Inspection on 09/08/05 for Lorna House

This inspection was carried out on 9th August 2005.

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

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

Other inspections for this house

Lorna House 15/01/09

Lorna House 25/01/07

Lorna House 15/02/06

Lorna House 17/12/04

Lorna House 27/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Lorna House Devons Road Torquay Devon TQ1 3PR Lead Inspector Stella Lindsay Announced 9th August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lorna House Address Devons Road, Torquay, Devon, TQ1 3PR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01803 329908 01803 606532 Crocus Care Limited Mrs Linda Christine Vans-Colina Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Dementia, over 65 years of age (24), of places Physical Disability, over 65 years of age (24) Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/12/04 Brief Description of the Service: Lorna House provides residential care for up to 24 older people who may have physical disabilities, and who may have mild levels of mental confusion. The house is a large detached property with a level garden in the Babbacombe area of Torquay, by Cary Park. There are 20 single rooms, 9 of which have en suite facilities, and two double rooms, both en suite. There are three bathrooms, two of which have Aquatec powered bath seats. Accommodation is on two floors, with a stair lift. Access around the ground floor is level, with a ramp to the garden via the front door. There is a dining room and a large lounge, leading to an attractive conservatory. The Crocus Care car is freely available for local journeys, with a charge for petrol for longer journeys, and a minibus has been provided. The service is not aimed at people with advanced dementia or severe physical disabilities, though best efforts are made to continue caring for residents whose health deteriorates after moving in to the home. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on a Tuesday in August 2005, between 9.45am and 6.30pm. It included a tour of the premises, examination of care records, staff files, health and safety records and the medication system. As well as discussion with the Registered Manager the inspector met with ten residents, two visiting relatives, and five staff who were on duty, and thanks all for their time. What the service does well: What has improved since the last inspection? What they could do better: Environmental improvements which are planned but still awaited include; -Ramped access from the conservatory to the garden -Refurbishment of the laundry, including sluicing equipment -Provision of a second ground floor toilet Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 6 -Provision of an accessible shower. Quotations have been gathered for these, and all these developments will be beneficial to residents and help staff in their work. Safe and level floors are essential to the safety particularly of frail residents walking with mobility aids, and people with poor balance. All floors should be reasonably smooth. At the time of the inspection there was a ridge across the dining room floor which needed attention. The laundry and bathroom floors also needed attention, to make them hygienic. The medication system was administered properly, with the exception of breakfast time, when pots had been sent up on trays instead of being administered directly by the responsible person. The Manager operates a sound system of recruitment, but had not retained proof of identity for all staff, as is required by the regulations for the protection of residents. Lorna House has a spacious level garden. A suggestion that arose during the inspection was that the residents would be further encouraged to use it if a shaded area were provided, such as a gazebo or summer house. 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. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,5 Residents are given clear information before they move into the home. EVIDENCE: Lorna House has produced a Statement of Purpose and a Residents’ Guide which are clear and concise. The ethos of the home in promoting positive choices and a stimulating social life is presented. Crocus Care also has a website – www.crocuscare.co.uk. Statements of terms were seen on residents’ files, signed by themselves. They included the annual fee review, as well as clarifying reasons why the person might have to leave. Residents confirmed that the Manager had visited them before they moved into the home. All new admissions are on the basis of a trial month. Intermediate care is not offered at Lorna House. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 Good care was given, health professionals had been consulted appropriately, and relatives felt involved in the care planning process. The procedure for administering medication at breakfast-time needed to be brought in line with the practice during the rest of the day, as residents had been put at potential risk of harm. EVIDENCE: Residents said that the staff were very good to them. Very dependent residents were seen to be smartly dressed. Visiting relatives confirmed that they are involved in their relation’s care plan review. A relative of a very dependent resident said that everything was ‘always perfect’, her relative was ‘always clean and dressed’, and that she had ‘improved in some respects’, which had not been expected and was due to the care and understanding of the staff and management at Lorna House. Care plans were seen to contain assessments by Social Workers and health care professionals. There were personal fact files, including some social history. The person’s preferred daily routine was recorded. Service Users’ satisfaction questionnaires were kept on file, so their opinions were recorded. Professional risk assessments were seen on residents’ files when the use of bed guards had been considered, showing that the advice of District Nurses Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 10 had been obtained. A Senior Carer often takes residents to their medical appointments. Staff took trouble to see that residents were comfortable for their meals, and one resident who felt unwell during lunch was taken back promptly to the lounge. Professional advice is being sought for a resident whose frequency of care needs are causing concern. There is evidence of good multi-disciplinary work to deal with residents’ illness and anxieties. District Nurses visited every day during the final week of a resident who had wished to return home from hospital to die. The Manager was responsive to increased care needs and arranged for a night care assistant to be with a gravely ill resident. Staff are supporting residents who have suffered bereavements. There is a policy and procedure for administering medication, which is generally adhered to with care. However, the breakfast medications had been delivered by other staff than the one taking responsibility for the administration of medication, and this must stop, to avoid potential risk to residents. Residents are enabled to self-medicate if they are able. Suitable risk assessments had been recorded, and were seen on residents’ files. There is a suitable and sufficient method for recording and storing Controlled Drugs. Staff who administer medication have received training. A resident who was maintaining independence as far as possible, and preferred to stay in their room, said that their wishes for privacy were respected. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 A good variety of activities is maintained. The meals provided are very good, with choice and variety. EVIDENCE: Lorna House has a lively atmosphere, and a variety of activities are provided. A Monthly Planner is displayed in the entrance hall to let residents know the activities that are due. On the day of the inspection an activity organiser arrived with her radio to lead an exercise group in the morning, and ‘Jenny’s Antics’ took place in the afternoon. Additionally, a Senior Carer took a group of residents out to celebrate a birthday with a riverside lunch. Domestic staff run an in-house shop, and take orders for shopping for residents’ personal requisites. A minibus had just been provided for the sole use of the home, and residents were excited at the prospect of more outings. Some residents are able to walk to the park and the local shops unaccompanied. A garden fete had been held the previous weekend, with music and a bouncy castle as well as stalls. On the day of the inspection there was a choice of soup, melon or fruit juice for starter, then roast chicken or tuna salad. A menu board was displayed on the dining room wall. Residents said that the cook was ‘excellent’. A carer brought round the sweets trolley, so that residents could choose any Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 12 combination of fresh fruit salad, rice pudding, cream and ice cream. One resident, who finds eating difficult because of their disabilities, said that the food is very good, and ‘well worth the effort’. A vegetarian diet is supplied. Food eaten is recorded, as a record of residents’ nutrition, and in order to be able to trace the cause if any food related illness should occur. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 There is good evidence at Lorna House of management listening and responding to residents’ concerns and suggestions, and the Manager is taking action to ensure that staff know how to protect residents from abuse. EVIDENCE: The complaints policy is displayed in the entrance hall, and included in the Service Users’ guide. Complaints had been recorded, which showed that there had been a proper response. The Adult Protection policy was in place, but did not include the local multidisciplinary reporting arrangements. The Manager has booked places for staff to attend training on awareness of their role as ‘alerters’. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,26 Lorna House is suitable for the purpose of caring for frail elderly people, though work is still required to make the building safe and hygienic throughout. EVIDENCE: Lorna House is a large detached property in the Babbacombe area of Torquay, by Cary Park. The garden is level, and residents confirmed that they are able to walk around it. Access will be improved when the ramp from the conservatory is provided. A handy man is employed 17.5 hours per week. He carries out repairs promptly, and can be assisted in heavy jobs by an employee from another Crocus Care home. He keeps a book to record maintenance tasks, and requests from residents for minor alterations, such as lowering a mirror or the rail in a wardrobe. He was cleaning carpets on the day of the inspection. The home has been re-carpeted through out its communal areas. The residents were involved in the choice of carpet, though their first choice turned out to be unavailable in the amount needed. The lounge area has been greatly enhanced by the provision of a large and attractive conservatory. Unfortunately, use of the conservatory has been Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 15 limited during this summer because the ramped exit has not yet been built, and the door has to be kept shut unless a member of staff can be present to assure safety, and residents have found it too hot during the day. Quotations are being actively gathered for this work. The dining room is bright, in spite of being a large room with only one window – the lighting is good, and the room has been newly redecorated. A ridge is apparent across the dining room floor. The Manager stated that this is the site of an old party wall. It may be that the new carpet has accentuated the effect of the ridge, or may be camouflaging it. Following advice from an Environmental Health Officer the dining room furniture has been re-arranged to avoid residents tripping. A long-term solution to levelling the floor must be found. There are call bells in every room, and a print-out is produced which should show how often the bell has been used, which room the call came from, and how long staff took to answer. However, the date was incorrect, so it was impossible to check the frequency. There is a stair lift to the first floor, and a call bell has been installed so that residents can call for assistance when they want to come down. One resident who is not able to use the stair lift or bath is living upstairs and does not come out of their room. They are a priority to move to a ground floor room when it becomes available. There are three bathrooms. There are plans to provide an accessible shower and a toilet instead of the ground floor bath, and quotations for this work were seen. This will be a benefit for residents. At present there is only one ground floor communal toilet. A sliding door has been provided for it, to enable residents with walking aids to use it and maintain privacy. Up stairs, one of the bathrooms has been little used, but its use will increase when work on the shower starts downstairs. It needs refurbishing. The main bathroom, which is in frequent use, has some peeling paintwork and the base of an old hoist is still screwed into the floor. The bedrooms are of vary sizes, and all are above the minimum space required. Two are large enough to be double rooms, one of which is occupied by a married couple. All other rooms are for single occupation. One resident told the inspector she ‘has a lovely room’, and loves having her own toilet. Both the double rooms and nine of the single rooms have en suite facilities. One resident who had quite a small room said it was well organised, to include everything she needed. Most rooms have pleasant views across the gardens. The house was sweet-smelling throughout, and a visiting relative confirmed that it is always kept clean. The laundry floor had not been sealed, as was required at the last inspection. There were patches on the walls where the paint was peeling, and there were cobwebs plus small insects caught across the ceiling. The laundry must be maintained in a hygienic condition. There are plans to install a sluice sink and a sluicing machine for cleaning commode pots. Quotations have been gathered, and the Manager stated that the flooring will be renewed in the course of this project. Staff lockers are currently located in the laundry, though there is not a great deal of space for them. A system is in place to prevent cross infection of laundry. