Inspection on 30/09/05 for Manor II

This inspection was carried out on 30th September 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

Manor II 08/01/09

Manor II 01/05/08

Manor II 04/06/07

Manor II 09/11/06

Manor II 08/06/06

Manor II 25/05/05

Manor II 24/01/05

Manor II 31/08/04

Manor II 23/06/04

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

CARE HOMES FOR OLDER PEOPLE Manor II 205-207 Hainault Road Leytonstone London E11 1EU Lead Inspector Kristen Judd Unannounced Inspection 30th September 2005 2.35 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 Manor II DS0000058844.V255074.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 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. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor II Address 205-207 Hainault Road Leytonstone London E11 1EU 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) 0208 539 0079 Aermid Health Care Limited Mrs Ruta Starkute-Nahani Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2005 Brief Description of the Service: Manor II is registered to provide care for up to 20 elderly people with dementia, both male and female. At the time of inspection there were 9 residents in the care home. Accommodation comprises 16 single bedrooms and two doubles, a lounge, dining room and conservatory, which is also the designated smoking area. The home is situated in Leyton with good transport facilities to local shops and amenities. Aermid Health Care took over the home last year. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced which took place on a Friday afternoon. This inspection followed up the requirements made at the unannounced visit held on 25th May 2005.The inspector spoke with service users, staff and the registered manager during the inspection. A tour of the environment was undertaken and samples of the homes records were examined. There were ten service users placed at the time of inspection. There have been 11 requirements and 2 recommendations made following this inspection. Verbal feedback was given to the registered manager at the end of the inspection. The inspector wishes to thank the staff and service users for facilitating this unannounced inspection and actively contributing to the regulatory process. What the service does well: What has improved since the last inspection? 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. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 6 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 Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 7 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 the following standard(s): 1,2,3&4 It is the inspector’s view that new admissions are made to the home following a full assessment of needs. However information regarding the home must be maintained accurately to enable service users and others be clear about the service provision. EVIDENCE: The Statement of Purpose and a service user guide were seen which have been amended since the previous inspection. Some documents are now being separately produced and are available in the home this means that the service user’s guide does not include all the information such as the qualifications and experience of the proprietor, registered manager and the experience of staff; this information is within the statement of purpose. The document also does not include a summary of the complaints procedure or service users’ views of the home and the terms and conditions of the home. These are important issues for service users. The document does make Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 8 reference to these issues however the National Minimum Standards clearly state that this information must be included in the guide. The organisation does have a feedback booklet, which was seen on display during the inspection. This is for service users, relatives or other to complete. Individual records are kept for each of the residents; records for the most recent admission were inspected. Evidence was seen to show that the registered manager admits service users only on the basis of a full assessment having been undertaken. There has been much improvement in the homes recordings on the service users care plans and additional records within the home. Through the tracking of care it was evident that the service users care plans were being developed from the pre admission assessments. There was evidence to demonstrate that the home is meeting the assessed needs of the current service users accommodated in the home. The service users have individual contracts in place; and service users are provided with a contract/statement of terms and conditions of occupancy. Contracts seen were signed and dated. Specialist services are provided/ accessed for any service users requiring them The home does not provide intermediate care. If, at a future date, the registered provider should wish to provide such care, consideration would need to be given to staffing levels, appropriate staff training and the provision of dedicated space for this purpose. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10&11 It was the inspectors view was that medication was not being accurately administered; this must be addressed as a matter of urgency. Staff must be fully trained and competent before being permitted to administer medication. EVIDENCE: The inspector acknowledges that much work has been done to improve the care plans since the previous inspection. There are care plans in place for all service users, which contained information to enable staff to meet the assessed needs of service users. The plans indicate the assessed needs and the action required. However the plans are in separate sections including the evaluation, which does not enable easy referencing. This was discussed with the registered manager during the inspection, as information was not readily available to access. It is recommended that the individual service users plans be re formatted to bring the relevant information together to provide a more comprehensive document. Some of the service users are being monitored by the use of tuning charts and fluid intake charts. However recordings were poor , no up to date and did accurately reflect the care provided. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 10 The inspector cross referenced particular aspects on the files, for one service user it was noted that there was no information on the service user plan regarding the toileting programme that was in place. There is a specific care plan that addresses service users care needs during the night, which includes information about incontinence issues. The inspector cross-referenced aspects of the care plans with risk assessments. There was evidence of basic issues being assessed such as moving and handling. However there remain a lack of risk assessments in particular one service user who could be physically violent to staff when being assisted with personal care. There was no record of any risk assessment, associated plan and no preventative measures in place. This could potentially put staff and service users safety and wellbeing at risk. At the time of inspection none of the service users had pressure sores, although some service users had been deemed at risk and appropriate pressure relieving aids were in place. Pressure relieving equipment is provided for one service user, the mattress was appropriately set at the time of inspection however the setting was not recorded on the service users plan. This is of particular importance as the health professionals have recommended the setting, as staff are unable to weigh the service users in question. Random checks were completed on medication, which was stored appropriately. Five checks were undertaken four of which were deemed inaccurate. During the inspection a staff member was observed administering a liquid medication from a kitchen desert spoon. The staff member was unaware of the actual dose administered. The inspector re measured the amount, which determined that the service users had received half the prescribed dose. The staff member stated that this was the normal method for administering the medication. The inspector was extremely concerned as the staff member in question also administered cream to service users feet in the dinning area, which in its self was deemed inappropriate but additionally service users were still eating their evening meal. When spoken to the staff member in question did not appear to be aware of what the problem was with this practise. The registered manager has further developed relevant guidance for staff to follow in the event of a death in the home. The guidance links into the individual information on service users files with regards to individual cultural and spiritual needs. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 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 the following standard(s): 12,13,&15 It is the inspectors view that activities are still limited which restricts choice to service users. EVIDENCE: Staff take responsibility at present to arrange and facilitate activities in the home. This means that activities can only be offered once staff have finished relevant tasks such as personal care. However the inspector acknowledges that there has been some improvement and there is a programme of activities on display. On the day of inspection service users had received manicures from staff on duty. Service users were seen watching television throughout the afternoon. However activities still remain limited and include listening to music, and simple exercises. Service users would benefit from being offered a wider range of activities. There are no restrictions on visitors and the registered manager has held a garden party for service users and relatives to attend. Photographs were on display of the event in the home. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 12 The inspector was informed that the registered manager was planning relative and service users meetings and that these would become a rolling programme. The staff meeting, which was in process at the time of inspection, was also an opportunity for the registered manager to request ideas for Christmas, the staff are to organise a party for service users. The inspector acknowledges that it takes time to develop programmes however staff should consider how to proactively develop this area of the homes facilities for service users. Menus seen reflected that the breakfast, lunch and evening meals provided were healthy and appetising. The cook prepares fresh homemade soups regularly and bakes a variety of cakes. There has been a great improvement in this area. Fresh fruit and vegetables are now being purchased locally. The inspector saw the food storage facilities; fresh, frozen and dry stocks were appropriately stored. The inspector was present during the evening meal being served once again there was little interaction noted between staff and service users during the service of meals. One staff member observed assisting a service user and did not interact at all. There is a need for further improvement. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 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 the following standard(s): 16&18 It is the inspector view that staff would be able to respond to an allegation of abuse however clear guidance must be available for staff to respond to allegations of abuse effectively and efficiently in order that service users are protected. EVIDENCE: There are policies and procedures in place for all aspects of complaint handling that states that any complaint will be acknowledged within two days and that any complaint will be investigated, within timescales indicated. The policy also provides guidance for staff if a verbal complaint is received. There is information about how to complain on display in the home. The registered manager is responsible to investigate complaints and concerns that service users, relatives or staff may have. The complaints log was seen however there have been no complaints received since the previous inspection. The registered manager is fully aware of the procedures to be undertaken in the event of an allegation or suspicion of abuse occurring. The inspector was informed that the Abuse policy had been updated as required in the previous inspection however it was not available at the time of inspection. The registered manager must ensure that all updated policies and procedures are made available to staff to reference when needed. Therefore this requirement is carried forward to be re assessed at the next inspection. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 14 The majority of staff has undertaken training in Adult protection/ Abuse Awareness and training is scheduled for the remaining care staff. It is a requirement that this training has extended to all staff working in the home including the cook who does take part in sleeping in duties. The registered manager has updated the financial systems. Service users finances were seen which were being recorded accurately and were deemed correct. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 19,20,21,22,23,24, 25 & 26 It is the inspector view that at present the environment is suitable for purpose. EVIDENCE: The home is situated in a quiet residential area of Waltham Forest and is within easy access of transport links and the local community. The home is within walking distance of some local amenities; there is a garden area and parking available. A tour of the premises was conducted with the registered manager. There is a large conservatory attached to the dining area, which is the main communal area an additional lounge at the front of the house. Communal areas are comfortably furnished and decorated. The home is adapted and equipped appropriately with grab rails and other mobility aids provided in corridors and toilets/ bathrooms. At the time of this inspection there were ten service users placed which provides adequate private and communal areas however as stated in previous Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 16 inspection reports this will need to be monitored to ensure that the home remains suitable for the aims and objectives of the service. There is a concern that there are only two-assisted bathrooms/shower; while this is adequate for the present number of service users this could become a concern if the numbers increase above sixteen service users. Additionally whilst there is enough communal space at present there is no separate visitors lounge. At present the main lounge is hardly used, as service users tend to sit in the conservatory or dinning area as such the separate lounge can be used for visitors. Once again this could become an issue if the numbers of service users rise. These aspects will require monitoring over the future inspections. All of the individual rooms seen had been personalised and were comfortable. All of the communal areas and service users bedrooms were of adequate cleanliness and hygiene. There are three double rooms, which at present are occupied by single service users or are vacant. Rooms may only be shared where this is a positive choice for both residents to share with each other. There is a laundry facility in the basement, and an additional facility on the first floor which staff use for items such as towels. There was evidence of appropriate aids and adaptations available for service users including mobility aids and hoists with accompanying slings. The bathrooms have suitable equipment to meet the need of service users. There is a call system throughout the home. There is no lift however there is a chair lift fitted to one of the staircases. On the day of the inspection the home was clean and free from offensive odours throughout. All of the environmental issues raised in the previous report had been addressed with in time scales. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29& 30. It is the inspectors view that there has a focus on training staff however any staff member working in the home must be deemed competent by the registered manager so as not to potentially put service users at risk. EVIDENCE: Rotas indicate that staffing levels are satisfactory and there is sufficient staff on duty to meet the needs of the service users. For the current ten service users there are two staff on duty throughout the day plus one waking night and one sleep in. The inspector observed staff, and service users, during the inspection there still remains concern with regards to the competence of staff. As previously stated there was little interaction with service users during the meal service. Additionally as previously stated a staff member administered cream to a service users feet (personal care) in a communal area and as previously stated there remain concerns about administration of medication. Staff files seen evidenced that appropriate checks had been undertaken to ensure protection of residents. Criminal Records Bureau checks were complete for all staff. The staff files were seen and evidenced that staff have completed the TOPSS induction programme. Each staff member had a clear training profile, which Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 18 indicates the training attended, and assessment of training needed, and when training should be completed by. Training undertaken includes Health and Safety, First Aid, Dementia, Infection Control and Food Hygiene. Training was also planned for Fire and Abuse training in October 05. The registered manager also stated that two staff have completed the National Vocational Qualification Level 2 and there are plans for additional staff to commence the course. The home therefore yet has to achieve the minimum 50 of staff with level 2. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,34,35,36,37&38 The inspector believes that the home is run by a registered manager who is competent to run the care home in line with its stated purpose. However further work is need with regards to ensure that all staff only undertake tasks where they are deemed competent. EVIDENCE: The registered manager has the Registered Manager’s award. She has several years experience of working in a residential care settings and was able to demonstrate a good understanding of service users needs and the home’s aims and objectives. The inspector continues to be satisfied that the registered manager is competent and experienced to run the care home in line with its stated purpose. The inspector acknowledges that the registered manager has undertaken much work since she became the manager in November 04. Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 20 Records were seen during the inspection in relation to Schedule 4 of the Care Standards Act. Recordings were generally of good standard and contained relevant information. However there remain some inconsistencies in recordings of service users care, for example fluid intake records and turning records were lacking for a service user who was being monitored. Concern was also raised about some of the words that staff used to describe situations for example an accident report raised concern due to the language used. The inspector acknowledges that many of the staff English is not their first language however recording in the home must be of a set standard and clarity. Supervision of staff has commenced, records were seen that evidence that staff are supervised a minimum of six times a year. Staff meetings are being held one was in process at the time of this inspection. Minutes were seen which confirmed that in addition to day-to-day issues staff discussed relevant issues. The monthly-unannounced monitoring visits have been untaken and copies of the reports are being forwarded to the Commission for Social Care Inspection. The registered manager has updated the financial systems. Service users’ finances and petty cash records were seen which were being recorded accurately and were deemed correct. Much work has been completed to ensure that health and safety requirements are met and the registered manager monitors these monthly. All relevant certificates were place and available for inspection. Manor II DS0000058844.V255074.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 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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score 2 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x 3 3 3 2 3 Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? yes 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 OP1 Regulation 5.1 Requirement The registered manager must ensure that the Services Users’ Guide to provide accurate up-todate information, to be in a format suitable for the residents and to include all the information listed in standard 1 of the NMS and regulation 5 to the Care Homes Regulations 2001 The registered manager must ensure that all assessed needs such as toileting are recorded in the care plans. The registered manager must ensure that risk assessments must be implement for service users presenting challenging behaviuor and indicate preventative measures/strategies for staff. The registered manager must ensure that any advice from health professional regarding service user care is accurately recorded on the individual care plans. The registered manager must ensure that all medication is DS0000058844.V255074.R01.S.doc Timescale for action 30/11/05 2 OP7 15.1 15/11/05 3 OP7 13.4(c ) 15/11/05 4 OP8 13.1 15/11/05 5 OP9 13.2 31/10/05 Manor II Version 5.0 Page 23 6 OP10 7 OP18 8 OP18 9 OP27 10 OP28 11 OP37 accurately administered and recorded in the care home. 12.4(a) The registered manager must ensure that any aspect of personal care is performed privately to ensure service users dignity. 23.2 The registered manager must ensure that the adult protection policy and procedure is in line with government guidance on management of allegations of abuse and is available in the home. (Previous timescale of 31/08/05 not met) 18.1(c )(i) The registered manager must ensure that all staff that are in the care home receive Adult Protection Training. 18.1(a) The registered manager must ensure that all staff are competent to meet the assessed needs of service users. 18 The registered manager must submit a report showing how staff will be progressed through the NVQL2. 17 The registered manager must ensure that records are maintained accurately and up to date. 17/10/05 15/11/05 30/11/05 15/11/05 30/11/05 15/11/05 Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 24 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 Refer to Standard OP7 Good Practice Recommendations It is recommended that the individual service users plans be re formatted to bring the relevant information together to provide a more comprehensive document. It is recommended that staff further develop activity programmes to provide more choice for service users. 2 OP12 Manor II DS0000058844.V255074.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Manor II DS0000058844.V255074.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. 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