Inspection on 05/01/07 for Holly Lodge

This inspection was carried out on 5th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holly Lodge 16/01/09

Holly Lodge 04/11/05

Holly Lodge 05/05/05

Holly Lodge 24/02/05

Holly Lodge 07/09/04

Holly Lodge 16/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Holly Lodge Old Hospital Road Pewsey Wiltshire SN9 5HY Lead Inspector Karen Mandle Unannounced Inspection 8th January 2007 09:40 DS0000041025.V321542.R02.S.doc Version 5.2 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 DS0000041025.V321542.R02.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 Adults 18-65. 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. DS0000041025.V321542.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Lodge Address Old Hospital Road Pewsey Wiltshire SN9 5HY 01672 569950 01672 569952 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) White Horse Care Trust Amanda Jane Maloret Care Home 18 Category(ies) of Learning disability (18), Learning disability over registration, with number 65 years of age (4) of places DS0000041025.V321542.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No more than 18 service users with a learning disability at any one time No more than 4 service users with a learning disability, aged over 65 years of age at any one time The staffing levels set out in the Notice of Decision dated 12 August 2003 must be met at all times 4th November 2005 Date of last inspection Brief Description of the Service: Holly Lodge is registered to provide nursing care for 18 younger people with multiple disabilities. As a condition of registration four service users may be over the age of 65 years old. The home was purpose built in 2003 for the service users group currently living in the home. The home provides a good standard of accommodation suiting the needs of the Service Users. All 18 bedrooms are single with an en-suite facility. The home is divided into three units with six service users living in each unit. Holly Lodge is situated in the town of Pewsey in Wiltshire. White Horse Care Trust manages the home. The registered manager is Amanda Maloret. DS0000041025.V321542.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place January 8th 2007. The inspection commenced at 9.40am and was completed at 4.30pm. The manager Mandy Maloret was available to assist the inspector. The inspector was able to freely visit each unit. During the visits, the inspector observed staff interacting and caring for service users. Service users who were able to communicate spoke with the inspector about life in the home. A service user told the inspector “This is my home now and I’m very happy here”. Three surveys were received from service users; again these provided positive comments about the service provided at Holly Lodge. A number of records were reviewed such as care plans, medication records and health and safety records. Thirteen requirements had been made at the previous inspection, twelve of which had been met. Two requirements and 1 good practice recommendation were made following this inspection. The fees commence at £1,200. The judgments contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experience of people using the service. What the service does well: What has improved since the last inspection? Nutritional and pressure area risk assessments had been implemented into the care records ensuring that any risk identified will be addressed. The management structure of the home continues to improve with a far more flexible approach to the daily routines of the units. The menus had been revised to encourage service users to eat more fresh fruit and vegetables. Meals times are more flexible to suit the needs of the service user. The home had put a lot of work into improving the medication procedure, which is now safe and more manageable. The medication policy is now in line with the nursing registration. DS0000041025.V321542.R02.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000041025.V321542.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000041025.V321542.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The statement of purpose would not provide current or prospective service users with adequate information about the home. Service users are given a contract from the provider. EVIDENCE: The current statement of purpose is not up to date due to the change of management structure within the home. The information in the statement of purpose is limited. New service users are rarely admitted to Holly Lodge, with the last service user being admitted approximately two years ago. Therefore Standard 2 cannot fully be assessed at this inspection. Each service user had been given a contract from the providers, White Horse Care Trust, a copy of which had been retained in the care records. DS0000041025.V321542.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are provided with comprehensive care plans, however the format is complicated and lack simple instructions on how to ensure a care need will be met. Due to the very complex needs of the service users, decision making is limited, as is an independent lifestyle. EVIDENCE: Each service user is provided with a care plan. The inspector reviewed 2 care plans from each of the three units. The care plans provide detailed information relating to the support needs of the service users, health care needs and social background. Evidence was seen of the care plans being frequently reviewed. The staff had been required to sign the care plans once they have read them. However the format is complicated and information cannot easily be found, as each service user has three files, making up the care records. The manager is currently researching how to reduce the care records to ensure that the care plans become a working tool for the care staff. This will ensure that current DS0000041025.V321542.R02.S.doc Version 5.2 Page 10 care needs have been clearly documented and easily obtainable to the care staff. A nutritional screening tool had been implemented and each service user had a pressure risk assessment in place as required from the previous inspection. The service users at Holly Lodge have very complex needs, which limits their ability to make decisions. Through observation of the staffs’ interaction with the service user, it was evident where possible that the staff did support service users with decision making. A service user who was able to communicate confirmed that the staff supported her to make decision and said, “I can go shopping with a member of staff and always choose which clothes I buy” and “I can spend the day as I wish”. The service users are provided with a range of risk assessments relating to daily life in the home but due to their complex needs an independent approach to risk would again be very limited and impossible for the majority of service users. DS0000041025.V321542.