Inspection on 12/09/05 for Milton House

This inspection was carried out on 12th 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 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

Milton House 06/07/06

Milton House 07/02/06

Milton House 14/02/05

Milton House 03/08/04

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

CARE HOMES FOR OLDER PEOPLE Milton House The National Society For Epilepsy Chesham Lane Chalfont St Peter Gerrards Cross Bucks SL9 0RJ Lead Inspector Joan Browne Unannounced Inspection 12th September 2005 09:30 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 Milton House DS0000022999.V253971.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. Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Milton House Address The National Society For Epilepsy Chesham Lane Chalfont St Peter Gerrards Cross Bucks SL9 0RJ 01494 601432 01494 871927 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) The National Society for Epilepsy Mrs Mary Hooba Care Home 13 Category(ies) of Physical disability (13), Physical disability over registration, with number 65 years of age (0) of places Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the Home is to be registered to provide care for 5 (five) Service Users under the age of 65. That the home is also registered to provide care for 1 (one) Service User under the age of 30 until the 31st of July 2005. 14th February 2005 Date of last inspection Brief Description of the Service: Milton House is one of a number of residential and medical facilities that comprise the Chalfont Centre for Epilepsy. It provides personal care and accommodation for thirteen residents that suffer from epilepsy. The home has thirteen single bedrooms and two lounges. None of the bedrooms have en suite facilities. Accommodation at the house is all on ground floor level. It is situated in Chalfont St Peter not far from the village shop. Public transport and amenities are easily accessible. Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection of the home, which took place on the 12th September 2005. The lead inspector was Ms Joan Browne who was accompanied by Mrs Gill Wooldridge (Inspector). The inspection consisted of examining a number of records including risk assessments, care plans, medication administration record sheets (MARS). A tour of the building was carried out and the lunchtime meal was observed. Comment cards were received from residents, relatives and health care professionals. Overall residents were satisfied with the care that they were receiving and felt safe living in the home. They also felt that staff respected their privacy and dignity. Comments from relatives regarding the provision of care were positive. Staff were praised for their dedication and for making relatives feel welcome. One particular relative referred to staff as ‘friends due to their caring and down to earth attitude.’ Feedback was given to the manager and the assistant director on the findings of the inspection. What the service does well: Residents are encouraged and supported by staff to be independent. The home has a flexible visiting policy. Residents are able to invite friends and relatives into the home. Health care support for residents is good. Residents’ privacy and dignity is promoted within the home. Residents’ bedrooms provide single room accommodation. Staff training is in place and this includes induction training. Residents are confident of their position within the home. The house provides residents with a comfortable and homely environment. Residents benefit from well informed staff. The home has its own transport facility. Staff benefit from a supportive manager who recognises the value of personal development. Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 6 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. Milton House DS0000022999.V253971.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 Milton House DS0000022999.V253971.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): 3 The home’s assessment procedure needs to be strengthened to ensure that the needs of future residents would be clearly identified and met. EVIDENCE: The home had undertaken in-house assessments relating to two residents. These assessments covered the following areas: communication and awareness of health issues, mobility, epilepsy needs, assessments and regular medication. The needs assessment document does not fully reflect the detail as outlined in Standard 3. However, it is acknowledged that the manager has developed this system to support residents’ needs. It is recommended that a clear procedure and policy is developed to ensure any future admissions run smoothly. Milton House DS0000022999.V253971.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 Care plans examined did not contain all of the necessary information to enable staff to meet residents’ care needs. The home has systems in place to ensure that residents’ health care needs are met fully. Improvement in the recording of medication is needed to ensure that the safeguards that are place to protect residents’ health and well-being are adhered to. EVIDENCE: The care plans for two residents were examined, and their care tracked. The format of the care plan does not allow staff to write ample information in each section to ensure that a new member of staff can offer adequate support to a resident. Some of the information recorded under preferred daily routine indicated residents’ involvement. For example, the following information was noted in a particular resident’s care plan: ‘Likes to lie in bed.’ Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 10 Information recorded in the care plans examined did not always inter-relate. For example, it was noted that a particular resident ‘s plan referred to a behaviour programme and the individual provided with one to one care. There was no evidence of a structured plan in place and one to one care being provided. The level of assistance and support staff needed to provide were not clearly described. For example, one care plan described ‘closer observation regarding epilepsy at night.’ However, more detail regarding how frequent checks should be carried out, and an agreement that staff could enter the individual’s room would be helpful additions. A further entry to speak ‘simply’ was noted. This entry could have been better described as slowly and clearly. The following inappropriate language was noted in a particular resident’s care plan: ‘She whines and may even snort when she can’t have her own way.’ Staff are reminded to write with a positive slant. Some further issues identified in a particular resident’s care plan relating to eating in between meals may be perceived as a restriction of liberty. These issues need to be discussed in a multi-disciplinary forum involving the resident and her representative. Staff were knowledgeable about the residents’ care but were not recording details in the daily log and care plan and were doing themselves a dis-service. Inconsistencies in the daily report writing were noted and depended on who the author was. The key worker or manager did not always sign care plans. All residents are registered with a general practitioner (GP) that visits the medical centre on a weekly basis. Residents have access to dental and chiropody treatment as and when required. Yearly eye tests are available to residents. Every three months the neurologist reviews residents’ anti-epilepsy medication and yearly neurological checks are carried out. The continence adviser offers support and aids to those residents that require it. Residents are able to access specialist treatment from the National Health Service via their general practitioner (GP). The physiotherapist on site would offer support and specialist advice to those residents who may require it. Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 11 The medication administration record (MAR) sheets were examined and two gaps were noted. There was no explanation recorded on the MAR sheets to denote reason for omission. The medication record book for medicines entering and leaving the home was checked and was in order. Appropriate risk assessments were in place for residents that self-medicate. A record with the names and signatures’ of staff members that administer medication was in place. Update training for all staff who administer medication had taken place. The manager stated that work was in progress to ensure that staff’s competencies in the administration of medication are regularly assessed. The medication trolley was examined and stocks were stored appropriately. However, it was noted that the writing was fading on the label of a diazepam packet. It is recommended that the label be replaced. The manager is advised to develop a generic risk assessment for the storage and transporting of medication when residents are away on holiday this is deemed as a good practice. Staff are expected to provide personal care in private. Residents commented on comment cards that staff ‘respected their privacy and dignity.’ There is a telephone facility available, and residents can make calls in private. The manager explained that residents’ personal letters are given to residents un-opened. However, staff assist those residents who require assistance with opening their letters. If residents receive letters to inform them of hospital appointments staff would obtain residents’ permission to read the letters and record appointments in the office diary. Residents wear their own clothes. On the day of the inspection residents’ attire was smart, hair was well groomed and fingernails were clean. All bedrooms are single and those residents, who wish to, have been issued with keys for their bedroom doors. Milton House DS0000022999.V253971.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, 14 & 15 The home’s activity programme needs to be more vigorous to ensure that residents’ social and recreational interests are catered for. The home needs to advertise the services of an advocate. This would enable residents to exercise choice and control over their lives. The dietary needs of residents are catered for with a selection of food and drinks available that meet residents’ choices. EVIDENCE: Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 13 Residents are encouraged and supported by staff to pursue their own interests and hobbies. Two residents take a taxi into the village weekly unescorted to purchase personal items of shopping and have a cup of coffee in the local café. Occasionally, residents have planned group trips and outings to the theatre escorted by staff members. Some residents recently had a week’s holiday in Devon escorted by staff members. Residents stated that they ‘thoroughly enjoyed the holiday and staff looked after them very well.’ One female resident spoken to had recently attended a summer ball. She felt very privileged to have been offered the invitation, and praised the manager and staff for their support in assisting her to choose the right dress and accessories. Some residents raised concerns regarding their attendance at the day centre. They felt that they had been forced to reduce their daily attendance to twice weekly because of staff shortage and were not happy with the decision that had been made. They felt that senior managers should be doing more to address this shortfall. On the day of the inspection there were no residents using the services of an advocate. The manager explained that she had tried on several occasions to encourage residents to take up the services of an advocate but they had declined the offer. It was suggested that the manager should invite the advocate to the house to meet with residents informally. It was noted that a befriender was visiting one resident. Residents are made aware that they can have access to their personal records if they wish to. The lunchtime and evening meals are prepared in the main kitchen and there is a selection of choices on offer to choose from. Lunch was observed, and choices on offer were cheeseburger in a bun with fried onions, grilled fish with lemon, vegetarian mixed grill, sweet and sour chicken with rice. Dessert on offer was egg custard, apple and sultana crumble. Residents confirmed that the meals served were tasty and of a high standard. It was noted that staff were supporting one resident to prepare her own meals. Fresh fruit was on display and available to residents as and when required Lunchtime looked a relaxed activity. Those residents that needed assistance with feeding or prompting were offered assistance by staff in a sensitive and discreet manner. Milton House DS0000022999.V253971.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 & 18 The arrangements for protecting residents are satisfactory and ensure that they are not placed at risk of harm or abuse. EVIDENCE: The home has a complaints policy in place, which is written in a pictorial format and issued to residents and their relatives. The complaints policy was displayed in the home. There is a complaints folder in place. Since the last inspection the home had not received any complaints. The home’s vulnerable adult procedure and whistle blowing polices were recently updated. All staff have undergone training in abuse awareness and the protection of vulnerable adults. Staff were able to describe the different types of abuse and how they would action any alleged, potential or actual abuse. Milton House DS0000022999.V253971.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, 24 & 26 The home is well maintained, pleasantly decorated and furnished to meet the needs of residents. This provides residents with an attractive, safe and homely place to live in. EVIDENCE: The home is situated on the ground floor in a two –storey building. The building was recently inspected by the local fire service and no shortfalls were identified. The corridors are painted in a bright pink colour. Lighting provided was adequate. The outside of the building was recently painted, which has improved the appearance of the building. The home has adequate numbers of toilet and bathroom facilities, which meet the assessed needs of residents. Staff maintain the facilities to a satisfactory standard to create a homely feel. Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 16 Residents’ bedrooms were personalised with family pictures and mementos, which reflected the characters of individuals. The home provides each resident with a comfortable bed, wardrobe, chest of drawers and a chair. Residents are able to provide their own furniture if they wish to and it was evident that some of them provided their own furniture. All bedroom doors are fitted with locks. Those residents that wished to lock their rooms were issued with keys. On the day of the inspection the home was clean and free from offensive odours. The laundry room is situated away from the kitchen and dining areas. Adequate hand washing facilities are sited in areas of the building where infected material or clinical waste is handled. The washing machines are not fitted with the specified programming ability to meet disinfection standards, as they are top loaders. Soiled linen is sent to the general laundry on site. It was noted that general waste bins in some areas were of the swing top type. A requirement is being made for bins to be replaced with the foot pedal type to prevent the spread of cross infection. Milton House DS0000022999.V253971.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, 29 & 30 Staffing levels appeared inadequate, this has the potential to indicate that not all residents’ needs are met. The home’s procedure for the recruitment of permanent staff appears robust. However, checks relating to agency staff members were not evident, this could potentially put residents at risk. A considerable amount of training has taken place. However, staff training profiles need to be kept updated to ensure full competence amongst the staff team. EVIDENCE: Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 18 Since the last inspection there has not been a significant change to the staffing numbers. The home continues to depend on bank and agency staff to make up the staffing numbers. The rota was examined and it was noted that there were times when the manager was not supernumerary to the rota. The manager is required to keep the dependency levels of residents under review using an appropriate tool, based on residents’ personal care needs and mobility to ensure that the appropriate level of staffing is provided. Comments from a relative regarding staffing numbers indicated that there are times when sufficient numbers