Inspection on 15/01/07 for Henley House

This inspection was carried out on 15th January 2007.

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

Henley House 16/09/08

Henley House 03/10/07

Henley House 23/02/06

Henley House 01/09/05

Henley House 11/01/05

Henley House 11/08/04

Henley House 12/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Henley House 225 Whalley Road Accrington Lancashire BB5 5AD Lead Inspector Mrs Lynn Mitton Key Unannounced Inspection 10:00 15th January 2007 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 Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Henley House Address 225 Whalley Road Accrington Lancashire BB5 5AD 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) 01254 232763 01254 237022 Wellfield & Henley House Ltd Ms Susan Margaret Brady Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service shall, at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection. 23rd February 2006 Date of last inspection Brief Description of the Service: Henley House is registered with the Commission for Social Care Inspection to provide accommodation and personal care to 23 older people. The property is Victorian and set in well-maintained gardens. The home is located on the main Whalley Road and is close to local shops, this road is also situated on a main bus route to all towns in the Hyndburn area. Accommodation is provided in 23 single rooms, 18 of which have en-suite facilities. There were two lounge areas and a dining area. Smoking is permitted in a specially designated area. Fees for the cost of a weeks care at Henley House between £320.00 and £360.50 per week. There was information available to potential residents and their families advising them of the home and giving them details about the type of service they could expect. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted on 15th January 2007. The registered manager of the home had completed a pre inspection questionnaire. The inspector spoke to most service users, visitors to the home and to the care staff on duty at the time of the inspection. Throughout the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of service users. Records regarding these people were inspected. Two residents was case tracked, their file examined in detail and two support staff member’s files were also case tracked. Four of the Commissions resident’s questionnaires were returned, and eight visitors/relatives questionnaires were returned. Comments and findings of these surveys are referred to throughout this report. The inspector conducted the inspection with the registered person and the registered manager. During the inspection a number of records, policies and procedures were also viewed. What the service does well: One resident’s friend; “we find the care home to be warm and friendly. The staff always welcome you on visits and are very helpful. Our friend is also very happy with the home and the level of care received”. Another relative wrote; “Since my relative arrived at the home two years ago, he has always been cared for in a positive way. Family visitors have been made very welcome and invited to any special events. I am confident that my relative is being well looked after”. One resident wrote; “The service and care are the best you can have”. Another resident told the inspector; “Its 1st class here – really great – the staff can’t do enough for you they are so very kind and caring and the food is very good indeed”. Information about residents care needs was obtained before they were admitted to the home. Visitors were made welcome at Henley House, and could visit at any reasonable time. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 6 Mealtimes were a social occasion and the food served was varied and enjoyed by the residents. The general layout and décor of the home provided comfortable surroundings, and was warm, tidy and clean. State of the art laundry facilities were in place. There were sufficient staff on duty to meet service users needs. The attitude of the staff and management is to run the home around the needs and choices of the residents. The views of residents and visitors about the running of the home were being sought. Resident’s finances were dealt with in a satisfactory manner. What has improved since the last inspection? What they could do better: Not all residents received a completed copy of the terms and conditions of their stay at Henley House. Care plans did not fully document resident’s personal care and health needs, nor did they fully demonstrate how they were to be met. Safe administration and recording of resident’s medication was not in place. A regular programme of activities would ensure that residents had opportunities for their enjoyment, mental and physical stimulation. The home complaints policies and procedures must be reviewed regularly and always on view and available to residents and the homes visitors. Revision of Henley House’s protection from abuse policies and procedures, and staff awareness training would be of benefit in ensuring the safety of the residents, and give care staff clear guidelines. Odour management in some areas of the home needed further attention. Recruitment and selection procedures do not fully protect residents. The safety of some facilities at the home must be in place in order to ensure to safeguard the health and safety of the residents and care staff team. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP2, OP3 & OP6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission procedure for new residents ensured that all information about their care needs was obtained before they arrived. This enabled the staff to have a clear understanding of what they needed to do for them. There was clear information about the terms and conditions of their stay at Henley House; unfortunately not all residents received a completed copy of this document. EVIDENCE: One resident wrote; “I was shown round the home, and was visited at my previous accommodation to assess my capabilities”. Any new resident wishing to stay at Henley House would have an assessment completed prior to their admission. Two residents were case tracked and both Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 10 had an assessment document in place, however, both these documents needed signing and dating. Resident’s contracts were seen. They explained the terms and conditions of residence at Henley House. However, there was not one in place for one resident, the other resident case tracked did have one in place, but personal details had not been completed, for example, the room number, the fees and signatures of the resident and the manager. Intermediate care is not offered at this home. