Inspection on 26/10/05 for Mayfair Lodge

This inspection was carried out on 26th October 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 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

Mayfair Lodge 19/02/07

Mayfair Lodge 10/05/06

Mayfair Lodge 21/02/06

Mayfair Lodge 25/01/05

Mayfair Lodge 17/06/04

Mayfair Lodge 11/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Mayfair Lodge The Walk Watkins Rise Potters Bar Hertfordshire EN6 1QN Lead Inspector Mrs Jan Sheppard Unannounced Inspection 26th October 2005 10:06 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 Mayfair Lodge DS0000019462.V260926.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. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mayfair Lodge Address The Walk Watkins Rise Potters Bar Hertfordshire EN6 1QN 01707 871800 01707 871861 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) Quantum Care Limited Care Home 62 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (61), Old age, not falling within any other of places category (61), Physical disability (1), Physical disability over 65 years of age (61) Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category of PD and DE applies only to the named service user and the registration will revert back once the named service user leaves the home. 25th January 2005 Date of last inspection Brief Description of the Service: Mayfair Lodge is a purpose built care home for older people, which is run by Quantum Care Ltd. and was opened in 1998. It offers 62 single bedrooms, 61 have en-suite facilities and one provides wash facilities only. These are grouped in four separate units; one unit provides specialist dementia care. The home is well equipped and is wheelchair accessible. It is located close to the town centre of Potters Bar where all the amenities of a high street can be easily accessed. All major public transport is within a short distance. The home offers a secure and homely environment for its service users. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of this inspection year and took place over one day when two inspectors spoke with residents, relatives and staff, examined records and made a tour of the building. The detail in this report reflects the findings at that time and also takes account of comments made in the pre inspection documentation and questionnaires completed by residents relatives and professional stakeholders in the home. Since the last inspection the manager and two care team managers have left the home all having transferred to work in other homes run by the Quantum Care group. The new manager has been in post for six weeks but one of the care team manager posts remains vacant. What the service does well: What has improved since the last inspection? Since the last inspection various works of redecoration and refurbishment have been completed these adding to the overall pleasant and cheerful appearance of Mayfair Lodge, which is well maintained and provides very good facilities to meet the individual needs of its residents. Since the last inspection a new manager has come into post and she is currently, in conjunction with other members of the management team, Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 6 reviewing some aspects of how care is delivered in the home this to ensure that the highest service is delivered at all times to all of the residents. 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. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 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 the following standard(s): 1,2,3,4 & 5. A pack containing the appropriate information including the Homes Information Sheet, a Schedule of Fees, of the Statement of Purpose and the Service Users Guide, the Complaints Procedure and a copy of the most recent Inspection Report, is available for prospective residents and their families concerning how the home operates and what procedures are in place to meet their care needs. Standard 6 is not applicable, as the home does not provided intermediate care. EVIDENCE: The home has a pre-admission policy and assessment procedure that meets the requirements of these standards. One of the homes managers visits the prospective resident in their own home or other setting to ascertain whether Mayfair Lodge could meet their care needs after which the prospective resident and their relatives are invited to visit the home and see the room that is available. One such visit was observed taking place during this inspection when a member of staff was seen to be accompanying the visitors and answering their questions. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 9 Several recently admitted residents who spoke to the inspectors said that their admission had been handled sensitively by the home staff and that this had helped them with the difficult transition from their own home into a residential setting. One said, “ Of course I would prefer to have remained in my own home but since my wife’s death this is not possible and here is the next best thing.” The contract statement of terms and conditions given to every new resident gives details of their room, the fees payable, the care and services that they will receive and the terms and conditions of their occupancy including their rights and obligations in the event of any breach of contract. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Personal care and assistance offered to the residents was witnessed during this inspection to be of a good standard, which was meeting, the individuals needs whilst maintaining their dignity and respect. The care plans were seen to be well maintained with current reviews and risk assessments. Good detail of how the residents care needs should be met, whether by one or two carers were clearly stated but it appeared from the other records that these instructions were not always being fully adhered to by the staff. The home has a robust policy and procedures for the administration of medication but the records evidenced a number of errors and omissions on the MAR sheets, which had not been, identified during the regular management checks of these records. EVIDENCE: Generally the residents appeared to be well cared for and to be relaxed and happy. Several told the inspectors that they are able to get up and go to bed when they wanted and that the staff always assist them to achieve a good standard of personal care with attention being given to their hair, mouth care, nail care and to shaving. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 11 One resident who appeared to be somewhat inappropriately dressed was gently coaxed away by a careworker who knew him and was helped into more formal day clothes. Individual residents who wished to walk about the home were not stopped from doing so but gentle direction and encouragement was given to assist them and to reduce anxieties arising from confusion. Staff were seen to work well together co-operating to assist one resident to be manoeuvred by hoist from her lounge chair into a wheelchair. Throughout this operation they were seen to be reassuring and talking to the resident in a jovial manner, which she clearly appreciated. Other care plan records shared with the inspectors by the homes manager indicated that staff might not have always be following closely the care instructions where two carers were required and these incidents were being appropriately investigated by the manager. A number of errors and omissions were found on the MAR, medication administration sheets and these were discussed with the homes manager and with the unit manager who has lead responsibility for the medication. Some of these deficiencies were already known to them and a review and retraining meeting had been previously planned for the appropriate staff, for the afternoon of this unannounced inspection. