Inspection on 20/02/06 for Khaya Project

This inspection was carried out on 20th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Khaya Project 23/11/06

Khaya Project 05/10/05

Khaya Project 03/03/05

Khaya Project 29/07/04

Khaya Project 24/02/04

Khaya Project 09/09/03

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

CARE HOME ADULTS 18-65 Khaya Project 71 Wellesley Road Ilford Essex IG1 4LJ Lead Inspector Stanley Phipps Unannounced Inspection 20th February 2006 16:30 Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Khaya Project Address 71 Wellesley Road Ilford Essex IG1 4LJ 020 8554 7902 020 8554 7902 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) Mr Ndumiso Mafu Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A minimum of 2 staff on duty at all times. Unless residents are not on the premises. The rota to include designated time each week, supernumerary to the minimum 2 staff, for Mr Mafu to operate in his roles as proprietor and manager. There must be two staff on night-waking duty at all times, as there are no sleeping-in facilities currently in the home. 5th October 2005 Date of last inspection Brief Description of the Service: Khaya Project is a care home providing personal care and accommodation for five people ages 18 - 55 with a history of mental illness, who need support in order to live in the community. It is privately owned and run by Mr Ndumiso Mafu. The home is located in Ilford approximately 5-10 minutes from Ilford British Rail station and town centre and as such lends itself to all the amenities contained therein. These include a wide range of shops, pubs, the post office, entertainment centres, parks and library facilities. The home was opened in 2003 and is an ex-residential property built on two floors, which was refurbished in order to set up this service. There are bedrooms and communal rooms on both floors and staff would be expected to work closely supporting service users. The registered manager successfully applied for a variation in the summer 2004 to increase the number of beds from four to five. He has since added a conservatory that is spacious and contains a music centre for the enjoyment of service users. All the home’s bedrooms are single, and one of the five has en-suite facilities. Access between the floors is via two sets of stairs. The home has a large rear garden part of which is intended for gardening with the other for leisure. The leisure area is satisfactorily maintained and the garden is in the process of being developed. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in just under three hours and was timed to coincide with meeting service users, observing the evening routines and to monitor the overall progress of the service. The inspection found that Khaya project continued to generally offer a consistent and stable service, to individuals with complex mental health needs. This was evidenced by, the level of compliance with the national minimum standards for younger adults. The previous requirement was satisfied and service users spoken remained generally satisfied with the services provided at the khaya Project. Despite this there were a few areas that were identified for improvement at this visit. As part of the visit discussions were held with two service users and a detailed discussion was held with the senior member of staff on duty, who was very helpful during the inspection. A random sample of service user plans, staff training records and the complaints records were examined. The level and type of activities were also assessed followed by a tour of the environment. What the service does well: What has improved since the last inspection? The shower attachment has been replaced as required by the last inspection and one senior member of staff has achieved her NVQ level 4 in Care Award. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (4) As part of the admissions process, service users benefit from visiting the home prior to deciding whether they should live there. EVIDENCE: An examination of the records held on the most recently admitted service user, bore evidence that he visited the home prior to agreeing for a trial stay at the khaya. This has been consistently carried out by the home and was in line with the admissions procedure. Service users get the opportunity to see the facilities and meet with staff and service users living there. This is good practice and service users interviewed in the past were pleased at having that opportunity. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (7,10) At the Khaya Project all service users are empowered to make decisions in their lives. Working in most cases, closely with staff they are assured that information is held on them is handled sensitively and in their best interests. EVIDENCE: There are clear systems in place to support service users in decision-making about their lives. They include weekly key work sessions, service user meetings, reviews, access to advocacy input, provision of information by staff that is specific to the service user group and through informal discussions with the manager and staff. At the time of the visit it was observed that one service user goes out the local shops and part of his routine is having a meal the café. The service user also has a condition for which he needs to take responsibility for what he eats and drinks. From his case records staff were constantly providing advice and guidance to ensure that he takes responsibility for eating and drinking to promote his best interests. Clearly and at times he makes decisions that adversely affects his health, but the staff continued to explore ways of getting the individual to make more positive decisions with regards to his health and welfare. The service user was interviewed and he indicated that all the staff have worked in his best interests, but he sometimes find it hard to do the right thing for himself. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 10 Another example was where another service user in promoting his welfare, would take responsibility for going out for his depot at a day centre. This is positive and throughout the home individuals were given support to make decisions, what was clear however was that the decisions made varied in that some had a positive impact on individuals while others, much less so. For example, one service user had enrolled with the Redbridge Resource Centre and has been refusing to attend, while another stopped using the gym for hygienic reasons, however, he continues to work out in his own room. From the interview held with the senior staff on duty, it was clear that there was a sound awareness of how information held on service users is safely handled for their protection. This awareness was in line with the home’s policy on confidentiality and the sharing of information with other agencies. The files of service users are securely maintained in a locked cabinet in the promotion of confidentiality, particularly as service users are quite often in and out of the office for various reasons at various times. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (11,12,31,14) Service users at the khaya Project have opportunities for personal development and participate in activities of their choice. They are also integrated into the community in which they live and individually make choices about how they use their leisure time. EVIDENCE: There was evidence regarding how service users have been positively engaged towards their personal development. This is an area in which staffing support is critically crucial. Many of the service users entered the home with low selfesteem and with low levels of independent living skills. Currently there are service users who are able to carry out their laundering without assistance, able to tidy their room independently, are able to communicate in a socially acceptable manner as well as make positive choices in their lives. A good example could be drawn from the fact that most of the service users handle their own finances. This is a credit to not only the service users, but to the staff team who work flexibly in providing support to them. Quite often they are faced with varying challenges in trying to enable service users to meet their personal objectives. However they persevere and achieve results, though small in some cases, but significant to the lives of individuals. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 12 Service users live like a family at the Khaya Project, however they engage themselves in activities of their choice and interests. Collectively they enjoy having a take away on a Friday evening and they would with the help of staff order their requirements and hang out either listening to music or watching sky television. They at times find it difficult to agree on what they would like to do e.g. where they would like to have a party and this was apparently a stalemate over Christmas, but they are actively involved in determining what they would like to do. Individually they have their own friends and networks and they are encouraged to keep links with them. They are familiar with the local community as they use facilities such as the post office, shops, the pubs, cafes, doctors, pharmacy and dentist and this is not exhaustive. There are occasions in which a service user may choose to leave the home and not return and this is not because he is unfamiliar with the local community, but more because he prefers spending time away from the home. This case is in the minority and adequate systems were in place to ensure that he is safe as he possibly could be. All other service users use the community independently and to suit their individual needs. From a leisure point of view, the home offers sky television which all service users spoken to, were quite pleased about, puzzles, cards and a music entertainment centre. Two service users are noted for listening to classical music and they use the home’s system to enjoy this. Other service users use the music system as and when they feel the need to and this is positive. Service users may also visit the local pub, but this is done in a controlled manner as many are on psychotropic medication. This means that alcohol use may be contraindicated in some cases. Service users may also go to the cinema or outings, although the latter is reportedly more difficult to get tem motivated for. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19) Satisfactory arrangements are in place for providing personal support for service users at the Khaya Project. Generally key work sessions and effective links with multi-professionals ensure that the psychological and emotional needs of service users are met. However improvement is required to ensure that health issues are followed up with professionals in the interests of service users. EVIDENCE: During discussions with service users, they expressed their satisfaction with the quality of staff support in the home. It was acknowledged that service users needs were varied and as such the level of input was higher in some when compared to others, in key areas such as personal care and dealing with more complex issues such as compliance with medication or an individual’s dietary plan. Service users’ records bore evidence of interventions made with them individually and it was positive that their individual preferences were taken into account. Regular key-work sessions with service users provided good opportunities to ensure that service users were happy with the input of staff. The home has introduced a monthly key worker checklist and this takes into account visits and telephone calls made to a service user whilst he is in hospital. This ensures the continuity of care and provides a good audit trail in tracking the care of an individual. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 14 All service users were registered with a local GP and there were records on file of all appointments. This included the chiropodist, dentists and opticians. Service users have access to specialist health professionals as required e.g. the consultant psychiatrist and/or a community psychiatric nurse to provide for issues regarding their mental health. Staff work closely with them to ensure that appointments are kept and that effective links are made with these professionals to enable the service users to get the best possible care. Generally meeting the physical and emotional needs of service users is a strong area of the home’s operations. However in case tracking the care of a service user, in which there were serious concerns about an aspect of the individual’s physical health- the handling of it was not as good as it needed to be. The work of the key worker was outstanding in following up the matter and to some extent the registered manager also contributed positively to the monitoring and support to the service user. The registered manager wrote to the GP on the 19/1/06 regarding the team’s concerns about the service users condition and in the letter requested input from the GP. As it happened one month later during the inspection, the GP had not responded, the service user’s situation was unchanged and no record could be found to indicate that the GP had been chased up for a response. This is despite the key worker indicating between 19/1/06 (letter to GP) and the inspection visit 20/2/06 that he was concerned for the service users health. This inaction compromised the health and welfare of the individual concerned putting the specific aspect of his healthcare at risk. This must be improved. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (22) Service users and their relatives can feel reassured that concerns, when raised would be taken seriously through a timely and thorough investigation, which is in line with the Khaya’s complaints procedure. EVIDENCE: A satisfactory complaint’s procedure is in place and this is well advertised in the home. As a matter of course service users and/or relatives are encouraged to talk about issues they may have a concern with. This allows the management and staff, an opportunity to make early interventions to reduce the risk of problems arising. Service users in the main have the added advantage of raising issues informally and in service user meetings. There were no complaints on record, however various issues were discussed at their service user meetings. Two service users spoken to were aware of the procedure and importantly who to contact if they were unhappy with how a complaint is handled by the home. