Inspection on 01/11/05 for Lucerne House (21-23)

This inspection was carried out on 1st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Lucerne House (21-23) 13/10/09

Lucerne House (21-23) 22/04/08

Lucerne House (21-23) 23/05/07

Lucerne House (21-23) 08/05/06

Lucerne House (21-23) 10/02/06

Lucerne House (21-23) 10/03/05

Lucerne House (21-23) 28/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Lucerne House (21-23) 21-23 Lucerne Road Thornton Heath Croydon Surrey CR7 7BB Lead Inspector James Pitts Announced Inspection 1st November 2005 10:25 Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 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 Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 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. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lucerne House (21-23) Address 21-23 Lucerne Road Thornton Heath Croydon Surrey CR7 7BB 0208 239 9547 0208 239 9547 NO EMAIL 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) Mrs Naomi Wallen Mr Wayne Wallen Mrs Naomi Wallen Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2005 Brief Description of the Service: 21 and 23 Lucerne Road were two terraced houses, which have been joined by means of walkways on the ground and first floors. Having applied two years ago to run the two establishments as one home, the Registered Providers are registered as a single home accommodating up to a maximum of six adults with learning disabilities. At the time of inspection the home had one vacancy as a service user moved out earlier this year. The home is close to the town centre and accessible public transport. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place by arrangement with the home’s owners, one of whom is also the manager. The standard of direct care remains good and improvements to the way in which care planning takes place is also a positive sign. The service users are cared for by people who do have a genuine regard for their well being; however, aspects of professional management of the home do still require improvement. The manager has previously commented on the difficulties she has had with running a care home and undertaking the training in management that she requires. Again there have been improvements but the progress has been slow and the areas that are referred to in this report must now be addressed, as the Commission cannot keep repeating the same requirements time and again. What the service does well: What has improved since the last inspection? What they could do better: Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 6 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. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 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 Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Service users and other people are told what the home does and how it will do it. The service users can feel confident that the home will only care for people that the staff are able to care for. EVIDENCE: The home has a statement of purpose, which tells people what the home does and how the staff will care for the service users. The Statement of Purpose has all of the things included in it that have to be there. It was updated in last year. The home also has a service user’s guide, which tells the service users what the home is like and what the staff will do to help the people who live here. The guide is presented in an understandable way for service users. As Lucerne House is seen as a long term home for the people who live here it is unusual for anyone new to move in. Even when this does happen it is only very infrequently. No one new has moved into the home for quite some time and so these standards will be looked at again at some point in the future at a time when a new service user comes to live here as there is now a vacancy as someone moved out earlier this year. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8, 9 & 10 The service users can feel confident that staff generally know what they need. The home still needs to establish a keyworker system to further support this work. However, the service users can be assured that the staff will try their best to make sure that each person who lives at the home is allowed to live the sort of life that they choose. The only risk to this happening well is that staff do need to get better at making sure that risk assessments properly reflect their needs. EVIDENCE: Each service user has an individual care plan. These plans have been amended further and are now more informative in terms of their details, aims, and objectives and how these will be achieved. The manager has introduced a person centred planning format, to ensure that care plans properly reflect the support that is required for each service user, and evidence that they are involved in compiling their own care plan. The only problem that was noted on one of these is that the date that it was last reviewed should be added. A keyworker system is still not in operation and one should still be established to provide focus on service user progress and support needs. A keyworker is a Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 10 member of staff who especially makes sure that the service user is being supported in the right way. The staff are good at making sure that all of the service users are allowed to make choices about how to live their life. Service users are asked about the things that they like, what they want and how they want things to happen. All of the service users are in contact with either their family, an advocate or a volunteer. The service users and usually Mrs Wallen as the manager get together for a house meeting, usually each month. At this meeting everyone should talk about what it is like to live at the home and about anything that has changed or needs to get better. This meeting is somewhere that everyone can also say how they are feeling about living together and to ask for the things that they want. The minutes of these meetings are brief and could be better at reflecting the things that service users say and what choices they are offered about the things that happen in the home. The home writes a risk assessment for each of the service users. A risk assessment tells the staff how to make sure that each of the service users is kept safe from anything that might harm them. The staff are very good at doing this about very particular needs for each of the people who live here but they must also still write risk assessments for more general areas of safety, for example if it is safe for particular service users to go out alone. They must then make sure that the risk assessments are looked at very regularly to make sure that these are changed if they need to be. The staff are very good at making sure that nobody is told anything about any of the service users unless the person is allowed to know. The staff are also very good at making sure that they tell the right people about things that are happening to the people who live here. But they only tell those people that are allowed to know. The home has a confidentiality policy that tells staff about how to make sure that they keep to this. However, there should still be an access to files policy that can tell the service users how they may see what is written about them and have this explained to them if they need it to be. