CARE HOMES FOR OLDER PEOPLE
Highwell House Highwell House Highwell Lane Bromyard Herefordshire HR7 4DG Lead Inspector
Sandra J Bromige Unannounced Inspection 5th December 2005 10:35 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 Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 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. Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Highwell House Address Highwell House Highwell Lane Bromyard Herefordshire HR7 4DG 01885 488721 01885 482882 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) Ms Karen Anne Rogers Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28), Physical disability over 65 years of age of places (19) Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Service users assessed as being in the nursing category must be accommodated in the fifteen bedded nursing unit. Service users in the physical disability category must be accommodated in the nursing unit or on the ground floor of the residential unit. From time to time up to three (3) service users between the ages of 60 and 65 years of age can be admitted into the nursing unit as long as their needs can be appropriately met within an elderly setting. Service users who have mental health needs relating to confusion, mild dementia can be accommodated in the nursing unit as long as these needs are secondary to their general nursing needs. 11th July 2005 4. Date of last inspection Brief Description of the Service: Highwell House is owned by Ms Karen Rogers, who also owns and manages another Care Home for older people in Bromyard. Highwell House is situated half a mile from Bromyard town centre and enjoys excellent views across the Froome Valley to the Malvern hills. The home provides nursing care for sixteen older people in a purpose built unit and personal care for twelve older people in an adjacent Georgian house. Some service users may have a physical disability. Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 6.25 hours. focus of the inspection was to follow up the requirements recommendations from the last report dated 11th July 2005. The and The Inspector looked around parts of the building and a number of records were inspected. Residents, staff and a visitor were spoken to. There is no registered manager in post and the registered nurse who has been supporting the staff on an interim basis has recently left. The Provider was not at the Home at any time during this inspection. A response was received from the Provider following receipt of the last inspection report. Thirteen requirements from the last inspection report have been brought forward as they have not been met within the timescales given. These relate to healthcare records, privacy for residents’, infection control, health & safety of people living and working in the Home and the monitoring of the Home by the owner. Failure to meet the requirements of this report may result in the Commission taking enforcement action against the Home. What the service does well: What has improved since the last inspection?
The nursing unit has increased its registered beds from 15 to 16. Three new specialist nursing beds have been purchased along with further mattresses to prevent the breakdown of residents skin due to pressure.
Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 6 Hand cleansing gel has been provided throughout the Home for staff and visitors to enhance the Home’s procedures for the management of infection control. Residents’ who are immobile were being transferred to wheelchairs by the staff by using hoists and other moving & handling equipment. There were sufficient stocks of medicines. The correct checks are being carried out for staff prior to employment. What they could do better:
Care plans must be improved and reviewed each month or more often if the care needs change, to ensure that the staff know what to do for each resident. Risks to residents’ when moving, and for skin care, dietary needs and continence must be reviewed each month. Residents’ must be consulted about the content of their individual care plans and their agreement to the content obtained. Residents’ must be weighed each month to ensure that they are not losing or putting on too much weight, which may be a risk to their health. The management of the residents medicine must be improved to ensure that they are stored at the correct temperature in the fridge, they are written up correctly on the medicine records, residents’ allergies are recorded and items are dated when opened. A new medicine reference book needs to be purchased for both units. More screens are still needed in two shared bedrooms to make sure that the resident’s privacy is maintained at all times. Records of complaints and concerns raised by residents, visitors and staff must be recorded and be available for inspection as part of the Home’s monitoring of the standard of the service provided. Foul washing needs to be sluiced in the machine provided and not by hand. Bath seats must be thoroughly cleaned underneath each time they are used. The laundry floor must be upgraded to provide a washable surface that is not impervious. Two care staff must be on duty at all times during the daytime in the residential unit to ensure that the residents’ care needs are met. All new staff must receive structured induction training to ensure that they are aware of the required standards, policies and procedures in the Home. There were four serious concerns noted during the inspection. These were that
Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 7 cleaning products when not in use by staff were being left accessible to residents who are confused, a broken reclining chair was in use by a resident, a rusty commode was being use by a resident and an electric light was in use and the wires were exposed. Immediate requirement notices were left at the Home with the Nurse in Charge and follow up letters were sent to the owner the next day telling them that these issues must be put right immediately. More training is needed for staff in fire procedures, moving and handling, and Protection of Vulnerable Adults. More checks need to be made by the Home to ensure the water is stored at the right temperatures to stop the growth of any organisms, the bath/shower water is the right temperature before use, bed rails are used and fitted correctly to the right bed, and wheelchairs are safe to use and the tyres are inflated. The health & safety posters in both of the units need to be completed with the relevant information for staff about local arrangements for health & safety in the Home. The owner needs to make sure that she sends a monthly report into the Commission about the quality of the service and the premises. The owner needs to review the condition and quality of the commodes in use in the Home to ensure that they are suitable for moving by staff and that they have washable surfaces, which are not damaged to ensure that cross infection does not occur. The radiator in the ground floor toilet in the residential unit needs replacing. 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. Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 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 Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 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): None of these standards were assessed. EVIDENCE: Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 No progress has been made on improving arrangements to ensure that the health care needs of residents are identified in the individual care plans and are met. These shortfalls have the potential to place residents at risk. Some progress has been made regarding management of medication, although further improvement is needed to ensure that residents’ medication needs are met. Resident’s privacy and dignity is not being maintained at all times. EVIDENCE: Care plans are not in place showing all care needs for identified residents, including social care plans. Moving & handling risk assessments are not being reviewed each month. Care plans identifying problems with mobility including being at risk of falls are not being reviewed each month. Neither of the care plans seen had been reviewed each month. Nutritional & continence risk assessments were not in place for all residents’. Residents’ are not being weighed on a monthly basis. Skin care assessments are in place but are not being reviewed each month. All residents seen were nicely dressed. There was information showing that residents’ are being referred to other professionals as required.
Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 11 Medication Administration Records are still at times being handwritten and are not being checked by a second nurse to ensure that the medication has been written up properly. Information about resident’s allergies is not always being completed on the Medication Administration Records. Creams and ointments are not being dated when opened. The temperature of the medicine fridge is not being checked every day. Two shared rooms on the residential side did not have sufficient screening around the beds to ensure that resident’s privacy is not compromised when personal care is being given. Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed. EVIDENCE: Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 13 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 & 18 Complaint records are not available, which are important records to enable the Provider to measure the quality of the service offered by the Home. Staff training is needed about abuse to ensure this is recognised and acted upon by the staff in the Home. EVIDENCE: The complaint records were unable to be located by the administrative staff other than a letter to a complainant from the Provider dated February 2005. A report from the Provider dated August 2005 indicates that a complaint had been received from the family of a resident, and a complaint from a visiting professional has also been received but the records of the Home’s investigation into these complaints were not available. Not all staff have received Protection of Vulnerable Adults training particularly regarding the Herefordshire local procedures for Protection of Vulnerable Adults. Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 14 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): 22 & 26 Some of the aids and equipment provided by the Home are broken or in a poor condition which may be a potential hazard to the people using them. The current practice for the handling of foul laundry is still not in line with recommended practice for the control of infection. EVIDENCE: New equipment has been purchased since the last inspection such as specialist nursing beds and skin care equipment. No new reclining chairs have been purchased by the Home since the last inspection. A reclining chair identified at the last inspection as not functioning properly was still in use by an identified resident. An immediate requirement was made on the day of the inspection requiring the Home to risk assess the safety of this chair. A number of the commodes in use in the residential unit are badly worn, have no wheels for staff to move them and are made of wood, which may have implications for moving & handling and infection control.
Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 15 The assisted bath on the ground floor of the nursing unit is still not in use. The underside of the bath seat on the assisted bath on the ground floor of the residential unit needs a thorough clean and the non-slip mat on the seat was badly stained. The care staff changed this on the day of the inspection. The radiator in the ground floor toilet adjacent to the kitchen in the residential unit is very rusty. In addition to the Home’s current procedures for infection control, they have also now provided hand-cleansing gel for use by staff and visitors to the Home. This is good practice. Special bags are provided for foul laundry that opens up in the washing machine to minimise the risk of cross infection through handling of foul washing. This procedure is still not being followed at all times, as staff are hand sluicing foul laundry. The bags are also being overfilled and will not go through the opening on the washing machine unless they are opened by the laundry staff and transferred to another red bag. This is not good practice, as laundry staff have to handle foul laundry. Linen is being washed at the correct temperatures to thoroughly clean the linen and control the risk of infection. The laundry is situated in the cellar of the Home. The concrete floor has been painted, but is now very badly worn and needs attention as it is now not impervious, which makes it difficult to keep clean. Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 16 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. 29 & 30. The deployment and numbers of staff on duty at the time of the inspection were sufficient to meet the residents’ care needs. There are not always sufficient staff on duty in the residential unit to meet the residents’ care needs. The procedures for the recruitment of staff are robust offering protection for the people living at the Home. Staff are not receiving any structured induction training to ensure that they are familiar with the Home’s standards, policies and procedures. EVIDENCE: There was a registered nurse and two care staff on duty in the nursing unit for 13 residents and two care staff on duty in the residential unit for 11 residents. In addition there was a cook and one member of domestic staff in each unit. The domestic staff covering the residential side was also working in the laundry. Administrative and maintenance staff were also available on the morning of the inspection. The Provider was not in the Home throughout the duration of the inspection. Rotas show that on the weekend prior to the inspection there were times during both days when there was only one member of staff on duty in the residential unit. The recruitment records of a recently recruited member of the care staff team were satisfactory. There was no documentary evidence of any induction training for this identified member of care staff other than a signed copy of the Home’s Whistle Blowing policy. Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 17 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 & 38 All systems are not in place to promote and protect the health & safety of the people living and working at the Home. EVIDENCE: There is currently no registered manager in post and the temporary registered nurse appointed for an interim period to support the staff team has now left. A manager (designate) has been appointed and it is anticipated that she will join the Home in the New Year. Since the last inspection in July 2005 the Commission has only received two reports from the Provider in August and October 2005. These should be submitted on a monthly basis. Not all staff have received any fire training since they started working at the Home and the last fire training was held in February 2005, 8 months ago. Staff were unable to locate a list of the names of the staff that attended the fire training in February 2005.
Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 18 Records show that staff have not received moving and handling training in the last twelve months and a number of the staff have not received moving and handling training since starting work at the Home. There were no records of the monitoring of hot and cold water storage temperatures by the maintenance person, and bath water temperatures are not being recorded by the care staff. Bedrails and risk assessments are in use. The risk assessment documentation needs reviewing, as it does not show that the Home has considered all of the potential risks to residents prior to use. There are no records of any monthly maintenance checks taking place. Wheelchairs are not being checked monthly by the Home. Cleaning products are being left unattended in bathrooms and the main store of cleaning products are accessible when staff leave the laundry room unattended. A commode in the residential unit had a rusty bar at the front of the toilet seat. An immediate requirement was made for this to be replaced. An electric light in the residential unit had exposed wires. An immediate requirement was made for this to be repaired and the exposed wires concealed. A reclining chair in the nursing unit was still in use although it was broken as a footstool was being used to hold it in a reclining position. An immediate requirement was made for this chair to be risk assessed to ensure that it is safe to be used. The health & safety poster in the nursing and residential unit needs completing with the information required. Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 19 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X 2 X X X 2 STAFFING Standard No Score 27 2 28 X 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X X 2 1 Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 Requirement Timescale for action 28/02/06 2 OP7 3 OP7 4 5 OP8 OP9 6 OP10 Comprehensive care plans must be in place for all residents. Records showing evidence of the care provided must be kept up to date in both units. Timescale of 30/09/05 not met 13, 14, 15 Mobility, skin care, nutrition, & continence risk assessments must be in place for all residents’ and reviewed each month. 15 Care plans must be drawn up with the involvement of the resident and agreed and signed by the residents and/or their representatives. 14, 17 A record of residents weight gain or loss must be recorded on a regular basis. 13 The temperature of the medicine fridge must be checked and recorded each day. Timescale of Immediate & ongoing not met 12, 16 Screening must be provided in shared bedrooms to ensure that the residents’ privacy is maintained. The screening must enclose the space around the bed and washing area.