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 Staff were seen to be competent, caring and employed in sufficient numbers to meet the needs of the residents. The Manager took care to recruit suitable staff, but proof of identity must be obtained for all employees, for the protection of the residents. EVIDENCE: Staff rotas are kept, which show that three care staff are employed from 8am till 8pm. The Registered Manager is additional. On the day of the inspection a fourth carer was employed from 8 –2pm, which had been the previously agreed staffing level. The cook is employed from 8-2, and Kitchen Assistant from 9 – 3pm. They serve breakfast and lunch and leave dessert prepared for tea. A carer goes into the kitchen between 4 and 6.30pm. Domestic staff are employed Monday to Friday, as is the handyman/driver. At night there is one waking carer and one sleeping in. An extra waking night carer had been employed to cover the induction of new staff, and also to sit with a very ill resident. New care staff had been appointed. The Manager was deploying them with established staff, for their support and to give choice of carer to the residents. Of the twelve care staff, 8 have either completed NVQ 2 or are working towards it, and one Senior Carer has achieved NVQ3. The home has a procedure for recruitment, to ensure residents’ safety. Application forms were seen satisfactorily completed, CRB clearances and references had been sought. Proof of identity must be obtained and kept on file in respect of each staff member, for the protection of residents. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,38 The Registered Manager is well qualified and competent to lead the team with the support of the Senior Care staff. Good communication is actively promoted, between staff and management and with residents and families. Systems are in place to maintain safe methods of working in the home. EVIDENCE: The Manager has achieved the Registered Managers’ Award, and is awaiting receipt of her certificate. She is now working for her NVQ Assessors’ award. She has recently been awarded a Front Line Management certificate. She has three-monthly meetings with the other Crocus Care managers, and gives herself monthly goals to assure the home of continuous improvement. Staff said that they feel the team work well together. The care needs of residents vary considerably at different times, and there have been stresses with recent losses. Staff said that the team work together to get through difficult times. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 18 Senior care staff have monthly meetings. The minutes of staff meetings were available, and showed that the Manager was leading the team in promoting a caring attitude and the provision of social activities. Residents’ meetings are held. Residents raised issues including menus, proposed building works, performance of some staff, and suitability of activities. One resident confirmed that a discussion on flavouring of food resulted in her wishes being met. Minutes are kept. Care staff have helped residents filling in quality assurance questionnaires. A new set of questionnaires had been completed – a new summary and action plan are awaited. The annual Quality Audit was completed on 15th July, and the Commission for Social Care await the report with interest. Management are seen to listen to residents, and respond to suggestions made. Some residents like to have their bedroom doors open during the day, while they sit up in their chairs, so that they are in touch with people going by, as well as for circulation of air. Ten hold-open devices have been purchased to enable this to continue in safety. The annual service of the fire precaution system took place on 20/04/05. All but three staff had attended fire training in the week before the inspection. The Manager said she would ensure that they attend the next session booked for October 2005. Training is delivered every three months. The in-house fire check is conducted by the handyman. The home has a three-monthly visit under contract by a pest control agency. Following the Environmental Health Officer’s visit in February 2005, a new stand for the dishwasher was obtained, and new tiling around the handbasin in the kitchen. Staff training has continued with Moving and Handling and Infection Control having been delivered, and Food Hygiene and First Aid up-dates booked. Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 2 4 2 2 3 3 x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 4 3 3 x x x x 3 Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Timescale for action 31/08/05 2. 3. 4. OP19 OP26 OP29 23 23 17 Medication must be directly administered from the dispensed labelled container, including at breakfast time, and the MAR chart must be signed immediately after administration. The dining room must have a 30/11/05 safe and level floor. The laundry and bathroom floors 31/12/05 must be sealed. Previous timescale 31/03/05 The record of all persons 30/09/05 employed at the home must include proof of identity. 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. 2. 3. Refer to Standard OP19 OP22 OP22 Good Practice Recommendations A shaded area in the garden would be a benefit in warm weather. The print-outs from the call bell system should be comprehensible. There should be equipment available to enable staff to lift a resident who has a fall upstairs. D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 21 Lorna House Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon, TQ13 7UP 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 Lorna House D54-D07 S18390 Lorna House V233110 090805 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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