Inspection on 19/01/06 for Old Registry (The)

This inspection was carried out on 19th January 2006.

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

Old Registry (The) 11/01/07

Old Registry (The) 19/09/05

Old Registry (The) 23/03/05

Old Registry (The) 11/10/04

Old Registry (The) 21/03/04

Old Registry (The) 10/02/04

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Ashlong House

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Edenvale

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Chatsworth Care - Dawson House

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

CARE HOME ADULTS 18-65 Old Registry (The) 70 Aldborough Road South Seven Kings Ilford Essex IG3 8EX Lead Inspector Stanley Phipps Unannounced Inspection 19th January 2006 16:25 Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 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 Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Old Registry (The) Address 70 Aldborough Road South Seven Kings Ilford Essex IG3 8EX 020 8590 7076 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) Mr Alan John Philp Mrs Pamela Joan Philp Mr Robert Steer Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Moderate to high level of disability. Date of last inspection 19th September 2005 Brief Description of the Service: The Old Registry is registered to accommodate 8 adults with learning disabilities. Service Users have high levels of dependency and limited communication and cognitive abilities. The home is operated by Alpam Homes, a private organisation, which operates three other registered care homes for people with learning disabilities in the London Boroughs of Redbridge and Newham. Alpam Homes also operate their own day care centre, for service users who live in their care homes. The home is situated in a residential area of Seven Kings, in the London Borough of Redbridge and is close to shops, places of worship, community facilities and transport routes to central Ilford, London and Essex. The house is in keeping with other properties in the area and does not set users apart from the local community. The house is well decorated, furnished and maintained. The premises are not fully accessible to wheelchair users, although there are bedrooms and a bathroom/shower room on the ground floor. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the second for inspection year 2005/2006, and was unannounced. It took place in just over three hours and was timed to meet with service users, follow up on outstanding requirements from the last inspection visit and to monitor the overall progress of the service. As part of the inspection, informal discussions were held with five service users, detailed discussions held with the manager and a formal interview with one of the staff on duty. Several records were assessed including: menus, risk assessments, staff training records, service user plans, policies and procedures and records pertaining to health and safety. A tour of the environment was also undertaken. The inspection found that there were several improvements since the last visit and this included compliance with all outstanding requirements previously made. The registered persons also acted upon a recommendation and this is commendable. In concluding there were many positive outcomes arising out of this inspection and this is great for all service users living at the Old Registry. What the service does well: The registered persons are good at ensuring that service users are engaged in activities best suited to their interests and this includes socially and personally. To this end they provide their own day care services, but service users are not limited to this facility only. Depending on their needs and interests they may attend other facilities in the community and this is positive. What is also important is that they are given some choice in determining what is best for them. The registered persons have also demonstrated that they are prepared to support staff through training and staff supervision, which has a positive impact on outcomes for service users. At the Old Registry, there has been consistency over the last year in providing a safe, warm and homely environment for service users who were all happy with living in the home. It was also clear at the inspection that the staff and management of the home has been supportive of ensuring that service users maintain effective links with Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 6 their loved ones and from speaking with service users, they appreciate these links. This is positive. From the menus assessed and feedback received service users gave the ‘thumbs up’ to meals provided by the home in that they are offered choices the meals are varied and in line with their nutritional requirements. This is integral to maintaining a healthy lifestyle and as such, has a positive impact on the health and welfare of service users. What has improved since the last inspection? What they could do better: The registered persons should give an indication as to when staff in the home would achieve their NVQ Level 2 In Care Award, as only one member of staff had achieved an NVQ qualification. The minimum standard requirement as for fifty per cent of the staff to achieve Level 2 by 2005 and this had not been achieved. The registered persons could also familiarise themselves more, with the notification of significant events that may affect the welfare of a service users under Regulation 37 of the Care Homes Regulations 2001. During the inspection, an event under the said notification had not been reported, as the registered person was not sure. This was discussed in detail and advice offered including; if in doubt, then the Commission could be contacted for verification. The registered manager did formally and promptly provide the Commission with details of the event, thereafter. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 7 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. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (3,4) Detailed assessments and an updated statement of purpose provide service users with the reassurance that their needs could be met by the home. They also benefit from being able to visit the home prior to accepting a place there. EVIDENCE: A detailed and in-depth assessment is carried out on each service user prior to their admission to the home. This provides the basis for determining whether individual needs can be met. Once assessed the needs are matched against the home’s statement of purpose, upon which a decision is made whether to admit or not. It must be said that having an updated statement of purpose is significant to this process and this is made available to both current and prospective service users. There are also arrangements for service users to have a trial stay during which either party could take a decision as to the suitability of the placement. This period is usually over three months. Although there were no recent admissions to the home, there are systems in place for service users to visit the home prior to accepting an offer to live there. This gives individuals a good opportunity to meet with staff and other service users and to get a first hand view of how care and support is offered to service users. This is part of the home’s admission process and is good practice. