Inspection on 02/06/08 for Hilbre House

This inspection was carried out on 2nd June 2008.

CSCI found this care home to be providing an Adequate service.

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

Hilbre House 05/12/07

Hilbre House 29/05/07

Hilbre House 12/12/06

Hilbre House 21/06/06

Hilbre House 28/02/06

Hilbre House 09/12/05

Hilbre House 18/02/05

Hilbre House 21/06/04

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 05/12/2008.

CARE HOMES FOR OLDER PEOPLE Hilbre House St Margarets Road Hoylake Wirral CH47 1HX Lead Inspector Peter Cresswell Key Unannounced Inspection 2nd June 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000018896.V363517.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. DS0000018896.V363517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hilbre House Address St Margarets Road Hoylake Wirral CH47 1HX 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) 0151 632 6781 della@hilbrehouse.fsnet.co.uk Mrs Della Haynes-McManus Manager post vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places DS0000018896.V363517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2007 Brief Description of the Service: Hilbre House is a large detached property overlooking the Dee estuary in Hoylake, a few minutes walk from Hoylake village with its shops and community facilities. The home has twenty bedrooms and is registered to provide care for up to 27 older people. At the moment, though, none of the rooms are shared and 19 people live at Hilbre House, all in single bedrooms. All of the bedrooms have en suite facilities and some are very spacious. The home has a large lounge and a spacious combined dining room and conservatory with fine views of the beach, estuary and Hilbre Island. All parts of the home are accessible by a passenger lift. In addition to en suite showers, Hilbre House has assisted baths to promote the safety and independence of the people who live there. Fees at Hilbre House are £395 a week. DS0000018896.V363517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection included an unannounced site visit. We spoke to the acting manager, and a number of staff as well as several residents. We toured the home, visiting all of the shared areas, the kitchen and several of the bedrooms. We examined care plans, medication, fire safety records, financial records, recruitment files and the menu. One relative completed a survey form during our visit. The manager had completed a CSCI Annual Quality Assurance Assessment (AQAA) some weeks before the site visit. What the service does well: What has improved since the last inspection? What they could do better: The activities organiser was not in post for long and although some activities do take place, the residents would benefit from a fully developed programme of activities. An application needs to be submitted for the registration of the manager. It is important to make sure that all the requirements of the Environmental Health Officer are implemented. DS0000018896.V363517.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. DS0000018896.V363517.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000018896.V363517.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are able to make an informed choice using written information about the home and visiting before making a decision. EVIDENCE: A service user guide is now available but still needs some minor amendments (the CSCI contact number is now 01772 730100). We examined a number of case files and found that people had been properly assessed before moving to Hilbre House. The assessment document is part of the home’s computerised care management system and gives detailed information about the person in question. The acting manager has completed the document in this form for existing residents as well. Residents are encouraged to visit the home usually have a trial stay for two weeks at a special rate before a final decision is made. Residents are given a written contract. One relatively recently admitted resident told us that he was settling in well and liked the home’s location. Hilbre House does not provide intermediate care so Standard 6 does not apply. DS0000018896.V363517.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care planning at Hilbre House provides information to help staff to focus on the needs of service users. Medication is well organised, protecting the health and safety of the residents. EVIDENCE: Each person who lives at the home has a care plan which is now kept on computer, making it easier to update. The plans are detailed and cover all of the essential information needed for the person’s care. The plans are fully reviewed after the first month and then each month by the key worker, with a full review by the manager every six months. The care plans are changed if necessary in between reviews. The system flags up when the next review is needed. Daily reports are made on the computer, to which all staff have access. All care staff have been trained to use the computer by the acting manager. Although daily reports can be changed retrospectively this would be recorded by the program. The care plan also includes helpful information for care staff (in one case, for instance, the difference between