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP7, OP8, OP9 & OP10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans did not fully document resident’s personal care and health needs, nor did they fully demonstrate how they were to be met. They were being reviewed to ensure that any changes were documented. Safe administration and recording of resident’s medication was not in place. EVIDENCE: One resident wrote; “The home has good working relationships with medical dispensaries, doctors and district nurses as well as being efficient with dispensing medicines etc”. Two care plans were case tracked; on them was some information identifying resident’s care and health needs and how they were to be met by care staff. The inspector and registered manager discussed how more detail would benefit these documents. There was no evidence that residents or their next of kin had been involved in the care plans. The contents of the daily records were also Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 12 discussed with the registered manager. Some information was also missing from the files, for example, a photograph. The inspector examined the homes medication system. A monitored dosage system was in place. Consent of administration of medication forms were seen. Oxygen storage notices were in place. Regular temperature checks of the medication storage fridge were made. The inspector noted that there was a discrepancy in the controlled drugs register, where the new delivery of drugs had not been recorded properly. Also, the number of pain relieving patches for another resident were not being recorded at all. One tablet was found by the inspector on the dining room floor. The inspector advised that care staff administrating medication must be vigilant in ensuring that drugs are taken at the time they are distributed. A drugs administration consent form was found for only one resident case tracked. Residents spoken to told the inspector that they were spoken to and treat with dignity and respect and gave examples of this. The inspector observed very positive, caring and respectful interaction between residents and care staff. One resident told the inspector; “Its first class – really great – the staff can’t do enough for you, they are so kind and caring and the food is very good indeed”. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, OP13, OP14 & OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A regular programme of activities would ensure that residents had opportunities for their enjoyment, mental and physical stimulation. Visitors were made welcome at Henley House, and could visit at any reasonable time. Mealtimes were a social occasion and the food served was varied and enjoyed by the residents. EVIDENCE: One resident wrote; “I’m not certain that staff have time to organise many activities”. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 14 One resident wrote; “the food is good and varied”. The inspector and registered manager discussed comments written by one residents relative regarding the food. The inspector spoke to the resident concerned during the inspection and discussed and agreed an outcome with the registered manager. The inspector observed resident’s exercising choice and control over day-today elements of their lives. Care staff were seen to respect residents choices and opinions. Records had not been kept of any residents’ recreational activities undertaken since July 2006. The inspector was advised that a concert for residents was due to take place on 18th January. The inspector was advised that there were a number of frail residents who had not been able or wished to participate in some activities. The inspector was advised that clergy from the local Church’s visit residents on a regular basis. There were a number of visitors to the home on the day of the inspection. One resident was taken for a visit out of the home by a relative. A payphone was available and seen to be used by residents. The inspector was advised that all residents’ finances were dealt with by themselves or their family/next of kin. The homes 4 weekly rotating menus were seen. Varied meals were offered to residents with different dietary needs. Choices of food were available for breakfast and at suppertime. Specialised cutlery was seen to be in use. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP16 & OP18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home complaints policies and procedures must be reviewed regularly and always on view and available to residents and the homes visitors. Revision of Henley House’s protection from abuse policies and procedures, and staff awareness training would be of benefit in ensuring the safety of the residents, and give care staff clear guidelines. EVIDENCE: One resident’s relative wrote: “we are very satisfied with the care our sister receives. We have made minor complaints and these have been resolved amicably”. There had been no recorded complaints to the home or the Commission since the previous inspection. The complaints procedure was seen, however this had not been reviewed since June 2002. There was no evidence of a policy or procedure in the homes communal areas, however this was rectified during the inspection. The inspector advised that the complaint policy and procedure should be in clear evidence in communal areas of the home. The inspector noted there was a protection of vulnerable adults policy – this had not been reviewed since December 2004. The inspector advised that reference should be made to abuse being a criminal act, and that if this is the Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 16 case, what action should follow. The Whistle blowing policy had last been reviewed in August 2002. Not all care staff had undertaken recent prevention of abuse training. The inspector advised that this matter should be given high priority. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP19 & OP26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general layout and décor of the home provided comfortable surroundings, and was warm, tidy and clean. Odour management in some areas of the home needed further attention. State of the art laundry facilities were in place. EVIDENCE: One resident’s relative wrote; “My relative is self funded and has a tiny bedroom. I don’t complain because I feel my relative may suffer if I say anything. Apart from this my relative appears happy at Henley House”. The inspector conducted a tour of the communal areas, and some resident’s bedrooms. The home was clean, tidy warm and the standard of cleanliness and hygiene was good. The inspector was advised that there were 36 hours per week cleaning hours. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 18 The inspector advised that risk assessments must be put in place for all bedroom doors that are wedged open during the waking day. Laundry facilities were seen and industrial facilities were in place. The inspector noted that a new Otex ozone system had been installed, which will eradicate the risk of dangerous superbugs. The registered manager reported that this had made a significant improvement to the cleanliness and hygiene of the laundry system. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP28 OP29 & OP30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were sufficient staff on duty to meet service users needs. 76 of care staff were trained to NVQ level 2 standard. Staff training ensures that the care staff team are able to competently care for the service users. Recruitment and selection procedures do not fully protect residents. EVIDENCE: One resident wrote; “Staff seem to work hard tending to needs but are not always as “prompt” as they should be due to apparent staff shortages”. The staff rota was seen and this demonstrated which staff were on duty at any time during the day or night. The inspector was advised that 13 out of 17 care staff had now obtained NVQ 2 care qualification. The inspector observed residents being supported by competent and caring staff. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 20 Two staff recruitment files were case tracked and both were found to have shortfalls in the documentation required by legislation. This included POVA 1st check and CRB records and a photo. The inspector was advised that staff team meetings were held every 8 weeks. The last one was held in November 2006. The minutes of this meeting was seen and the inspector was advised that the net one was due to be held in the next three weeks. The inspector advised that evidence of staff training should be available on care staff’s file, and ensuring that gaps in employment are fully accounted for and recorded. For example, there was no evidence that either staff member case tracked had completed induction training, or had received 1:1 supervision. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP33, OP35 & OP38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The attitude of the staff and management is to run the home around the needs and choices of the residents. The views of residents and visitors about the running of the home were being sought. Resident’s finances were dealt with in a satisfactory manner. The safety of some facilities at the home must be in place in order to ensure to safeguard the health and safety of the residents and care staff team. EVIDENCE: Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 22 The registered manager advised that she had completed her NVQ 4 in care qualification, and the registered manager’s award. The registered manager was undertaking the Certificate in Managing and Safe Handling of Medicines training course, which it was expected would be completed by the end of January. The deputy manager had completed her NVQ 4 training. The registered person visits the home most days. The registered manager was not appointee for any resident; the inspector was advised that personal financial affairs were dealt with by the residents themselves, their next of kin or families. The inspector was advised that the last Quality Assurance survey had been completed in September 2006, and that a business plan was in the process of being completed, and that this would be available in the next three months. The inspector noted that the fire system had been independently checked in November 2006, and the fire fighting equipment had last been serviced in May 2006. The last fire system test had been conducted on 10th January, but there was no evidence of a fire drill. There had been a Gas Safety check completed in September 2006. A portable appliance test had been completed in December 2006, and the 5year electrical wiring certificate was not available. The homes lift had last been service in November 2006. The inspector noted that care staff case tracked had received training regarding moving and handling and prevention of fire, however, there was no evidence that these staff had received food hygiene training, 1st Aid, or infection control. The inspector advised that risk assessments must be put in place for all bedroom doors that are wedged open during the waking day. The inspector and registered manager also discussed the practice of staff holding one residents cigarettes as a means of monitoring their intake. The inspector advised that a risk assessment must be completed for this practice and evidence that this practice is in accordance with the resident and their next of kin. The inspector and registered manager discussed what action was being taken for one resident who had had 14 falls whilst in their bedroom – there was not reference in the care plan as to what action if any, had been taken to resolve this issue. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5(1)(b) Requirement The registered person must produce the terms and conditions in respect of accommodation to be provided and include the amount and method of payment of fees. The registered person shall have in place a written plan as to how the residents’ needs health and welfare are to be met. The registered person shall have in place a written plan as to how the residents’ needs health and welfare are to be met. The registered person shall make arrangements for the recording, handling, safe keeping, administration and disposal of medication. The complaint policies and practices must be in accordance with this legislation. The registered person must ensure that by staff training or other measures, to prevent residents from harm, abuse or being placed at risk or harm or abuse. Facilities at the home must be DS0000009436.V314783.R01.S.doc Timescale for action 01/06/07 2. OP7 15(1) 01/06/07 3. OP8 15(1) 01/06/07 4. OP9 13(2) 01/06/07 5. 6. OP16 OP18 22 & Schedule 4 (11) 13(6) 01/06/07 01/06/07 7. OP19 23 (2) 01/06/07 Page 25 Henley House Version 5.2 8. 9. OP29 OP30 19 10. OP38 kept odour free and safe. The registered person must operate a thorough recruitment procedure at all times. 18 (1a) The registered person is required (c)Sch 2 & to ensure that at all times 4 suitable qualified staff are working at the care home, and that they receive training appropriate to the work they are to perform. 13(6) The registered person must ensure that by staff training or other measures, to prevent residents from harm, abuse or being placed at risk or harm or abuse. 01/06/07 01/06/07 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP3 OP12 Good Practice Recommendations Resident’s needs assessment should be signed and dated on completion. Opportunities should be given for regular planned social and recreational activities. Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Henley House DS0000009436.V314783.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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