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (7,10) The management and staff work closely with service users in enabling them to make decisions in their lives. They carry out their duties in a professional manner, which ensures that service users’ confidentiality is maintained. EVIDENCE: The management and staff work closely and in different forums in enabling service users to make decisions in their lives. This may take the place on an individual basis, with the input of relatives, in monthly service users meetings and through surveys, which forms part of the quality assurance process. An essential aspect of achieving this, is the way in which staff communicates with each service user. For most, non-verbal communication is used and this is done mainly through ‘signing’ and the use of pictorials. A good example could be drawn from how staff determines individual preferences for food and this process is dynamic, in which staff provides information to enable the individual to make an informed choice. Further evidence to support the practice that service users make decisions about their lives could be drawn from the fact one service user attends the Chadwell Centre up to three days per week, while another attends the Mulberry Lodge up to five days per week. Other service users attend the day centre run by the registered persons. Clearly individual choices were made and this is positive. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 11 From the interview held with one staff member, viewing the policy and procedure file and observing how records are stored, it was conclusive that information held on service users is handled appropriately. The staff member showed a sound awareness of when and how to disclose information and this was in line with the home’s policy. All confidential files were maintained in a locked facility and this ensured that all personal information was safe and secure. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (11,14,15,17) At the Old Registry, service users benefit from accessing opportunities for personal development, engaging in a variety of leisure activities and maintaining positive relationships with their relatives. Their nutritional needs are also adequately provided for. EVIDENCE: Each service user had in place, an individual plan of activity as well as an individual service user plan. These documents set out what has been drawn up and agreed with service users in relation to their personal and social development. For most, their attendance to various day centres allows them learn new skills as well as meet with their peers. A key feature of their attendance to the various institutions is the enhancement of their confidence levels. They also are supported to produce artwork, pottery and enjoy the benefits of a sensory room (available at the Alpam run day centre). The inspector had an opportunity to visit the day centre run by the registered provider and was satisfied that service users are provided a wide variety of stimulation. As important was the observation that they were all engaged and appeared happy doing so. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 13 From assessing the records, it was evident that all service users are engaged in various forms of leisure activities. This included bingo (designed for service users with a learning disability), attendance to evening clubs (three service users attended a Thursday evening club), discos, birthday and Christmas parties, and dinners. This is a strong area of the homes operations. Their social and leisure activities are enhanced with the involvement of their relatives, although this is more skewed towards birthdays and Christmas periods. It was however commendable that there was involvement and contact with up to six of the service users relatives and this could only be positive for the individuals concerned. The management and staff work really well in ensuring that these contacts are maintained, which at times involve supporting service users to visit their relatives e.g. one service user visits their relation in a residential home. This is positive and another strong area of the homes operations. There was an improvement in this standard, as food had been more appropriately stored i.e. covered and dated once opened. From the menus seen, they appeared varied and service users spoken to, indicated that they were satisfied with the food provided by the home. Staff support for individuals requiring assistance with meals was satisfactory in that the treated service users with dignity and sensitivity. The evening meal on the day of the visit comprised of spaghetti on toast and tuna and salad sandwiches, which the service users enjoyed. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (18, 21) At the Old Registry personal support is provided on an individual basis and in line with the wishes and needs of service users. Adequate systems are in place to support service users, should they become unwell and/or die in the home. EVIDENCE: Staff work closely with service users and their agreed service user plans in providing personal support to them. This is important as the range of special needs of the service user group is quite varied and as such, would be best provided in line with the preferences of each individual. The staffing deployment in the home also takes full account of this and every effort is made while providing the support – to promote and maintain service user independence. In a brief discussion with one of the more independent service users, she was quite pleased with the staffing input, as she enjoyed her independence in what was to her, significant areas of her life. Both her confidence and self-esteem was quite easily noticeable and this is positive. Staff interviewed, demonstrated the ability to identify when the health of service users deteriorate. There is also clear policy guidance for staff to follow when these situations arise. Emergency numbers are widely posted in the staff office to acquire further assistance as required. From assessing the files of service users, it became evident that staff knew what they were doing in supporting service users when they become unwell. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 15 A clear policy on death and dying is in place and this is accessible to staff. Although there were no deaths in the home, the registered manager confirmed that support and counselling would be made available to staff, as and when necessary. Where possible the wishes of service users regarding death are noted in their case files. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (22) Satisfactory arrangements are in place for service users to air their views at the Old Registry. This includes the availability of an appropriately formatted complaints procedure, which is accessible to all service users and their relatives. EVIDENCE: Service users have various forums to air their make their views known. This could take the form of an informal discussion with the manager or a member of staff, contributions at service user meetings, through their quality surveys and the home’s complaints procedure. These mechanisms were all operational at the time of the inspection. The complaints procedure is accessible and in a format that service users could relate to. There were no complaints on record at the time of the visit and staff spoken to, were aware of the importance of supporting service users to express their concerns. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (24,25,26,27,28,29,30) At the Old Registry service users benefit from a clean, warm, homely environment that is generally safe. This includes the communal areas and private spaces of service users. Toilets and bathrooms were also adequate in number and they promote both the privacy and independence of the service user group. EVIDENCE: On entering the Old Registry there is a warm and homely feel to the building and this is partly created by the layout and the welcome one receives from the service users and staff. The home was decorated to a high standard throughout, and was clean and free from offensive odours. On the day of the visit most of the service users were at one point in the dining area having their supper and then in the main lounge comfortably relaxing. They manoeuvred their way through the communal spaces with great ease and from feedback received, were quite happy doing so. Service users’ bedrooms were in sound decorative order and they are able to choose how this is done. Their bedrooms were also quite personalised and arranged so that their independence is maximised. All service users were happy with their private spaces. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 18 The toilets and bathrooms were well maintained, and adequate in number. Satisfactory arrangements were now in place to ensure that toilet paper is available at all times for the benefit of service users. The toilets and baths also promote the privacy and independence of the current service user group and this is positive. The lighting and heating throughout the home was satisfactory and this included the kitchen and laundry areas. Hand washing facilities were also available throughout the home and fire safety measures were satisfactory. It was conclusive that the home remained fit for its purpose and the registered providers have put a lot of effort into maintaining a safe and homely environment for all. Service users bedrooms were particularly impressive. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (31,32,33) A dedicated, competent and motivated staff team is on hand at the Old Registry to provide good quality care and support to all service users living there. EVIDENCE: All staff have the benefit of a clearly defined job description, which sets out their responsibilities in the home. On the day of the visit they were organised and clear about who does what, and on each shift there is someone who leads the coordination of the work. A key-worker system is also in place and service users benefit from having an identified person leading on their individual cases. From the interview held with one of the staff on duty, it was clear that staff individually contributed, significantly to the welfare of the service user group. The registered persons have put in place a staff ‘training and development’ plan for their benefit, which identifies the training that staff undertook as well as the training that is required. Staff have the benefit of receiving specialist training such as the Learning Disability Award Framework training, challenging behaviour, medication, and abuse. It was reported that a Makaton training video is used for the benefit of staff to enhance their communication skills with service users. In essence staff are equipped with training to enhance their competence in working with the service user group. However, it was noted that only one of the staff had NVQ training and the organisation needs to invest in enabling staff to achieve at least the NVQ Level 2 in Care Award. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 20 The staffing deployment currently meets the needs of the service user group. The home has eight service users and a minimum of two staff is always on duty. The registered manager works across the day shifts and is an addition to current care staffing arrangement. One person is awake on nights along with one person sleeping in. Staffing levels are adjusted in line with service user needs and this is good practice. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (37,38,40,41,43) Sound management systems are in place for providing a good quality service at the Old Registry. This includes, a system for keeping policies and procedures under review, maintaining records required by regulation, having regular team meetings and clear lines of accountability in relation to the service. EVIDENCE: In discussion with service users and staff, it became clear that they were satisfied with how the home was run. The registered manager has worked closely with the service users, staff, relatives and commissioners to raise the standards of care in the home. This was evident from the increased number of minimum standards that were met, at the last two inspections. Staff described the registered manager as accessible and supportive, which are important elements to providing good quality care. They also informed that their participation and ideas are encouraged as part of improving the service at the Old Registry. Service users also shared the view that the registered manager was accessible and it was clear from the way in which he interacted with them that they were quite comfortable with him. This is positive for the service as a whole. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 22 Policies and procedures were assessed on the day of the visit and found to be updated and in line with regulation. They were also accessible to all staff and service users if required. The records required by regulation were also assessed and found to be in order and this included and importantly so: staffing recruitment records, financial records, records held on service users, complaints and records pertaining to health and safety. It was accepted that the registered persons by virtue of complying with the minimum standards and its associated regulations, were acting in the best interests of service users and staff in the home. A significant improvement was noted in this standard in that the registered persons made available to the Commission the accounts for the service. Although they were for 2003, they were the most recent that were finalised and as such were used to confirm that the service was financially viable. In this respect service users and their relatives could be reassured that the service is a viable one. The registered providers also have insurance that is appropriate to the nature of the business and this was in line with the minimum requirement set, by the standard on finance. There are clear lines of accountability in the home and staff and service users were aware of them. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 x ENVIRONMENT Standard No Score 24 3 25 4 26 4 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 X 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X 3 3 3 X 3 3 X 3 Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA32 Good Practice Recommendations The registered persons should provide the Commission with an action-plan with timescales to demonstrate how staff would achieve their NVQ Level 2 in Care Award. Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Old Registry (The) DS0000025931.V278622.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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