hypoglycaemia and hyperglycaemia). DS0000018896.V363517.R01.S.doc Version 5.2 Page 10 Night staff also have access to a file which contains a full summary of each residents’ details, to be used in the event of an emergency admission to hospital, which is good practice. Appropriate referrals had been made to community and specialist health services such as GPs, district nurses and a hospital chiropodist. Good records were kept of visits by and contact with health professionals. Most medication is supplied in a monitored dosage system individually tailored blister packs for each set of tablets). The Medication Administration Record (MAR) sheets were clear, complete and methodically completed. The assistant manager has prepared guidelines for the administration of PRN (‘as required’) medication but this does need to be extended so that details of each such medication are on file for easy reference. In one case we saw this information as written on the MAR itself, which is fine as long as it is signed. Nobody currently looks after their own medication but the acting manager has put a risk assessment tool in place for anyone who wants to do so. Controlled drugs are properly recorded. The home does not have a controlled drugs cabinet but we were told that the owner has ordered one for the home. All people living in the home have single rooms with en suite facilities and there are no plans to reintroduce sharing of rooms (unless two people such as married couples or partners especially want to share). Personal care can be therefore be given in complete privacy. Most people have their own telephones and others can use the home’s cordless telephone. The home’s Annual Quality Assurance Assessment says that ‘care of the dying policies take into account the wishes of the patient and any religious observations required to be met for his/her faith’. DS0000018896.V363517.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ nutritional needs are met by well prepared meals, made with good quality ingredients, served in very attractive surroundings. In the absence of an activities organiser has begun to help meet residents’ recreational needs and choices but not all social and recreational needs are met. EVIDENCE: Residents at Hilbre House tend to choose their own routines – when we visited, some were in their own rooms (one listening to classical music), others were in the main lounge whilst some sat in the conservatory or in the large hall. Since the last inspection an activities organiser had been appointed for both of the owner’s homes (the other, Hilbre Court) is nearby. However he has resigned and not yet replaced; the acting manager said that the owner is seeking to replace him. The record of activities that people had taken part in was not detailed and did not give a picture of the full range of social activities that people enjoyed. Several people, for instance, told us that they had been to Parkgate with the owner on the previous day. They had all enjoyed the trip. There was a list available of possible venues for such trips, including their accessibility. Some residents make their own arrangements for activities – one told us about regular visits to a local historical society for instance. Hilbre House has a collection of DVDs but the acting manager said that they are no especially popular. One of the home’s own survey forms from a relative was DS0000018896.V363517.R01.S.doc Version 5.2 Page 12 generally very positive about Hilbre House but pointed out that the resident in question was ‘bored’ and ‘would welcome more activities’. Relatives and friends are welcomed into the home and there are written instructions to staff to ensure that visitors are properly welcomed. One visited whilst we were there and completed a survey form. That form and one received before the visit were very positive about the home. One said that ‘my family are always informed of any untoward incident’ regarding their relative and felt that the home ‘provides anything that service users need’. Religious ministers visit the home regularly. The home does not generally deal with residents’ finances as they are usually dealt with by their families. The owner does look after the personal allowances for some residents and keeps a record of when money is given to them and receipts for any money spent on their behalf. A new, qualified chef has been employed since the last inspection. Those people who spoke to us said that they enjoyed the meals in the home. There was no set choice for the main course at lunchtime but one resident who requested an alternative was offered and accepted an omelette. There is always a choice of sweet and residents are asked before lunch what they would like. When we visited there were four sweets on offer, all of them home made. Vegetables are put on each table in serving dishes and the tables were well presented, helping to give the mealtime a homely atmosphere. People helped themselves to vegetables but those who could not manage were given help by the staff. People told us that they had enjoyed their lunch. There is normally a choice of lighter meals or sandwiches at tea time when, again, there is a choice of sweet. The choice when we visited was bacon and egg on toast, cheese salad, tuna and mayonnaise sandwich or sardines on toast. The owner puts great emphasis on fresh, high quality ingredients and the home therefore does not use a delivery service for fresh food. Staff do the shopping so that the quality and freshness of the supplies can be assured at the point of purchase. DS0000018896.V363517.