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (24,26,29,30) Service users enjoy a clean and comfortable and generally safe environment at the Khaya Project and this is viewed positively and appreciated by them all. Service users have bedrooms that promote their independence, which is positive. However, some improvements are required to the various parts of the home to enhance the homely feel to the khaya. EVIDENCE: On the day of the visit the home was relaxed, generally comfortable and safe. Service users spoken to were happy with it, as they were able to use and enjoy their home with great ease. The took responsibility for doing their little bits towards maintaining it and felt that the manager and staff did well in maintaining a safe and warm place to live. The heating, lighting and ventilation were satisfactory, although some of the décor needed improving. As part of maintaining a safe environment a GORGI registered engineer had recently carried out a gas safety check with positive results. The health and safety file was updated and this adds to the promotion of health and safety in the home. However some improvement was required to the home i.e. 1) to replace the cracked tile in the laundry area, 2) to fill the hole in the wall in the stairwell and redecorate the walls in the stairwell and 3) to repair or replace the floor covering of the kitchen. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 17 Although none of the bedrooms were seen on this visit, discussions held with two service users indicated that they were in a satisfactory condition and as such, they remained happy with it. One of the service users on the ground floor has an en-suite facility and this allows him to maintain his independence. All service users have keys to their bedrooms and this enables them the autonomy to access it as and when they want. At the time of the visit there specialist equipment, was not a feature of the home, as all service users are independent. This means that they are able to fully enjoy the facilities without the use of any specialist aids. Staff and service users do a good job in ensuring that the home is clean and hygienic. Staff are particularly good at teaching and guiding service users with regard to maintaining a safe and clean environment. This was evident on the day of the inspection. The laundry arrangements in home were satisfactory and policies and procedures were in place with regard to infection control. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (32,33) A dedicated and skilled staff team provides good quality services to service users living at the khaya. This is enhanced by the satisfactory deployment of staff to provide the care and support to individuals. EVIDENCE: Staff were observed carrying out skilled interventions with service users. They had a good working relationship with them and demonstrated a sound understanding of their needs. They (staff) were also quite motivated and worked closely with service users in meeting their needs. The registered manager has been proactive in that over seventy five percent of the staff had completed their NVQ level 3 in Care Award. One of the senior staff had also just completed her NVQ level 4 and was awaiting her certificate. This is commendable. Staff have also been provided with statutory training during their induction and has received training to understand the needs and behaviours of mental sufferers. Their training enables them to understand aggression, appropriately deal with abuse as well as challenging behaviour. This is a strong area of the homes operations. The staffing deployment is effective in meeting the needs of service users in that it takes into consideration the skills of staff, the needs of service users including their cultural and gender mix. In previous visits the registered manager provided evidence of his intention to increase his search for staff from the mainstream of society, as he was conscious that he does not have this at the moment. However the current staff team is effective as they work flexibly, Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 19 they are in adequate numbers to support service users on a twenty-four basis and are supported by an experienced manager. Regular staff meetings are held and staff spoken to indicated that they find them supportive and useful. There are low levels of sickness in the team that is well established. In essence service users are supported by a skilled team of regular staff who are keen to meet their needs. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (38,39) An experienced and dedicated manager is in place to ensure that service user needs and best interests are provided for. The quality of the service is enhanced by consistently, seeking and incorporating the views of service users in developing the home. EVIDENCE: The registered manager works closely with all service users and the staff. Service users spoke highly of him with regards to his support for them. One service user stated: ‘that Dumie (manager) is a good guy. I should listen to him more as he really cares about me. I would have been healthier if listened to him’. He is accessible to all service users and works with them at all stages from assessment to move on. He gives clear direction to staff and by virtue of his experience in mental health supports the team to ensure a safe and stable environment at the Khaya Project. Staff also spoke highly of him in that they stated; ‘he is accessible, approachable and encourages them to contribute to the service’. The registered manager’s commitment to equal opportunities are clear in the policies he wrote and the training provided to staff in this area. This is a strong aspect of the home’s operations. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 21 An annual development plan had been provided previously and the registered manager actively seeks the views of service users and staff. Annual service user surveys had bee carried out in 2005 and more recently on the 10/2/06. The results were published and identified areas are taken forward for developing the home. Feedback received from service user meetings regularly held, are also used to positively influence what happens in the home. The manager also monitors the service through regular supervision, staff appraisals and team meetings. Externally feedback is obtained from holding service users reviews and this is also considered in the development planning for the home. Policies and procedures were updated and accessible to both staff and service users. In essence adequate systems were in place to promote and maintain quality service provision in the home. Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 X 2 X 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 x ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 x 32 4 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x 3 X X 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 X X x 4 3 X X X X Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 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 YA19 Regulation 12,13 Requirement The registered manager is required to ensure that appropriate action is taken to follow up key inputs that are required from external professionals – at all times. This is specific to the promotion of service users’ healthcare. The registered manager is required to carry out all the remedial works identified in Standard 24 of this report. Timescale for action 30/05/06 2 YA24 23 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Khaya Project DS0000037133.V284364.R01.S.doc Version 5.1 Page 25 - 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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