 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 20 Regulation 13 [2] Requirement Staff must record the date of opening to ensure that the medication is not used past its shelf-life. This is a repeat requirement. Staff must be up-to-date with their training in safe working practices including infection control, fire, health and safety, food hygiene and manual handling. The Society must formally notify the commission of the change in registered manager and must outline the arrangements that have been made, or are proposed to be made, for appointing another appropriate person to manage the home. The newly appointed manager must complete a registered manager’s application with the CSCI’s Central Registrations Team. Timescale for action 01 August 2005 2. 35 & 42 13 [3] [4] [5] [6] 27 September 2005 3. 37 39 01 August 2005 4. 37 Care Standards Act 2000 27 September 2005 FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 24 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 6 Good Practice Recommendations Ideas for making the care plans more accessible to service users should be considered and implemented. FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26/28 Hammersmith Grove London W6 7SE 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 FLAT 3, GREAT WESTERN ROAD (22-24) G60-G09 S10877 FLAT 3 UIV229390 270605 STAGE 4.doc Version 1.40 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. 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