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. The home provides a range of activities, choices of menu and alternative relaxation areas and encourages participation in the home by the local community. EVIDENCE: A number of visitors were seen in the home on the day of this inspection. Some said that they visit regularly, weekly, or even more frequently whilst others who had made a long journey came only rarely. One resident told the inspector that her daughter visits weekly and takes her out and another said that she visits her family every Sunday for lunch. One new resident said that he had moved to this home away from his own home area so that he could be close to his children who both work in London and travel from the local Potters Bar station and that he usually received evening visits from them. The in-house activities programme was seen to be advertised around the home as was information concerning the activities organised by the” Friends Of Mayfair Lodge”. The home now has an Activity Organiser for four hours each day and every resident is offered a programme, if they wish, this programme being arranged to meet their individual interests and needs. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 13 The organiser told the inspectors that with the limited time she has available and because of the residents very varied needs it was often difficult to offer as comprehensive programme as she would wish. The recently introduced Hand Message therapy has been very well received by some of the residents. Many of the residents commented favourably about the food although one said that she would like more fruitcake and another complained that better availability of fresh fruit would be appreciated. Residents on one unit said that they would like to have more cups of tea during the day whist on another unit the residents expressed the wish to have a cup of tea served immediately after the lunch rather than waiting until mid afternoon. The homes four week rotating menu provides an interesting and varied diet and good examples of residents having extra snacks between meals to increase their calorific intake was seen. Soft and pureed diets are available for those who require them. Lunch on the day of this inspection offered a choice of Fish Pie or Mild Beef Curry with mashed potato, carrots and beans with a sweet of Apple Crumble and custard to follow. This meal looked very appetising and was attractively presented to the residents with varying portion sizes to meet their individual wishes. Most residents spoken with were aware of the dishes of the day and could remember the choices that they had made several commented that they were looking forward to the mild curry, which was described as a “cooks special”. Lunch was seen to be taken in a relaxed and unhurried manner with staff assisting residents where needed to the minimum extent that help was required there by allowing them the greatest autonomy over their own eating as was possible. The chef manager toured the home whilst lunch was being taken to ensure that supplies were sufficient and to ask the residents for their comments about the meal. Later in the day a birthday cake was seen to have been prepared for one resident who was celebrating their birthday. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The home has a robust complaints procedure and follows the Adult Protection procedures as set out in the Hertfordshire County Council joint agency guidelines. EVIDENCE: A copy of the complaints procedure is available to prospective and current service users. Reference is made to the Commission for Social Care Inspection. Residents and relatives spoken with were aware of their right to make a complaint and of how this should be done. Several residents said that they would talk to the staff about any problems first and expressed their confidence that their concerns would be dealt with promptly. Five complaints have been received since the last inspection of which one was substantiated. Staff confirmed that they had received training on Adult Abuse and they were aware of the literature concerning the Hertfordshire County Council Adult protection procedures, which are displayed in the home office. The homes training records demonstrated that training on protection and Whistle Blowing is undertaken by all staff on an ongoing basis. Since the last inspection there has been one Adult Protection investigation in the home. Mayfair Lodge DS0000019462.V260926.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 and 26. Mayfair Lodge provides its residents with a safe and comfortable environment. On the day of this unannounced inspection the home was found to be clean and tidy and with one exception had a pleasant and hygienic smell. Overall, the building is well maintained and with one exception (laundry equipment) was found to have an adequate provision of equipment and other effects to ensure the safe operation of the home so as to meet the residents needs. EVIDENCE: The residents all have single rooms and all except one of these has integral ensuite facilities. Since the last inspection many of these bedrooms have been redecorated and these works along with the redecorations to some corridors and lounge dining areas have greatly improved the ambiance and given a fresh and attractive appearance to the whole home. Many of the residents commented on the attractiveness of their rooms and it was noticeable that most had been well personalised by the residents, this often with the help of their families and friends. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 16 During the time leading up to lunch the inspectors noted that many residents were sitting quietly in their rooms either reading, watching television, making private phone calls or entertaining their visitors in private. Staff were seen to facilitate this by taking their mid morning coffee to their rooms and by ensuring that they had any individual equipment that they needed to ensure their comfort. Eg. footstools and extra cushions etc. Overall the home was found to be clean and tidy. One inspector noted that the bathrooms were much cleaner and better organised with no evidence of clutter and the spaces used for the storage of inappropriate pieces of equipment as had been noted during previous inspections. However both inspectors noted that there was a unpleasant smell along the corridor of Bryon unit and the communal toilet near to the lounge where the extractor fan was malfunctioning (this is an internal room) also had an unpleasant smell and had no paper towels or soap in the dispenser. The gardens provide a pleasant safe area with mature trees and pathways, which enable residents to walk safely. Several of the residents said that they had enjoyed sitting on the patio areas during the summer months and some had helped staff with the maintenance of various large pots and planters, which had recently been planted with spring bulbs. The laundry is well equipped and is of a sufficient size and with adequate equipment to deal with the volume of laundry, which the home generates. Several of the residents spoke appreciatively of the manner in which their laundry is done, quickly and is well ironed and returned to their rooms. A number of deficiencies in the equipment in the laundry, clothes hanging frame with broken rails and very cumbersome and heavy to move clothes trolley, both of which could poise a safety risk to the staff were pointed out to the inspectors. A requirement is made. Mayfair Lodge DS0000019462.V260926.