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Service users can feel confident that the staff of the home will provide opportunities for everyone to develop their personal and social skills. This includes active support for each person to participate in the community both in terms of the activities of daily life and leisure interests. The opportunity for each service user to develop and maintain personal and family relations is also offered and actively supported by the staff team. EVIDENCE: Usually the people who come to live here stay for a very long time, although sometimes people might move somewhere else if they want to, as happened earlier this year. The service users are supported by the staff to be as independent as possible and to make as many choices as they can. The staff are good at helping each of the service users to learn new things and to obtain new skills to make each person as independent as possible. All of the service users go to day centres or to college and to the shops and to make use of other things in the community such as the cinema, the pub and other places of interest. When service users are not at the day centre or colleges the staff do Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 12 support people to have a fulfilling week by offering the choice of doing other leisure activities and in-house activities. The staff help the service users to be a full part of the local community. There is no car that people can use to go out but the home is very close to bus stops and a train station. All of the service users are physically able to use buses and trains. All of the service users are able to take a part in choosing what activities they want to do together. The staff are very good at helping each service user to keep in contact with their families and friends. Family and Friends are made very welcome when they visit the home, as too are advocates and a volunteer who visits one of the service users twice a week. There are not many rules at this home. The most important one is that no one is allowed to smoke in the house. One person who lives here does smoke but they do that in a room that this person alone uses (he calls it his smoking room|). All of the people who live here are allowed to use the entire house, except other people’s bedrooms or one of the lounges if a meeting is happening. Each of the people who live at this home is allowed to make choices about what they want to eat. The staff are good at making sure that healthy food is always on offer. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 Service users can feel confident that they will get the right support to take care of their healthcare needs. Anyone who needs to take medicine regularly to help them stay well will get the proper support from staff to make sure that this happens. EVIDENCE: Lucerne House employs one other person part time and the owners or other family members provide the rest of the care. The owners, Mr & Mrs Wallenshowed that they are very aware of what each service user needs and they are sensitive about how they should meet those needs. Each service user has a care plan that tells the staff in detail the way that each service users wants to be cared for and supported and about what each person likes or does not like. All of the people who live at the home usually go to see a local GP if they are not feeling well. The service users can see any local GP but most see the same one that the staff know very well and get along with. The staff are very good at writing down anything that happens if anyone becomes unwell. If any of the service users have an illness or something else is wrong with them then the staff do know what this is and how to help them to get the treatment that they Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 14 need. All of the service users need to take medicine every day and the staff are very good at making sure that this happens so that they can stay well. The staff are also good at making sure that no one can get hold of any medicine that they should not have and so they keep medicines locked away. All of the staff have had training about how to give medicines safely, which was a requirement at the time of the previous inspection. The home has also introduced good guidance for staff about the ageing of service users and what to think about should anyone pass away. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The service users can feel confident that the staff team at the home know what to do if there are complaints or concerns about abuse. The home has clear guidance for staff about the procedures to be followed in either of these circumstances. EVIDENCE: The service users are given clear information about how to complain and what happens when they make a complaint. One person made a complaint a few months ago. This was looked into by the placing authority of the person in question and although the home was not found to be a fault the person chose to move somewhere else to live. The staff team are good at making sure that all of the service users are protected from abuse (this means that the staff at the home do everything that they can to stop any of the service users from being hurt by someone else). There is also clear written information for staff about what to do if they think that a service user is being hurt or abused by another person. The staff know what they then have to do to keep people safe. The home has a whistle blowing policy, and also one dealing with bullying or harassment, although this still only refers to staff and must be expanded to refer to service users. There was still no evidence of all staff having read any of these policies this must be remedied without further delay. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The service users can feel confident that they are living in a well maintained and clean home. EVIDENCE: The home is comfortable and the staff do the right things to make sure that the house is generally a safe place for the service users to live. Some areas of the home are showing signs of wear, however, the owners have recognised this and included areas of refurbishment that need to be done as a part of their annual development plan. The house is kept very clean and is free of any unpleasant odours. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 & 36 Service users cannot feel confident that there is a proper procedure for recruiting staff who are safe people to support them. The quality of the support that is offered by the staff team could still be compromised if staff are not supervised properly. EVIDENCE: All but one of the staff has been employed within the home for some time, and all have job descriptions. A copy of the General Social Care council code of practice must still be obtained and be issued to staff at the home. The home recruited a new member of staff to work part time a few months ago. However, it is of serious concern that the proper background checks were not completed before this person started working here. There are no references and no CRB check, although the manager was able to show that this is being chased up. The owners / manager must ensure that they adhere to proper recruitment procedures and take up the references for the person they recently employed. Once this has been done the manager must write to the Commission to confirm that the \CRB and references have been obtained. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 18 The home keeps records which say what training courses staff have done, and when they did them. The law says that half of the staff must have a proper qualification to work with adults who need support in a care home. The name of this qualfication is NVQ 2. The owners of the home have both completed NVQ level 3. The home is still not able to evidence that staff receive any form of formal supervision (this is a time that each member of staff spends talking about how they are getting along in their work). This must be implemented and additionally the manager must attend training in order to gain an awareness of the purpose and function of the professional supervision of staff in a care setting. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 & 43 The service users cannot feel confident that they are living in a home that properly considers the need for diligent management. However, the can feel confident that most of the necessary health and safety checks are properly carried out. EVIDENCE: Mrs Wallen, who is also the manager, said that she is planning to start the NVQ level 4 in January at a nearby college. The need for the manager to have this qualification has been mentioned at previous inspections and this must not be delayed any further. The home was told at the previous annual inspection that they must introduce a quality assurance system, but an annual development plan has now been written. A quality assurance system must be established, as this remains an unmet requirement from previous inspections. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 20 The home has in place a comprehensive selection of policies and procedures covering most of the topics set out in Appendix 3 of the National Minimum Standards for Care Homes for Adults. The manager is aware that an Individual Planning and review policy still needs to be put in place, as well as a Staff smoking policy and a racial harassment policy. The home manager must still also expand the volunteer policy to refer to the need for prospective volunteers to undergo criminal record (CRB) and protection of vulnerable adults (POVA) checks. The policies and procedures must still be dated and reviewed regularly. Staff have access to the homes policies and procedures which they should still sign and date as poof that they have read and understood any new or revised policies and procedures. The manager again said that service users are welcome to view their own files and any personal information held about them by the home, should they wish. The homes records are kept secure in a locked cabinet in the first floor office. There have been some improvements in the keeping and updating of these records as referred to in other areas of this report, and this progress is encouraged to continue. The following health and safety checks have been carried out within the last year: Fire Alarm System: 08/06/05 Fire Extinguishers: December 2004 Gas Safety Check: 07/06/05 Legionellosis: 01/04/05 Portable appliances: October 2005 Electrical Installation: 05/06/03 The home is good at making sure that the people who live and work here are kept safe from fire and other hazards. The mome also carries out a check of the hot water temperatures each week to make sure that these are within safe temperature range. The inspector was informed at the last inspection that an accountant was developing a business and financial plan for the home. This has now been completed. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 1 1 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 1 3 x 1 3 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lucerne House (21-23) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 x 1 2 3 3 3 DS0000025808.V255985.R01.S.doc Version 5.0 Page 22 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 YA8 Regulation 4(1)(c) Sch. 1(10) Requirement Timescale for action 01/11/05 2 YA9 3 4 YA23 YA31 5 YA34 Consultation with service users must be in greater evidence and show that the home is taking their views and preferences into account (this requirement remains outstanding from the previous inspection although some signs of improvement are noted) 13(4)(b) Risk assessments must be more detailed and outline the nature of any perceived risk, and must be updated at regular intervals. (this requirement remains outstanding from the previous inspection) 13 (6) The bullying and / or harassment policy must be expanded to also refer to service users. 18 ( c ) (i) A copy of the General Social Care council code of practice must be obtained and be issued to all staff at the home (this requirement remains outstanding from the previous inspection). 19(1)(a) The manager must write to the (b)(i) Commission to confirm that the 5(d) \CRB and references have been obtained for the newly appointed member of staff and these DS0000025808.V255985.R01.S.doc 01/11/05 01/01/06 01/11/05 01/01/06 Lucerne House (21-23) Version 5.0 Page 23 6 YA36 19(5)(b) 7 8 YA37 YA39 9 (2) (b) (i) 24(3) 9 YA40 NMS Appendix 3 checks must in future be carried out prior to staff commencing in post. All staff must receive a minimum of six supervision sessions per year, which are recorded. (this requirement remains outstanding from the previous inspection) The manager must commence the NVQ level 4 qualification without further delay. The Registered Providers must develop quality assurance tools, which are designed to obtain the views of service users families (this requirement remains outstanding from the previous inspection). The home manager must expand the volunteer policy to refer to the need for prospective volunteers to undergo criminal record (CRB) and protection of vulnerable adults (POVA) checks. The policies and procedures must still be dated and reviewed regularly. 01/11/05 01/02/06 01/11/05 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA10 Good Practice Recommendations A keyworker system should still be established to provide focus on service user progress and support needs. An access to files policy should be established. The aim of this policy should be to enable service users to have reasonable access to information that is held about them by the home, and to restrict access to particular third parties without the express consent of the service user. Staff have access to the homes policies and procedures, which they should sign and date as poof that they, have read and understood any new or revised policies and DS0000025808.V255985.R01.S.doc Version 5.0 Page 24 3 YA40 Lucerne House (21-23) procedures. Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Lucerne House (21-23) DS0000025808.V255985.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!