Inspection on 23/06/05 for Joseph House

This inspection was carried out on 23rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Joseph House 19/06/09

Joseph House 21/06/07

Joseph House 03/07/06

Joseph House 24/01/06

Joseph House 28/02/05

Joseph House 06/01/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOMES FOR OLDER PEOPLE JOSEPH HOUSE The Old Rectory Reedham Norwich NR13 3TZ Lead Inspector David Welch Unannounced 23 June 2005 06:50hrs. rd The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Joseph House Address The Old Rectory, Reedham, Norwich, Norfolk, NR13 3TZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01493 700580 01493 700994 rt700700@aol.com Joseph House (Reedham) Ltd Mrs Beverley Mary Terry Care Home 35 Category(ies) of LD(E) Learning dis - over 65 registration, with number of places JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Thirty-three (33) service users who are learning disabled may be accommodated. Those service users may be over the age of 65, but do not fall within the category of Older People. 2 Two (2) service users who are named in the Commissions records may be accommodated within the category of Older People only. 3 The total number not to exceed thirty-five (35). Date of last inspection 28 February 2005 Brief Description of the Service: Joseph House is a care home providing personal care and accommodation to 34 adults with learning disabilities, the majority of whom are also elderly, and 1 older person who is named in the Commission’s records. The home is privately owned and has been run by the same proprietors for a considerable period of time. It is located in the village of Reedham, approximately 20 miles from Norwich. The service is located in a large period house which has been extended. There are also two small units in the grounds. The home has a total of 21 single bedrooms, some of which are en-suite, and 7 shared rooms, all of which have en-suite facilities. The main house has accommodation on the ground and first floors and has a shaft lift. Joseph House is on a no through road so has little passing traffic and stands in large grounds. There is off-road parking. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place unannounced during one day in mid June and began very early in the morning for no other reason than the Commission for Social Care Inspection (CSCI) has to demonstrate that it carries out a proportion of its inspections ‘out of office hours’. It lasted for almost 5 hours during which time the Registered Manager, Mrs B Terry, was on hand to assist the process. It was possible to chat with over half the residents as they began their day with breakfast and as, with staff, they decided how to spend their time. One particularly useful observation was the transport arrangements made for those service users who were going off to college or day care elsewhere. Another was the breakfast routine. A number of the staff were spoken to as they went about their early morning duties, helped residents with eating and dispensed medication. One of the directors of the company was also on hand and some time was spent with him discussing possible future changes and informing him, and the home’s manager, about the new format that CSCI has introduced, hopefully to ensure that the report is more accessible to those people interested in how the home is running. It is significant that the 3 requirements made in this report all are concerned with environmental matters such as bath water temperatures, maintaining high standards of infection control and safety guarding radiators rather than the personal care and relationships between staff and residents, which were of a high order. One recommendation relates to the introduction of a formal handover period. What the service does well: Despite being close to a commercial business, a pet centre, that attracts numerous visitors to the village, the home is in a tranquil setting with lots of space around it. Joseph House is well staffed and there were some lovely interactions between carers and the people living in the home. The atmosphere is busy, purposeful, but relaxed and there are numerous individual ‘arrangements’ between staff and residents that mean people can spend their day as they wish. Where required, there is 1:1 assistance and attention. The residents have the chance to be as independent as possible and help with some chores such as clearing the dishes and taking their own washing to the laundry. The medication administration is sound and daily plans of care tailored to individual needs and wishes. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 6 Staff are well aware of fire safety arrangements. Handover arrangements clearly worked, but a recommendation has nevertheless been made. The relationships with workers from partner agencies, such as transport, are good, with residents benefiting from being known by helpful and sensitive staff who showed a real competence for their job. Mealtimes are a particularly relaxed affair. What has improved since the last inspection? What they could do better: The temperature of water supplied to all baths and showers must not exceed safe limits. Staff must be reminded about some infection control practices. Forms of address could be looked at again to be sure that everybody is happy with how they are spoken to. There are one or two ‘institutional’ practices such as displaying staff qualifications in the corridor that could be reconsidered. These could be more appropriately shown in the staff office. Mrs Terry explained about the use of digital locks on the door of the Dining Room. She said that this area has to be locked to protect residents from harm, as the hot water urn that they need for their drinks is in the Dining Room. We wondered whether there was some other solution to this situation that would allow the Dining Room to be left open as it would in a normal family home. The recommendation has been made that 15 minutes is built in to the staff roster as a handover period. There is clearly a lot of staff goodwill attached to the current arrangement, but it should be put on a more formal footing. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 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 standard(s) 3 and 4. Many of the people have been living at Joseph House for a long time and the management and staff clearly understood their needs and were meeting them well. EVIDENCE: Each resident had a Care Plan that gave precise details of the care to be delivered based on specialist outside assessment and the home’s own observation of individual need. Each member of staff undergoes induction training in line with TOPSS specifications within the first 6 weeks of taking up their post and after that they do foundation training. This provides them with the knowledge and informs them of the skills to care properly for the individual needs of residents. They were seen to be sensitively and confidently assisting residents at the beginning of the day in preparation for whatever activities they were to be involved in. The staff interacted with residents in a very calm way, taking time to listen to them and to help compassionately and patiently, when required. Despite some JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 10 service users on first acquaintance being quite difficult to understand, the staff had clearly tuned in to individual’s speech patterns and, using good listening skills, could have a conversation that was satisfying to both sides. The residents made their wishes known to staff. The visit offered the chance to discuss with the manager the needs of service users and the different categories of registration that they fall into. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Enough of the daily plans of care were seen for us to be confident that each resident’s individual needs have been considered and their care delivered in the way they want. The service users health needs are well met. The core principles of good care practice such as the promotion of privacy and dignity are being upheld, allowing residents to live their lives in ways acceptable to them. EVIDENCE: The service user plans set out in very precise detail the care that staff should provide. This included very specific instructions about what the person wanted, and needed, to live his or her preferred lifestyle. Plans are regularly reviewed. Where appropriate, plans were signed by the service user concerned. Evidence of this was checked. One resident spoken with confirmed that because of a particular medical condition she has regular eye tests and a chiropodist managed her foot care. The home had access to an Occupational Therapist. The medication administration was sufficiently robust with staff obviously used to working to a set pattern to ensure consistent and safe practice. One carer gave out the medication according to the prescription while another JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 12 administered it to the service user overseen by the senior. Only then was the Medication Administration Record (MAR sheet) initialled. Those staff trained to give out medication were on a list displayed on the drugs trolley with their specimen signature and initials shown. The drugs trolley was kept in a safe location within the home, padlocked to the wall. Treating service users with respect is part of staff induction. Observation confirmed that the personal care being given at this important time in the life of the home was suitably discrete. Staff kept doors closed and if a resident required help with, say, shaving, which they did during the early morning visit, staff did this in the privacy of their bedroom and not in the lounge. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14and 15. The many and varied different personal arrangements as to what people wanted to do spoke volumes about the match between residents’ expectations and what the home was able to provide. The dining experience was nicely easy going. EVIDENCE: On arrival, it was clear that some people were up, or just getting up. This was their choice and might have been because they had to catch transport for daytime activities away from the home. In other cases, it was simply that they liked getting up early. This was checked in two cases by referring to the Care Plans of the people concerned. Most people came down for breakfast, but others could have it in their bedrooms if they wished. Staff said that they asked residents their preference. During breakfast, and afterwards, some residents made their wishes known about going out – to do some shopping or to go to the seaside. This ‘negotiation’ appears to have taken place directly with carers. One resident said that he had arranged with a carer to drive him to the Norfolk Show the following week. Another arranged to go with a carer to buy some diabetic sweets. Mrs Terry said that in this case staff always talked to the pharmacist for advice. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 14 One person had some wheelchair help getting to the Dining Room, but decided to make his own way, with staff support, once he was there. During the visit some arrangements were made for residents to go out for a pub lunch. Breakfast was a busy, but quite relaxed affair. Staff helped service users with their meal. Residents were not hurried up by staff and some sat on in the Dining Room until they were ready to depart. There was a wide choice of cereals and a cooked breakfast of scrambled egg, if that was preferred. Tea and a cold drink were available. Some residents served themselves while others had varying amounts of assistance. On carer was seen putting milk into a teapot to ‘pre-milk’ the contents. When asked about this, the manager explained that the teapots are individual and that is how the residents want their tea. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18. The management has taken suitable steps to protect residents from abuse in all its forms. EVIDENCE: Following the last inspection, the home were advised to repeat its adult protection (POVA) programme. Mrs Terry said that this had been done with senior staff undergoing direct training and other carers watching the video, doing a worksheet and questionnaire. In order to keep abreast of POVA procedures, she intends to invite a trainer in again next year. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19, 20, 21, 22, 25 and 26. The home appeared to be a safe environment, although we intend to look into some of the different levels and slopes at the next inspection. One bathroom caused concerns, though not in a major way. Residents were being helped to be as independent as possible. This seemed like a pleasant place to live. EVIDENCE: A tour inside the building showed that passageways were clear and no fire doors were wedged open. There are some different floor levels and it is clear that steps have been ramped in the past, leaving some quite steep inclines. Some doors close automatically when the fire alarms go off. There was an electric hoist parked in a corridor, but this was in a wide alcove and did not cause a problem. Residents had a pleasant sitting room with music. There was a conservatory and, outside the front of the house, some garden furniture where service users could relax in the sunshine if they wished. The Dining Room had full-length sliding doors that could be opened for additional ventilation. On the day of the JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 17 inspection, although the early morning was