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 and 30. The number and mix of staff provided on the day of this unannounced inspection was found to match the planned staff rota. The staff are well trained and said that they receive regular supervision although the records available did not evidence that this standard was being fully met. See standard 36. The homes policies and procedures for the recruitment of new staff ensure the proper protection for the service users. EVIDENCE: The inspectors noted that the careworkers worked well together as a team providing support for the residents in an unhurried manner. They were found to be familiar with the needs of the residents and a good rapport was seen to exist between them. The staff were positive about their duties and called upon each other for assistance where needed. Recently appointed staff confirmed that they received good induction training and that they were not expected to carry out duties for which they had not been trained. All staff confirmed that they were well supported by the homes management and that they received regular supervision. Many spoke appreciatively of the varied training opportunities that are available for them. The home had, in July last, 30 of its carers holding NVQ level 2 or 3 and 12 more staff were studying for these qualifications. Since then a number of these have completed their courses and others have commenced new courses. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 18 The homes records demonstrated that an annual training plan is in place for the home this compiled from the training needs of each individual member of staff, which are determined during their individual supervision meetings throughout the year. The homes deputy manager over sees the training programme and she was able to demonstrate to the inspectors the current position of the home concerning this programme and spoke also of where new training had been arranged to meet new and recently emerging training needs. Mayfair Lodge DS0000019462.V260926.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): 31,33, 35, 36 and 38. The recently appointed manager is well qualified and has had several years previous experience running and managing residential homes for older people. She is assisted by other managers who are also appropriately qualified and experienced and all appeared to be working well together as a team giving priority to meeting the residents needs at all times. Questionnaires are used to gather feedback from residents and relatives on the quality of the service being provided. A sluice door on one higher needs unit was found not to be locked and this could put the safety of the residents at risk. EVIDENCE: Staff, with one exception, confirmed that the management team were approachable and that they spent time out and about in the home talking with residents relatives and staff. Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 20 The issues of concern bought up by one member of staff were immediately taken up by a manager who went to speak personally with her. See Standard 26. Regular visits are made to the home by a representative of the company, which also has a quality monitoring system in place, which includes consultation and feedback to residents and relatives. The manager explained that interviews with residents and relatives had taken place over the past weeks she being assisted with this task by a representative from the company’s human relations department. The results of previous consultations were seen to be summarised in the company report copies of which were available in the homes entrance hallway along with the latest inspection report and other documentation which might be of interest to prospective residents and their relatives. Staff spoken with all confirmed that they felt themselves to be well supported by the managers and that they had regular supervision. However the records did not support that all staff had received supervision at least six times in the preceding year. A requirement is made No changes have been made, since the last inspection, to the homes procedures for the safe keeping of residents monies. Residents are able to deposit small amounts of money for safekeeping with the records that are kept of the detail of these monies paid in and out being countersigned and receipts kept for cross checking. A number of the homes statutory records were examined and were found to be well maintained. The fire records were checked and these confirmed that regular tests and fire drills are carried out. Arrangements are in place to train a new lead member of staff who will take the lead responsibility for maintaining fire training for all staff with in the home this following the recent promotion of the previously responsible person to work in another home. Staff spoken with were found to have a good awareness of health and safety issues relating to the care of the residents. Risk assessments were seen to be regularly updated. To ensure the safety of the residents at all times the sluice doors should be kept locked. A requirement is made. Mayfair Lodge DS0000019462.V260926.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 Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 3 2 Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP38 OP26 Regulation 13(4)(a) 12(1)(a) & 16(2)(k) Requirement To ensure the safety of the residents at all times sluice doors must be kept locked. The smell associated with incontinence must be eliminated from the corridor in Bryon unit. The stained carpet in room 46 must be cleaned or replaced. The internal communal toilet on Bryon unit must be kept free of unpleasant smells and must be provided with adequate supplies of soap and paper towels. Suitable equipment, safe and fit for purpose must be provided to assist with the homes laundry this to ensure that the safety of the laundry staff is not compromised. Accurate records must be maintained for all medication administered. The registered person must ensure that the carers follow the care plan instructions precisely so that unnecessary risks to the health and safety of the residents are avoided. Staff must be appropriately DS0000019462.V260926.R01.S.doc Timescale for action 26/10/05 26/10/05 3 OP26 23(2)(c) 30/11/05 4 5 OP9 OP7 13(2) 13(4)(c) 30/11/05 26/10/05 6 OP36 18(2) 30/11/05 Page 23 Mayfair Lodge Version 5.0 supervised. Records should be maintained to evidence that staff receive at least six formal meetings a year. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Mayfair Lodge DS0000019462.V260926.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!