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adult safeguarding policies and protocols are available to help protect residents and staff have been trained in how to respond to any allegations or incidences of abuse. EVIDENCE: Hilbre House has a complaints procedure which is available to all residents and their families. The home had received no serious complaints since the last inspection; minor complaints are recorded in a complaints book. One recent one was about several residents not liking a steak and kidney pie and action had been taken to resolve that. Most staff have now received training on the protection of vulnerable adults from abuse via a course organised by Wirral Borough Council and the remainder are booked to attend later in the year. Copies are available of the safeguarding adults protocols for Liverpool and Wirral. DS0000018896.V363517.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hilbre House provides a comfortable and homely environment for its residents. EVIDENCE: Hilbre House is in Hoylake, directly overlooking the shore and the Dee estuary. It is several minutes walk from the Royal Liverpool golf course and Hoylake village, which has transport links to the rest of Wirral, Merseyside and Cheshire. We visited all areas of the home, including some people’s bedrooms. The large combined conservatory/lounge and dining room has a panoramic view of the estuary and Hilbre Island. The adjacent TV lounge is very spacious and has a number of comfortable sofas and chairs plus a large flat screen television. There are also several armchairs in the large hallway and a group of residents were sitting there chatting to a visitor during our visit. All of the furniture is attractive, good quality, well kept and comfortable. There is also an outdoor patio area with benches. Over the last twelve months new dining tables, chairs and other furniture have been bought. The outside of the home is currently being redecorated and scaffolding was in place for that purpose. DS0000018896.V363517.R01.S.doc Version 5.2 Page 15 All areas of the home were clean, attractively decorated and well maintained. The home was free of offensive odours. The owners employ a handyman and the home is well maintained. However, the toilets nearest to the lounge still do not have working locks that can be opened from the outside in an emergency. Locks were fitted after the last inspection but they do not now work. All of the residents have single bedrooms with ensuite facilities. Some of the rooms are exceptionally spacious and all of those seen were clean, well furnished and personalised to reflect the tastes and personality of the resident. Many of the rooms also have fine views. Some of the bedrooms are large enough for sharing and the home’s registration does allow for this but the owner - in line with the National Minimum Standards - will only allow rooms to be shared if both residents (such as a married couple or partners) make a positive choice to do so. The home has a number of assisted baths. DS0000018896.V363517.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s recruitment procedures protect residents from the employment of unsuitable staff. The home’s staff training programme ensures that all staff are adequately trained and qualified to meet the needs of the residents. EVIDENCE: On the day of the site visit for this inspection there were two care staff plus the acting manager on duty, as well as a member of administrative staff, the chef and the owner’s daughter. The rota indicated that there are normally three care staff (including the acting manager) on duty between 8am and 6pm . There are, however, only two care staff on duty from 6 – 10pm and on days when the acting manager is off duty. This still falls short of the staffing levels indicated as appropriate by the Commission for Social Care Inspection in a letter dated 16 September 2004 which stated that there should be three care staff on at all times during the day. At night there is one waking member of staff and one sleeping in on the premises. Hilbre House only employs one cleaner and no dedicated laundry staff, so much of this work falls to the care staff. In response to the last inspection report the owner said that a ‘resident dependency analysis and staffing review’ was to be conducted, with all duty rotas to be reviewed in the light of that. The acting manager said that shifts had been re-arranged but there did not appear to be a change in overall staffing levels. We carried out a “random” inspection in March 2008 specifically to look at recruitment records. All of the appropriate checks were in place on that DS0000018896.V363517.R01.S.doc Version 5.2 Page 17 occasion and no new staff have been recruited since then. Staff receive induction training and this is recorded, with each member of staff having their own induction booklet. The acting manager has put in place a detailed training programme for the year including training on Infection Control, Safeguarding Adults, and Bereavement/Funeral care. He is in the process of arranging further training on moving and handling. The home now exceeds the standard of 50 of care staff with NVQ2 or better. Staff without NVQ are studying for it and a further three staff are due to start training for NVQ3. The acting manager carries out regular one to one supervision with staff at least every six months and keeps a record of the sessions. DS0000018896.V363517.