Inspection on 27/09/07 for Lawrence Dene

This inspection was carried out on 27th September 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lawrence Dene 05/07/05

Lawrence Dene 30/01/05

Lawrence Dene 10/01/05

Lawrence Dene 19/10/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Lawrence Dene Basingstoke Road Spencers Wood Reading Berkshire RG7 1AP Lead Inspector Robert Dawes Unannounced Inspection 27th September 2007 10:40 Lawrence Dene DS0000011364.V351584.R01.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 Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lawrence Dene Address Basingstoke Road Spencers Wood Reading Berkshire RG7 1AP 0118 988 6002 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) grahamkenyon@atlas.plus.com Atlas Project Team Ltd Mr Graham Kenyon Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th March 2007 Brief Description of the Service: Atlas project team are the providers for Lawrence Dene, which is a care home providing personal care and accommodation for three young adults aged 18 to 65 who have a learning disability with associated behaviour problems. The home is situated on a main road within the village of Spencers Wood and is within walking distance to the local shops and a garage. The recreational and shopping facilities within the town of Reading are within a short drive from the home, and the home has its own unmarked vehicle. Lawrence Dene is a four-bedroom detached house. The ground floor has a large lounge, a dining room and large kitchen with patio doors that leads to the back garden. The first floor has three bedrooms one with en-suite facility, a sensory room and communal bathroom. The back garden has a summerhouse, trampoline, patio area and garden furnishings to be enjoyed by the service users in the warmer months. Off-street parking is available at the front for several vehicles. Fees range from £1782.15 to £2379.63 per week. Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit, which took place during the days of the 27th September and the 3rd October 2007. The site visit, together with the Annual Quality Assurance Assessment and a GP’s questionnaire, were the main sources of information for the key inspection. During the site visit the inspector interviewed the registered manager, home’s manager and two members of staff; toured the premises; looked at records; case tracked; and observed the interaction between service users and staff. No service users were spoken with because of communication difficulties. Twenty three standards were assessed during the site visit of which twenty standards were met and three exceeded. No requirements were made. What the service does well: What has improved since the last inspection? Service users’ personal money that had been used in error has been refunded. Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 6 All staff have received up to date safeguarding vulnerable adults training. A more stable core staff team is now in place. Improvements have been made to the environment. 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. Lawrence Dene DS0000011364.V351584.R01.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 Lawrence Dene DS0000011364.V351584.R01.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): Number 2. People who use the service experience good quality outcomes in this area. Prospective clients’ individual aspirations and needs are assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No service user has been admitted to the home in the last five years. There is a detailed admission policy and procedure within the home and the statement of purpose. The current files included evidence of ongoing review of needs and achievements. Lawrence Dene DS0000011364.V351584.R01.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): Numbers 6, 7 and 9. People who use the service experience excellent quality outcomes in this area. The home works hard to enable service users lead as independent a life as possible and a variety of communication tools and techniques are used to enable service users make decisions about their lives. The care plans are person centred and reflect the diverse and changing needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the three service users’ files contained comprehensive and very detailed individual care plans. The plans covered all aspects of personal and social support and healthcare needs. The plans contained communication profiles; guidelines to focus on positive behaviour; individual behavioural guidelines to address challenging behaviour; activity planners; ‘star profiles’ charts (Social Training and Achievement Record) to monitor and review individual skills; charts to record and monitor instances of challenging or inappropriate behaviour; and summaries of daily records which states what the service user Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 10 had done and how they had been. The care plans are reviewed annually with the service user, relatives and professionals. Therapy planning meetings take place every 6-8 weeks to discuss the effectiveness or otherwise of planned behaviour management interventions and review the goals for the individual service user. The home does not operate a key worker system, as there are only three service users resident in the home. Instead all the staff are responsible for meeting the service users’ assessed needs. From records seen, observation and discussion with staff it was evident that service users are encouraged and enabled to make decisions about their lives, i.e. what to eat, what to do, what colour to paint their rooms and where to go on holidays. All of the service users have significant difficulties in communication. The manager and staff use a range of communication techniques, such as makaton, objects of reference and PECS (Picture Exchange Communication System), to enable the service users communicate their views and make decisions about their lives. The case files contained communication profiles giving useful information on the individual methods used by residents to communicate their views. The service users capabilities are very limited but they are encouraged and enabled to be as independent as possible i.e. two service users make hot drinks with support from staff. Appropriate risk assessments are in place. Lawrence Dene DS0000011364.V351584.R01.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): Numbers 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. People who use the service take part in a wide range of appropriate activities which reflect their diverse needs; they participate in the local community and are enabled to keep in touch with their families and friends; their rights are respected and responsibilities recognised in their daily lives; and are offered a healthy diet and enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has a flexible activity planner which showed activities such as art and craft; visiting local pubs, restaurants and shops; using the Thames Valley adventure playground; going to the cinema and bowling; using the trampoline in the garden; walks; going out for drives and day trips; aromatherapy; hand and foot massages; using the sensory room; sensory toys; and music therapy were offered to the service users. Service users attention span can be very limited. A component of the care plans is to increase the amount of time they can engage in an activity. Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 12 None of the service users are capable of paid employment or attending college courses. Service users with relatives are encouraged and enabled to keep in regular contact. Service users were observed to have unrestricted movement around the home, except other people’s bedrooms. Service users can choose to be alone. Service users help with simple tasks around the house such as putting their own laundry in the washing machine and starting the machine; helping to lay the table for meals; and vacuuming and cleaning their own rooms. Two service users make hot drinks and one service user makes his breakfast. A positive and respectful interaction between staff and service users was observed. The menus showed service users are offered a range of healthy and nutritious meals. Service users eat the vegetables they grow in the garden. Staff observe service users’ likes and dislikes and picture cards are used to enable service users make a choice. One service user has benefited from loosing weight over the last year through his nutritional needs being assessed. Service users are encouraged to assist with preparing the meals. Lawrence Dene DS0000011364.V351584.R01.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): Numbers 18, 19 and 20. People who use the service experience good quality outcomes in this area. People who use the service receive personal support in the way they prefer and require; and their physical and emotional health needs are well met. Service users are protected by the home’s medication procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans showed service users preferences on how they want to be supported are clearly documented. Bedtimes, baths and meals are flexible. The service users have very complex needs and staff provide a high level of support. Detailed guidelines covering all aspects of the service users’ personal support needs were seen. Behavioural management guidelines are developed for each service user. Various methods are used to record patterns of behaviour and every 6-8 weeks therapy meetings are held to review the effectiveness of the interventions and methods of supporting the service users. The home operates a non-physical intervention policy. PRM medication is only used to moderate behaviour in extreme circumstances. Clear guidelines when they should be used are in place. Significant incidents are recorded within incident/accident records Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 14 The inspector observed staff assist and respond to service users in a caring, respectful and professional manner. In response to the question in the GP’s’ questionnaire ‘are you able to see your patients in private?’ the GP replied ‘yes’. The diverse needs of the service users are addressed on an individual basis. Specialist support is provided as required such as speech therapy and physiotherapy. Health records contained in the files showed the service users’ physical and emotional health is being well monitored, responded to appropriately and any problems are being promptly addressed. Service users attend for regular health checks including vision and dental; and have their medication regularly reviewed. Service users are encouraged to exercise by using the trampoline in the garden and going for walks. A service user who was encouraged to loose weight is now able to participate in more activities. Another service user has become significantly more secure, happier and less challenging since living in the home. In response to the question in the GP’s questionnaire ‘if you give any specialist advice is this incorporated in the care plan?’ the GP replied ‘yes’. None of the service users self-administer their medication. No controlled drugs are on the premises. The medication administration records were in order. All the staff have received medication training. Appropriate medication policies and procedures are in place. A pharmacist visited the home in March 2007 to inspect the storage, administration, recording and disposal of the medication. Any recommendations were addressed. In response to the question in the GP’s questionnaire ‘is service users’ medication appropriately managed in the home?’ the GP replied ‘yes’. Lawrence Dene DS0000011364.V351584.R01.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): Numbers 22 and 23. People who use the service experience good quality outcomes in this area. A complaints procedure is in place and a variety of communication techniques are used to enable service users express their views. Appropriate procedures are in place to protect the service users and all staff have received up to date training in identifying possible abuse and how to respond. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure in place. A complaints procedure in a user-friendly format is contained in the service user guides. No complaints have been made to the organisation or the Commission since the last inspection. The home has Berkshire’s inter-agency procedures for protecting vulnerable adults and the organisation’s internal policy to guide staff in the event of an allegation or suspicion of abuse. Phone numbers and addresses of the key organisations to contact if abuse is suspected to have taken place are accessible in the home. Staff interviewed knew how to respond to allegations or suspicions of abuse and who to inform. The inspector was informed that adult protection training is included in the internal induction programme for all new staff. All staff have attended Protection of Vulnerable Adults training except new staff who have been booked to attend. All deputy managers, managers and regional managers have recently attended POVA 2 training. Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 16 The home operates a non-restraint policy in the home. All staff receive SCIP (strategy for crises intervention and protection) training to support service users who become agitated and minimise their distress. The organisation follows the Department of Health’s ‘Guidance for Restrictive Physical Interventions’ to provide a safe service for the service users. The Commission has received no allegations of abuse since the last inspection. No service user manages his own money. Small amounts of service users’ personal money are held in individual wallets in the office. The accounts are checked by the manager every month and audited by the finance director once a year. Two regional managers have to sign to withdraw money from service users’ bank accounts. Each service user has an appointee. In response to a requirement made at the last inspection the records of expenditure of service users’ funds were reviewed in order to identify any inappropriate expenditure. Where errors were identified, reimbursements were made. Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 17 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): Numbers 24 and 30. People who use the service experience good quality outcomes in this area. The home is comfortable, safe and well maintained. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well decorated, comfortable, well maintained and safe. A service user’s bedroom has recently been decorated and the bathroom is in the process of being refurbished. The home was clean and hygienic. Lawrence Dene DS0000011364.V351584.R01.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): Numbers 32, 33, 34 and 35. People who use the service experience good quality outcomes in this area. An effective and competent staff team who receive a broad range of training support the people who use the service fairly, without discrimination and in a caring manner. The home is working hard to recruit a full staff team and enable more staff to achieve a NVQ 3 in care. The home operates a thorough recruitment procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Of the seven staff attached to the home, excluding the registered manager, two have an NVQ 2 or above in care. New staff will be enrolled for NVQ training when they have completed their LDAF induction training programme. Staff were observed to be approachable, respond patiently and kindly to the service users, use appropriate communication techniques and have a positive relationship with the service users. Staff were knowledgeable about the service users’ conditions and needs and were very enthusiastic about working at the home. In the compliments book a relative said she was very happy with the care her son was receiving. In response to the questions in the GP’s questionnaire ‘do staff demonstrate a clear understanding of the care needs of service users?’ and ‘are you satisfied Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 19 with the overall care provided to service users within the home?’ the GP replied ‘yes’. Two support staff are on duty from 7.30 to 11.30, three support staff from 11.30 to 5.30 and two staff until 9.30 when the night support staff come on duty. During the past year a significant number of day support staff have left the service. New staff have been recruited but the home is currently carrying three vacancies. To ensure experience staff are on duty at all times and no agency staff are employed, staff from other homes who have had previous experience of working in the home and the registered manager undertake care duties. The organisation operates a 24-hour on call system to provide advice and guidance to staff. Records showed the organisation complies with the recruitment regulations. In addition third references are requested if it is considered necessary, referees are phoned to authenticate the reference and any gaps in employment are discussed at the interviews. Staff said they considered the training they have received since starting in the home has been comprehensive and equips them to undertake their responsibilities and duties. All new staff receive internal induction training and are then enrolled on the LDAF induction training programme which includes modules on protecting vulnerable adults and equality and diversity. A training plan is developed with all staff and records showed all staff have received basic training plus training in communication, communication plus autism, makaton, POVA and SCIP. Staff who have recently started working in the home have been booked to attend the above courses. All staff have training profiles and refresher training takes place when require. Lawrence Dene DS0000011364.V351584.R01.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): Numbers 37, 39 and 42. People who use the service experience good quality outcomes in this area. People who use the service benefit from a well run home; their health, safety and welfare are promoted and protected; and their views underpin any changes that take place to the running and development of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager (titled Regional Manager) has overall responsibility for two homes including Lawrence Dene. The registered manager is qualified, competent and experienced to run the home. The home’s acting manager has been in post since February 2007 and is responsible for the day-to-day running of the home. She has previous experience in caring for vulnerable adults but has only worked with adults who suffer from a learning disability since taking up the post as acting manager. She receives daily support from the registered manager. Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 21 Staff were very positive about the management of the home. They said they were well supported, communication was excellent, their views were listened to and they received clear guidelines about how the service users should be cared for. The organisation ensures an effective quality assurance and monitoring system operates in the home through monthly staff meetings; regular managers’ meetings; seeking relatives’ and professionals’ views about the quality of care at reviews (questionnaires have been sent out in the past but the response was very poor); Regulation 26 visits being undertaken every month when quality assurance checks of areas such as medication, premises, record keeping and fire safety take place; and seeking service users’ views through a variety of forums. A maintenance plan for the premises is produced annually and changes to the way the home is run are discussed at the managers’ meetings. Records showed all health and safety checks and inspections are up to date and completed as required. Necessary health and safety policies and procedures are in place. The home’s fire risk assessment has been reviewed. An external health and safety audit takes place on an annual basis. All the service users’ files contained appropriate risk assessments and had been reviewed regularly. All the staff have received the necessary health and safety training including first aid. Lawrence Dene DS0000011364.V351584.R01.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 X 2 3 3 X 4 X 5 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 X Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 23 No 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. Standard Regulation Requirement Timescale for action 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 Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Lawrence Dene DS0000011364.V351584.R01.S.doc Version 5.2 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. 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