of staff were not on duty. Staffing numbers in the afternoon must not be reduced to less than three staff members. The manager and proprietor must recruit to all vacant hours on the rota. Two staff records were examined and they conformed to Regulation 19 and Schedule 2 of the Care Homes Regulations. However, information relating to agency staff working in the home was not available. The manager is required to ensure that information relating to agency members of staff conform to guidelines issued by the Aylesbury office of the Commission for Social Care Inspection. Training profiles for individual staff members were examined. Some training profiles were not updated. The manager stated that most staff had undertaken training in moving and handling, fire awareness, food handling and hygiene, infection control, basic life support and medication management update training. The manager is required to ensure that training profiles for all staff are kept updated. Staff competencies in basic first aid procedures should be regularly assessed. It was noted that some staff were undergoing National Vocational Qualification (NVQ) in direct care at level 2. Milton House DS0000022999.V253971.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): 35 & 38 Residents’ financial interests are generally safeguarded by good record keeping. The home needs to be pro-active by ensuring that all service records and the fire risk assessment for the building are kept updated. This would ensure that residents’ safety and health are not compromised. EVIDENCE: Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 20 No residents were handling their own financial affairs. However, some residents were able to access money from the finance office on site when required. A small amount of money is kept in the home for some residents. Money belonging to three residents was checked and balances on sheets tallied with money held. Staff are not allowed to witness or benefit from residents’ wills. Gifts donated by residents and relatives have to be approved by senior managers. There was evidence in place, which indicated that the boiler, central heating system and hoists were regularly serviced. The yearly portable appliance test on electrical equipment was up to date. The regulation of water temperature test to control the risk of Legionella was over due. Control of Substances Hazardous to Health (COSHH) sheets were in place for all cleaning liquids and substances used in the home. Risk assessments for safe working practices were up to date. The practice of duplicating records of accidents and seizures sustained by residents on individual sheets as well as in an A4 book should be reviewed as this pose a breach of the data protection Act. The fire risk assessment for the home was in place however, the assessment should be reviewed to include the supported living accommodation on the top floor. Milton House DS0000022999.V253971.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 x x 3 x x N/A 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 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 3 x x 3 x 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 x x 2 Milton House DS0000022999.V253971.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 Standard 7 Regulation 15(2)(a) (b) Requirement The registered manager must ensure that information recorded in care plans, which maybe perceived as a restriction of liberty is discussed in a multidisciplinary forum. The registered manager must ensure that contents in care plans are clear and that they inter-relate. The registered manager must keep the dependency levels of residents under review to ensure that the appropriate level of staffing is provided. Staffing levels in the afternoon shift must not be reduced to less that three staff members. The registered manager must recruit to the vacant staffing positions The registered manager must ensure that information relating to agency staff members conform to guidelines issued by the Aylesbury office of the Commission for Social Care Inspection. DS0000022999.V253971.R01.S.doc Timescale for action 31/10/05 2 7 15(b) 31/10/05 3 27 18(1)(a) 31/10/05 4 5 27 29 18(1)(a) 17(2) 31/10/05 12/09/05 Milton House Version 5.0 Page 23 6 30 18(1)(c) (i) 13(4)(a) 7 38 The registered manager must ensure that training profiles for individual staff members are kept updated. The registered manager must ensure that the service record relating to the regulation of water temperature to control the risk of Legionella is updated. 12/09/05 12/09/05 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 3 9 Good Practice Recommendations It is recommended that the registered manager develop a clear assessment procedure for future admissions. It is recommended that the registered manager should ensure that the diazepam packet with the fading writing on the label be replaced. Regular auditing of medication administration record sheets should be carried out and copies of auditing undertaken kept for inspection purposes. It is recommended that the registered manager should develop a risk assessment for the storage of medication when residents are on holiday. It is recommended that the registered manager should review the home’s fire risk assessment to include the supported living accommodation on the top floor. 3 4 9 38 Milton House DS0000022999.V253971.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Milton House DS0000022999.V253971.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. 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