extremely warm, a cooling breeze was blowing through the dining area. The garden are large and residents can use the space. The home is on a no-through road and people living in the home are unlikely to be at risk from fast-moving passing traffic. In one bathroom the temperature of the hot water supplied to the bath was in excess of 55oC. Vulnerable people could be at considerable risk. The shower attachment had clearly been used that morning and some soiled clothes had been left in the bath. This was brought to the attention of the manager who said that this bathroom is ‘never used by residents, more likely the clothes were left by live-in staff’. She was surprised that the water was dangerously hot as baths and showers, she said, have regulatory valves to keep water temperatures within safe limits (max. 43oC). Mrs Terry said that she would ask staff not to leave clothing in the bath in future and she would attend to the temperature as a matter of urgency. In recent inspections the matter of safety guarding radiators has been brought to the attention of the management. Progress was noted during the last inspection and further installations have taken place since then. There was still some little work to be done, however, until all the radiators are sufficiently guarded to protect the vulnerable people living in the house. It is on this basis that the standard is assessed as not being wholly met just yet and the requirement to complete the work has been repeated. Several residents were using wheelchairs on the day of the inspection. One person said that he has an electric wheelchair that is currently away for repair, but expected back shortly. He said he would ask Mrs Terry if there had been any progress. He confirmed that when the electric wheelchair is in use it is kept on charge in his bedroom. Other residents were using a variety of walking aids. One had brakes that were needed for the quite steep slope down to the laundry area. The home has an electric hoist. The home had Domestic Assistants who came on duty at 9.00am firstly to assist in clearing away debris in the Dining Room. During the house tour no unpleasant odours were noticed. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30. Staffing arrangements are sufficient and those on duty showed competence and knowledge about the people living in the home. EVIDENCE: On arrival, staff said that there were 5 people on shift, 3 carers who had been doing waking night duties and 2 others who had come on at 6.00am. During the inspection, more and more staff came on duty to carry out various tasks, including 1:1 assistance, catering and domestic duties. The breakfast cook worked 7.00am to 9.00am. One agency carer was in the home on the day of the inspection. Mrs Terry said that she only employs agency staff who have been to the home before. The agency confirm that all its workers have current CRB checks. There was an identified ‘senior carer’ on shift. The 6.00am shift was due to end at 2.00pm. If there is a problem ‘out of hours’ Mrs Terry said that staff call her at home. She lives very close and is available at all times. Staff described the arrangements for sharing important information about what had happened during the night. There had been a group ‘handover’. They said that this would be repeated when the afternoon shift came on duty. The arrangements clearly work, but the shift periods do not actually have any time ‘built in’ for handover and the present arrangements depend on the considerable goodwill of staff. It was been recommended that, say, a quarter of an hour is built in to allow handover to be on a more formal footing. Mrs Terry was open to this suggestion. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 19 We were able to verify that staff working ‘on the floor’ coincided with the roster. When asked, staff clearly knew what to do in the event of a fire happening. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, and 33. The unruffled and competent way the home was being run by the people in charge, and by the staff, was certainly to residents benefit. EVIDENCE: The home has a registered manager who has been through a fit person procedure. Mrs Terry keeps her knowledge updated. The home had a very pleasant atmosphere on the day of the inspection. The permanent staff obviously knew what they were doing and they had a very unhurried manner with the service users. There was a deal of good-natured banter and cheerful chat between residents and the people looking after them. Many people were on first name terms, but the use of endearments such as ‘darling’ were also heard on a number of occasions, called across the Dining Room. When asked about this, Mrs Terry said that many of the service users had been resident for a number of years and they appreciated terms of JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 21 affection such as this. From observations made during the visit, staff treated residents gently, with courtesy and in ways that safeguarded their dignity. One encounter observed was quite telling about the attention and alertness of staff. A member of staff was concerned that a resident should not be embarrassed by appearing in the Dining Room without a clean shirt on. The discussion between the two people was discrete and gently persuasive and an example of good practice. It certainly seemed from the way management and staff went about their business that the service users were the focal point of what was happening. JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 2 3 x x 2 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 3 3 x x x x x JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP21 Regulation 13(4)(a) Requirement Timescale for action Immediate. 2. OP21 13(3) 3. OP25 13(4)(a) The Registered Persons must ensure that the temperature of water supplied to all baths does not exceed 43 degrees Celsius, plus or minus 2 degrees, The Registered Persons must Immediate. ensure that staff are clear about only leaving soiled clothing in the proper places to promote good infection control. Immediate. The Registered Persons must complete the programme of safety guarding radiators. This is a repeat requirement from the last inspection, which had a timescale for action of 30th April 2005. 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 Persons should consider introducing a built in handover period to the staffing roster of, say, 15 minutes. I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 24 JOSEPH HOUSE Commission for Social Care Inspection 3RD Floor Cavell House St Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI JOSEPH HOUSE I55 S27295 Joseph House V223591 230605 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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