DS0000060412.V271072.R01.S.doc 31/12/05 28/02/06 31/12/05 31/12/05 31/12/05 Highwell House Version 5.0 Page 21 7 OP16 17 8 OP26 13 9 10 11 12 OP26 OP26 OP27 OP30 13 13 18 17, 18 13 OP37 26 14 OP38 13 15 OP38 13 16 OP38 13 17 OP38 13 Timescale of 31/08/05 not met A record of all complaints received & the action taken by the Home must be maintained and be available for inspection. Foul washing must not be sluiced by hand. Timescale of Immediate & Ongoing not met. The underside of the bath seats in the assisted baths must be cleaned each time they are used. The laundry floor needs refurbishing to ensure that it is impervious and cleanable. Two care staff must be on duty at all times during the daytime in the residential unit. All new staff must receive structured induction training, which must be recorded in their employment records. The Provider must forward to the Commission monthly monitoring reports. Timescale of 31/10/04, 30/04/05 & 31/08/05 not met. All staff must receive moving and handling training updates annually. Timescale of 30/09/05 not met All staff must receive moving and handling training upon commencing employment at the Home. Hot and cold water storage temperatures must be checked and recorded monthly by the Home. Timescale of 31/08/05 not met. Bed rail risk assessments must be reviewed in line with the guidance from the Medical Devices Agency called Advice on the Safe use of Bed rails. Monthly maintenance checks
DS0000060412.V271072.R01.S.doc 31/12/05 16/12/05 16/12/05 31/01/05 16/12/05 31/12/05 16/12/05 28/02/06 28/02/06 31/12/05 31/12/05 Highwell House Version 5.0 Page 22 18 OP38 13 19 OP38 13 20 OP38 13 21 22 OP38 OP38 13 13 23 OP38 13 24 25 OP38 OP38 13 13 must be carried out and recorded. Timescale of 31/08/05 not met. Wheelchairs must be checked each month to ensure that the tyres are inflated, the foot rests are in place and correctly fitted and that there are no defects. Timescale of 31/08/05 not met. All cleaning products must be locked away securely when not in use by staff. Timescale of 05/07/05 not met. An immediate requirement was issued. The green reclining chair in the nursing unit must be risk assessed to ensure that it is safe to use. Timescale of 14/08/05 not met. An immediate requirement was issued. An identified commode must be replaced. An immediate requirement was issued. An identified electric light must be repaired and the exposed wires concealed. An immediate requirement was issued. The health & safety poster in the residential & nursing unit must be completed to give clear local instructions for staff. Timescale of 14/08/05 not met. Brought forward amended. All staff must receive fire training at regular intervals. Timescale of 30/09/05 not met. All staff must receive fire training upon commencement of employment at the Home. 31/12/05 05/12/05 06/12/05 05/12/05 06/12/05 16/12/05 31/01/06 16/12/05 Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 23 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 OP9 Good Practice Recommendations It is strongly recommended that hand written entries on the Medicine Administration Records are signed by the designated person making the entry with a signed check by a second nurse. Brought forward. Residents’ allergies should be listed on the Medication Administration Records. Brought forward All creams and ointments should be dated when first opened. Brought forward The British National Formulary should be updated to the September 2005 edition. Brought forward All staff should be provided with Adult Protection training particularly regarding the Herefordshire Local procedures for Protection of Vulnerable Adults. Brought forward The Provider should review the condition and quality of the commodes in use in the Home, with particular regard to their suitability for moving and handling by staff and that all of the surfaces are washable and impervious for the control of infection. Disposable laundry bags for foul washing should only be filled to a maximum capacity that allows them to be put into the washing machine without being opened by the laundry staff. The radiator in the toilet on the ground floor of the residential unit should be replaced. The bath and shower water temperature should be checked and recorded each time it is used. Brought forward 2 3 4 5 7 OP9 OP9 OP9 OP18 OP22 8 OP26 9 10 OP26 OP38 Highwell House DS0000060412.V271072.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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