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities is provided which are appropriate to the social needs of the service users. Service users are supported by the home to participate in local events. Service users are provided with a healthy and balanced diet. EVIDENCE: Holly Lodge provides good transport facilities, which enables the service users to attend local events and activities outside of the home. A service user accompanied by two members of staff went swimming at the local sports facilities during the afternoon of the inspection. Several other service users attend Gateway Club fortnightly. Service users are supported and encouraged by the home to participate in local community events such as, music concerts and theatre productions. The home is located a short distance from the centre of Pewsey which offers a range of local amenities including shops and pubs, DS0000041025.V321542.R02.S.doc Version 5.2 Page 12 which service users are supported to visit. The home works hard to try and provide service users with holidays during the summer. The home also offers a range of activities such as crafty club, music and movement, DVD nights, Karaoke, skittles. The rear garden is now wheelchair friendly, which the staff reported was used a lot in the summer by service users. Service users are supported to maintain links with family and friends. A service user is supported to make weekly visits home and another service user said, “My Dad visits often”. It was evidenced in a service users’ care plan that a service user did not welcome all family visits, the home supported the service users’ decision. Family and friends can visit the home at any reasonable time, which was evidenced through the visitors signing in book. Each unit has worked hard to develop a more flexible approach to the daily routine, which suit the individual needs of the service users. Breakfast time is now in line with the service users morning routine, with some service users remaining in bed for longer, through their choice and through assessments. The staff appear more flexible in their approach to the daily routines of the home, creating a more relaxed atmosphere. The staff were observed knocking on doors before entering. Each bedroom is provided with a key, often used to prevent other service users entering each other bedrooms without gaining permission. The staff on each unit was observed interacting well with service users and even where communication was limited, the staff were able to understand the service users requests. Service users were seen spending time in the privacy of the own bedroom during the day, either resting or watching TV or in the communal rooms interacting with others. A service user, who is at high risk of falling and is not able to understand the risk, has been assessed through a multi disciplinary team as needing a safety belt when sat in an armchair. Systems are in place for the staff to make frequent checks and assist the service user with walking three to four times a day. The main hot meal of the day is served in the evening, which is cooked by the chef for two units. The other unit is serving the main meal of the day at lunchtime, as the staff reported that the service users appear to eat more at this time and provides a more relaxing evening for the unit. The home is actively encouraging service users to eat more fresh fruit and vegetables to try and promote a healthy life style. A service user who was able to communicate reported the food as “ always good, I enjoy it anyway”. The weights of service users are monitored and the nutritional risk assessments help to identify any dietary needs and swallowing problems. Two service users are fed through a gastric feeding tube with all appropriate systems in place to support this method of feeding. DS0000041025.V321542.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The nursing and personal care provided is of a good standard. The health care needs of service users are closely monitored. The medication systems have much improved with the medication procedure being safe. EVIDENCE: The care staff work hard to provide a good standard of personal care, which was evident through the very well presented appearance of the service users. Service users were seen to be wearing appropriate clothing to suite their age and needs. The clothes were all very well laundered and iron. A service that spoke with the inspector confirmed that all personal care was done in the privacy of the bathroom or their bedroom. This was also observed taking place whilst touring the home. Holly Lodge is registered to provide nursing care. Evidence was seen in the care records of the health care needs of the service users being closely monitored by the nursing staff and appropriate action taken when health needs DS0000041025.V321542.R02.S.doc Version 5.2 Page 14 changed. All service users are registered with a local GP and many of the service users due to complex needs are under the care of a Consultant. Evidence was also seen of other health care professionals being contacted when care needs changed, such as the continence advisor and a physiotherapist. Several service users suffer from swallowing difficulties and are under the care the swallowing specialist. It will be recommended that the home purchase a suction machine to assist service users who have swallowing difficulties. The nursing team had put a lot of work into improving the medication systems to ensure safer and more efficient systems are in place. The home has moved from a weekly to a monthly medication ordering system. A monitored dosage system is now in place. The medication administration records are now printed which were up to date and countersigned by two nurses when a medication order had been handwritten. Medications were stored correctly. The medication procedure was safe. The medication policy has been changed and now relates to Holly Lodge being a care home registered to provide nursing care. Service users do not self medicate due to complex nursing needs. DS0000041025.V321542.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A complaints policy and procedure is in place and available to service users. An abuse awareness policy is in place and staff knew how to report an allegation of abuse. EVIDENCE: A complaints policy and procedure is in place, a copy of which is situated in the main entrance of the home. Many service users have limited communication skills making it very difficult for them to voice a complaint. However a service user who spoke with the inspector regarding complaints said “I have just made a complaints video for the trust, so people living here know how to make a complaint”. The CSCI have not received any complaints regarding this service. White Horse Care Trust provides an “abuse” policy in place, which is supported by a “Whistle Blowing” policy. The care staff had been provided with training in abuse awareness and systems are in place if an allegation of abuse was reported. Both managers were fully informed of the local vulnerable adults procedure. DS0000041025.V321542.