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 33, 35, 36, 38.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home remains without a registered manager though the acting manager provides consistent leadership to his staff. EVIDENCE: Hilbre House still does not have a registered manager. It has been managed by the current acting maanger for over a year now and he has made considerable progression developing staff training, supervision and care planning. He has now successfully completed his NVQ4 and Registered Manager training. The owner agreed as long ago as 2006 to submit an application for a manager and there now appears to be no barrier to doing so. The assistant manager has started a programme of regular one to one staff supervision and is keeping a record of the meetings. The Fire Officer wrote to the Registered Person (owner) in March 2006 pointing out that fire doors must not be propped open. The owner replied in August DS0000018896.V363517.R01.S.doc Version 5.2 Page 19 2006 stating that ‘all staff have been reminded that no wedges should be used on fire doors’. Some fire doors were held open by approved electro-magnetic devices which release them if an alarm is sounded. However, despite the assurances to the Fire Officer, several others were simply propped open with wedges or other implements. This had been noted at the three previous inspections also. Fire doors must only be propped open if they are held by an approved hold-open device, otherwise they are ineffective as fire doors and vulnerable residents are at risk of fire. Fire extinguishers are regularly checked by a contractor and weekly tests of the alarm system were taking place. A gas safety certificates was in place but the electrical safety certificate could not be located. The home’s insurance cover was up to date and a certificate was displayed on the wall. Accidents are recorded properly but some which should have been notified to the CSCI had not been so reported. The requirements of Regulation 37 were discussed with the acting manager. The spacious kitchen was clean and, on the whole, well organised. Fridge and freezer temperatures had not been recorded for several days though the chef said that he does check them every day. The home uses the Food Standards Agency programme, Safer Food, Better Business. The Environmental Health Officer wrote to the home in April 2008 expressing concerns about the storage method used for cooked meat being stored overnight. This has now been remedied by the use of a special fridge in the outside building which is also used for storage of fresh vegetables. The building has been used for this purpose for many years and is now scheduled for renovation and improvement. The interior of one of the fridges in the building was dirty; it must be cleaned and included on the regular cleaning schedule. DS0000018896.V363517.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 2 DS0000018896.V363517.R01.S.doc Version 5.2 Page 21 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 OP31 Regulation 8 and s.11 Care Standards Act 2000 Requirement The registered person must appoint a manager who is responsible for the day-to-day management of the home. (Originally required by 30/08/06) 2. OP38 23(4) The registered person must take 01/08/08 adequate precautions against the risk of fire and must therefore ensure that: * fire doors are only propped open if an approved hold-open device is used; * the electrical system is checked by a (Originally required by 31/01/07) 3. OP38 13(4) The registered person must ensure that unnecessary risks to health and safety are eliminated and must therefore ensure that: * the fridge in the outside storage building is cleaned regularly; * daily checks are made and recorded on the temperatures of DS0000018896.V363517.R01.S.doc Timescale for action 01/08/08 01/12/08 Version 5.2 Page 22 the home’s fridges and freezers. 4. OP19 12(4) The registered person must 01/12/08 arrange for the home to respect the dignity and privacy of the people who live there and must therefore arrange for the locks to the two toilets nearest to the dining room to be repaired. The registered person must 02/06/08 notify the Commission without delay of significant events in the home affecting the welfare of the service users. 5. OP38 37 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 OP27 Good Practice Recommendations The registered person should review existing staffing arrangements both for domestic staff and for care staff between 6 and 10 pm. DS0000018896.V363517.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 DS0000018896.V363517.R01.S.doc Version 5.2 Page 24 - 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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