Inspection on 30/01/07 for Leominster Residential & Nursing Home

This inspection was carried out on 30th January 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

Leominster Residential & Nursing... 19/01/06

Leominster Residential & Nursing... 19/10/05

Leominster Residential & Nursing... 06/07/05

Leominster Residential & Nursing... 22/02/05

Leominster Residential & Nursing... 09/08/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Leominster Residential & Nursing Home 44 Bargates Leominster Herefordshire HR6 8EY Lead Inspector Wendy Barrett Unannounced Inspection 09:45 30 January 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leominster Residential & Nursing Home Address 44 Bargates Leominster Herefordshire HR6 8EY 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) 01568 611800 01568 611855 www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Mrs Monica Hartley Care Home 51 Category(ies) of Dementia - over 65 years of age (51), Old age, registration, with number not falling within any other category (51), of places Physical disability over 65 years of age (51) Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Leominster Residential and Nursing Home is owned and managed by BUPA Care Homes (CFCHomes) Ltd. The Home was opened in 1996 and consists of a two-storey modern purpose built Home with a Georgian style façade offering accommodation for a maximum of 51 older people of both sexes, who may suffer with dementia, a physical disability or frailty due to old age. The Home is located in the town of Leominster, a short distance from the shops and other amenities. The Home has 45 single en-suite bedrooms and 3 double en-suite bedrooms. The double rooms are all currently used as single occupancy accommodation. A designated single bedroom is available as a respite care facility. The Home has a passenger lift. The gardens are tidy and accessible. There is a pack of information that describes the service offered at the home. All enquirers receive one of these packs and each bedroom at the home is supplied with one. The Provider does offer to produce the information in a way that will be accessible to people who have difficulty reading the standard version e.g. large print. From 2007 the fees ranged from £485 plus up to £45 top up (for funded residents) to £692-25pence for privately funded nursing care. Additional charges are made for hairdressing, chiropody, private physiotherapy, private alternative treatments, toiletries, papers and magazines. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written with reference to information about the service and held by the Commission, survey responses from residents and relatives and an inspection visit to the service. What the service does well: What has improved since the last inspection? The Provider has revised the menus to be sure the residents are receiving a well balanced diet designed to suit the needs of older, frail people. A new method of recording the care provided each day has been designed so that it is more effective. A sensory garden was opened last summer. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home are carefully planned so that the resident (or their relatives) know what to expect of the service, and the staff have the information they need to decide if they can meet the prospective resident’s needs and expectations. EVIDENCE: There is a pack of information that describes the service offered at the home. A resident commented ‘plenty of information –brochures etc.’ All enquirers receive one of these packs and each bedroom at the home is supplied with one. The Provider does offer to produce the information in a way that will be accessible to people who have difficulty reading the standard version e.g. large print. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 9 A relative confirmed that she had received the information before her mother was admitted and family members had been able to look around the home, and the proposed bedroom, to decide if the facilities were acceptable. They were very happy with the way their mother had been introduced to the home. Records seen at the home contained details of the information gathered during this pre-admission work. It included reference to care needs and preferences e.g. preferred times of getting up and going to bed, preferred way to be addressed by name. Although the current record is very comprehensive the Provider continually tries to find ways to make sure each admission is successful. The way the initial information is recorded was being updated again at the time of this inspection. Every resident receives a contract of residence to confirm the arrangements and the fees. When charges are altered a letter is sent out to inform the resident or their relative. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ care is carefully planned to be sure it meets individual and current needs. Residents or their relatives are consulted as part of this work. There are records to show how the care is planned and provided. These are generally well maintained although there are a few examples where additional attention to detail would strengthen the overall picture. EVIDENCE: The care needs of each resident are regularly reviewed so that any changes in condition can be reflected in the type of care provided by the staff. Each resident has a written plan of care and relatives feel happy with the effect this has on the residents’ wellbeing –‘superb level of care’, ‘I have every confidence she is well treated and looked after’. A nurse was asked to go over a resident’s care record and showed good Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 11 awareness of the way information was being maintained. The record included examples of risk assessment work, monthly evaluations and consultation in compiling care plans e.g. a nutritional care plan referred to a wife’s wish to help feed her husband, a consent form had been signed regarding the use of bed rails. There were one or two examples where staff had not fully completed the records e.g. entry dates had not always been fully completed, a few care plans had not been signed since May 06 to confirm review. A few records were no longer relevant and should be removed to avoid confusion. Similar shortfalls were also identified at the last inspection. The Commission receives details of accidents and incidents that occur at the home. This reflects prompt attention and appropriate referral to other health care professionals. Accident records are regularly audited at the home as an additional safety measure. The Provider continues to improve the care planning processes at the home and copies of new documentation were being implemented at the time of the inspection visit. The home’s clinical co-ordinator helped with an inspection of the medication arrangements. These were generally satisfactory although there were a few examples when the procedures were not fully followed e.g. a few containers had not been dated when new stock had been brought into use (this shortfall was subject to a requirement following the last inspection), a hand written entry on the administration record had not been signed by two staff to confirm accuracy. Controlled drugs were being appropriately stored and actual balances of stock matched the balance recorded in the controlled drugs register. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The way that each resident is supported in maintaining their preferred lifestyle is commendable because although staff behave in a very respectful manner they also demonstrate warmth and approachability in the way they interact with the residents. EVIDENCE: The staff make considerable efforts to help residents spend their days as they wish. A care plan for a resident who has short-term memory loss included information to help the staff with this approach. There are regular programmes of organised activities and also good attention is given to supporting residents who benefit from one to one time. Records are kept of this work. A resident commented ‘I do the flowers every week - very good activities’. During the inspection visit there was a very relaxed but professional atmosphere and this was particularly evident during a tour of the home. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 13 Residents welcomed the Care Manager warmly and interactions were at all times respectful but relaxed. All staff reflected this attitude as they went about their work. Relatives support this view –‘very friendly and helpful’, ‘uplifting and happy’. A group of residents and visitors were observed enjoying a game of cards. There was much laughter and chatter. Live musical entertainment was happening during the second inspection visit for interested residents. One lady was observed in her wheelchair in the garden putting out food for the birds. Others were spending time in their bedroom reading, watching television or resting. Two residents felt unable to participate in activities due to their disability although each resident’s needs and wishes are routinely sought and recorded by the activities organiser. A resident agreed that she could spend her days as she wished. A relative was visiting her and they were looking forward to having lunch together at the home. Standard menus are audited by BUPA Hotel Services Group so that they are nutritionally well balanced and varied. The cook described a ‘5 a day’ exercise that had been introduced since the last inspection. This had resulted in amendments to ensure a suitable diet for older people e.g. full cream milk, home made soups, full fat yoghurts and plenty of cream. The cook was fully aware of the particular needs of individual residents – ‘she loves a sherry’, ‘he has a sweet tooth’, ‘small portions but it doesn’t need to be softened for him’. A resident was observed sharing a joke with the cook about his liking for walnut cake and another described the meals as ‘beautiful’. One comment referred to the use of agency cooks and observed that meals were less satisfactory when these staff were used. Agency staff are actually used very little and BUPA prefers to cover duties with its own relief staff. Records of food confirmed close attention to each resident’s requirements, particularly those who experience difficulty eating. The dining room is very spacious and was very attractively presented. Residents can choose to eat in the privacy of their own bedroom. A staff member was observed helping a frail resident with coffee and biscuits. This support was being offered sensitively without any sense of rushing the resident Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives know how to raise concerns and are confident they will be taken seriously. The residents are protected from abuse through prompt investigation of any allegations, and consultation with external agencies if this is necessary. The staff receive guidance to help them identify and report issues of concern. EVIDENCE: A complaints procedure is well advertised at the home and relatives confirmed their awareness of this procedure. A resident approached the Care manager during the inspection visit. She was concerned that a particular type of biscuit was not available. It was clear that she felt confident in approaching senior staff and her concern was listened to in a respectful manner. The Commission hasn’t received any complaints about the service since the last inspection. The staff have received training in adult protection since the last inspection. The clinical co-ordinator confirmed that the co-ordinator of the local vulnerable adults group had been invited in to speak to staff. There have been two occasions when the Provider has taken action following Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 15 internal allegations about inappropriate staff behaviour. In one case, the allegation was referred to the local vulnerable adults strategy group. The Provider and Care manager responded promptly in both cases to maintain the safety of residents. There was also an example of careful consideration and risk assessment in deciding whether a potential employee would be suitable to work with vulnerable adults. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from accommodation especially designed to suit their needs, and there is a high quality of furnishings and facilities. The premises are kept safe and hygienic at all times. EVIDENCE: The premises were purpose built approximately 10 years ago so that they were specifically designed to suit the needs of the residents. There has been regular attention to maintaining and improving the environment since the home was built e.g. a sensory garden was established last year (and won an award). Décor, furnishings and fittings are high quality and show no sign of deterioration since the home was first opened. Residents are encouraged to Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 17 personalise their bedrooms and those who are heavily dependent on staff support have furniture arranged in their room to facilitate this work. When rooms are allocated the staff take care to meet individual needs e.g. one married couple lived closely together, another couple were deliberately allocated bedrooms a little apart because they needed the opportunity for a little private space at times of the day. A resident was very happy with her room. She appreciated that the staff had given her extra cushions to make her armchair more comfortable. A sample of staff training records confirmed instruction in the safe use of equipment e.g. safe use of wheelchairs. The Provider conducts thorough audits of the premises so that any issues regarding health and safety are quickly identified and dealt with e.g. kitchen cleaning schedules, pest control measures. Staff are provided with the equipment they need to address infection control measures e.g. colour coding, protective clothing, hygienic hand wash facilities. They also have written guidance that is regularly updated to reflect current good practices. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is provided by a competent team of staff who have a clear understanding of their role. New staff are carefully selected and introduced to be sure they will work safely with the residents. The Provider encourages all staff to appreciate the residents’ situation and to contribute to the development of the service in the best interests of the residents. EVIDENCE: There were enough staff on duty at the time of the unannounced inspection visit to respond to the residents’ needs. Staff employed on direct care were well supported by a team of management, catering, administration, maintenance and cleaning staff. Sample duty rotas confirmed this satisfactory situation although one relative commented on occasional staff shortages. A resident spoke of her appreciation for the individual attention she receives from the staff – ‘the staff are so good. They brought me a new tube of ointment yesterday evening’. A training co-ordinator is employed at the home so all staff receive good support and oversight of their training needs and work performance. The Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 19 written evidence confirms a well organised approach to this aspect of the service. There are two staff who are qualified to train others in manual handling techniques. The training co-ordinator ensures that each member of staff receives the health and safety instruction relevant to their role and supports staff in their work on achieving a national vocational qualification (NVQ). She also has a lot of literature for nurses and care staff to use for reference. Although the national minimum standard to have 50 of care staff with an NVQ was not quite achieved at the point of this inspection there had been several qualified staff who had left the home during the previous year. Other staff were currently working towards the qualification. New staff are thoroughly checked, as required by regulation, before they start work at the home. An induction record confirmed that essential instruction had been provided to make sure the new staff member could work safely e.g. fire safety, safe bathing. The complete programme was in line with national specifications. The new staff member was being encouraged to work towards an NVQ once her induction was complete. The Provider is very innovative in staff development work e.g. all staff were participating in an exercise programme to help them appreciate ‘the customer’s experience’ of the service and make suggestions for improving satisfaction and exceeding expectations. BUPA won an industry award for ‘Best communicators with staff’ in 2006 Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect and has effective quality assurance systems that result in continuing improvements in the best interests of the residents. EVIDENCE: The Care Manager has been in post since the home opened approximately 10 years ago. She is, therefore, very experienced and well qualified. The Provider offers her regular opportunities to update her professional knowledge and awareness of changing legislation and good practices. Residents and Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 21 relatives express considerable confidence in the Care Manager –‘an efficient and caring Matron’, ‘Matron has great leadership’. Most resident survey forms named the Matron as a person they could talk to if they had a problem. A representative of the provider visits the home at least once a month. During these visits all aspects of the service are audited to be sure they are working in the best interests of the residents e.g. the Care Manager(Matron) was asked to undertake a night visit to the home to be sure everything was satisfactory. The Provider is very innovative in the way the business is run and there is ongoing attention to improving residents’ experience e.g. all staff were undertaking an exercise programme to help them appreciate the residents’ perspective and to think of ideas that would make things even better for the residents. The nutritional balance of meals had been reviewed and amended in 2006 in response to current guidance on the dietary needs of older people. Residents are encouraged to make their own arrangements for support with their financial affairs. When residents have to rely on the Provider to support them a dedicated bank account (with interest) is used for holding savings. Records of transactions into and out of this account were inspected and provided clear accountability for each resident. Health and safety of the premises is maintained through a regular programme of servicing and internal audits. A fire Officer’s inspection report at the end of 2006 reflected satisfactory attention to fire safety. Staff training programmes include routine refresher of essential instruction such as manual handling techniques, infection control, safe use of equipment. Leominster Residential & Nursing Home DS0000027682.V327086.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 3 STAFFING Standard No Score 27 4 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 x 3 x x 3 Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 23 l. Are there any outstanding requirements from the last inspection? no 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. 1 1 Refer to Standard OP28 OP37 Good Practice Recommendations Increasing the number of care staff holding a national vocational qualification would help maintain a consistent 50 minimum level. Closer auditing of records of care and medication management would help identify occasional shortfalls in maintaining accuracy. Leominster Residential & Nursing Home DS0000027682.V327086.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Leominster Residential & Nursing Home DS0000027682.V327086.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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