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Holly Lodge provides a good standard of accommodation, which is well maintained. The bedrooms are spacious and personalised. The home is well equipped to support the physical needs of the service users. The standard of cleanliness is good throughout the home. Infection control measures are in place. EVIDENCE: Holly Lodge is a purpose built home, which provides a good standard of accommodation for service users to live in. The home is built in three units. Each unit has six bedrooms, a communal assisted bathroom, and a good size kitchen and living/communal area. A large communal room links the units. The home is well maintained providing a safe environment to service users. The home is furnished with domestic type furnishings, as is the decoration of the home throughout. The communal areas on each unit provide a comfortable seating area with a TV and a dining area. DS0000041025.V321542.R02.S.doc Version 5.2 Page 17 The inspector was able to visit many of the bedrooms, which are spacious and have en-suite facilities. The bedrooms were clean, personalised and homely even though many of the service users require a lot of equipment to support their daily care needs. The home is well equipped with specialised equipment to promote and support the care/mobility needs of the service users. Overhead lifting hoists are provided. Individually assessed wheelchairs and armchairs are provided to suit the care needs of the service users. The home was clean throughout to a good standard. Domestic staff are employed for the cleaning of the home. Infection control measures are in place. Hand washing facilities are provided for the staff, as are disposable gloves, and aprons. Each unit has a good laundry facility, reducing the risk of cross infection between service users, all of which were clean and organised. DS0000041025.V321542.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team are effective and fully support both the health and social care needs of the service users. All staff had received mandatory training and further training in line with the care needs of the service users. Recruitment procedures were satisfactory. EVIDENCE: Holly Lodge is registered to provide nursing care therefore a minimum of 1 nurse is on duty at all times. The manager and deputy manager are both qualified nurses. The home has made some positive changes to the management structure of the units with a lead nurse now taking charge of the units during the day, providing more continuity of care to the service users. A team of carers supports the qualified nurses. The carers generally work on the same unit, again providing continuity of care to the service users. The home continues to promote NVQ training and LDAF. The interaction observed between the staff and service users was positive and respectful. DS0000041025.V321542.R02.S.doc Version 5.2 Page 19 The recruitment files of four members of staff were reviewed, all of which, apart from one file which only had 1 reference, contained 2 references, contract of employment, terms and conditions of employment and appropriate police checks. Interviews take place with 2 members of staff. The staff are given a trial period of three months. All staff had been provided with mandatory training. Other training had been provided as needed and identified through supervision; Migrant Workers Course, Epilepsy, The Role of a Key Worker, and Positive Dementia Care. Due to the complex care needs of the service users, carers who are on induction work closely with another experienced carer who fully understands the care needs of the service user group. DS0000041025.V321542.R02.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Holly Lodge is well managed. White Horse Care Trust provides quality assurance systems. Health and safety issues are dealt with appropriately providing a safe environment for service users to live in. EVIDENCE: The registered manager is Mandy Maloret who is a qualified nurse. Mandy has much experience in caring for the client group, which Holly Lodge is registered to provide care for. Mandy understands the aims and objectives of the home. Mandy works closely with the deputy manager Karen Britten. White Horse Care Trust had quality assurance systems in place, such as surveys, however the amount of service users at Holly Lodge who would be able to participate would be very limited. The surveys are sent annually to DS0000041025.V321542.R02.S.doc Version 5.2 Page 21 family and friends of service users to gain their views of the service provided at Holly Lodge. Health and safety issues are addressed providing a safe environment for service users to live in. Karen Britten is the designated health and safety person. Comprehensive risk assessments for the premises are in place. All accidents are recorded and what action if any was taken following the accident. The accident record is audited monthly identifying any pattern that may of occurred. The electrical equipment is tested annually. Hoists had been regularly serviced by, an outside contractor. The home is well maintained providing a safe environment for service users. DS0000041025.V321542.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 CONDUCT AND MANAGEMENT OF 3THE HOME Standard No 37 38 39 40 41 42 43 Score 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 X 3 X X 3 X DS0000041025.V321542.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 (1,a) Requirement The organisation will ensure that the pre admission assessment document is appropriate to the nursing needs of the prospective service user. Inspectors’ comment. This will be assessed at the next inspection following the admission of a new service user. 2. YA1 4 The manager will ensure that the statement of purpose is up to date and provides all relevant information about the service provided. The current system of care plan/records will be reduced in size or a format introduced that provides clear instruction of how to provide the appropriate care to the service user. Inspectors’ Comment. This requirement was made following the previous inspection. The format has not yet changed. However the manager has researched other care plan DS0000041025.V321542.R02.S.doc Version 5.2 Page 24 Timescale for action 01/05/07 15/03/07 3. YA6 15 15/03/07 formats and is currently working towards changing the care plans. 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 YA19 Good Practice Recommendations The home should consider providing a suction machine to support the needs of those service users with swallowing difficulties. DS0000041025.V321542.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000041025.V321542.R02.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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