Inspection on 22/12/06 for Pelsall Hall

This inspection was carried out on 22nd December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pelsall Hall 25/03/09

Pelsall Hall 03/03/06

Pelsall Hall 28/09/05

Pelsall Hall 04/03/05

Pelsall Hall 24/08/04

Pelsall Hall 22/03/04

Pelsall Hall 17/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Pelsall Hall Paradise Lane Pelsall Walsall West Midlands WS3 4JW Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 09:30 21 December 2006 st 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 Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pelsall Hall Address Paradise Lane Pelsall Walsall West Midlands WS3 4JW 01922 693399 01922 685525 pelsall@greensleeves.org.uk 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) Greensleeves Homes Trust Mrs Bridget Ann Ingleby Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 3rd March 2006 Brief Description of the Service: Pelsall Hall is a large detached property within in its own extensive grounds. The house has been converted to provide residential care for up to twenty-nine older people. The home has a large lounge/ dining room with a small quiet lounge and conservatory off it. Laundry and kitchen facilities are provided within the home. At the present time the home is undergoing major refurbishment and a large extension. Once completed this will provide service users with better facilities and a unit dedicated to the provision of care for people with dementia. The home charges £327.15 per week for social services clients and between £355 and £435 for private funded service users. There is no top up fee and items such as hairdressing, chiropody and newspapers are not included in these charges. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection completed by one inspector from the Commission for Social Care Inspection (CSCI). The inspection began at 09:30hrs and ended at 16:30hrs. The judgements made in this report have been reached by reviewing evidence provided to the Commission in the form of a pre inspection questionnaire, by talking to staff and service users, touring the building and reviewing the service user questionnaires that the Commission invited service users to comment on. In addition to this staff files were examined to ensure the home is continuing to recruit people in a satisfactory manner and service users plans were seen as part of the case tracking process to determine whether the home is continuing to meet the needs of the service users. The inspector would like to thank all of the staff and service users at the home for their kindness and hospitality throughout the inspection. What the service does well: The home is currently undergoing a major change in their environment with a new extension being built, it is to the manager’s credit that these major changes have been managed as well as they have under the circumstances. Despite some grumbles from some service users most are coping well with the somewhat cramped conditions. One service user stated “they did ask me if I wanted to sit somewhere else but I said no, it won’t be much longer now and we will have a big room again”. The manager and care staff are confident in their roles and ensure that service users receive the appropriate treatment and care at all times. Service users feel well cared for by staff, commenting “if I need the doctor they get him straight away”, relatives said “when I visit Pelsall Hall I find all of the staff caring and attentive, mom always appears to be settled”. The meals the home provides are good quality and of sufficient quantity to meet service users needs, there is ample choice on the menu’s but the chef is willing to meet any of the service users needs. “the food is delicious”, “there’s always a choice”. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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 Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users can be assured that before they move into the home their needs will be assessed in full and that they will have the opportunity to “try out” the home before they agree to move in wherever possible. Staff have the skills and knowledge to be able to care for the service users. EVIDENCE: The manager visits all prospective service users at home to assess their needs prior to admission, this is so she can be sure the home can meet those needs. service users files were examined as part of the case tracking process, it was pleasing to see that all of the files seen contained an assessment that was comprehensive and covered all of the activites of daily living. There was also information from the Single Assessment Process in addition to the homes own documentation. These assessments are then used to form the basis of individual care planning. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 9 All prospective service users are encouraged to spend time at the home before accepting a place there, where this is not possible relatives are invited to look round and spend time talking to service users about living at the home. Staff at the home have regular training to ensure that their skills and knowledge are kept up to date, more recently staff have completed dementia care training. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that their individual needs will be met, they will receive the health care they need and medication will be administered safely. Furthermore service users can feel confident that their right to privacy and dignity will be upheld. EVIDENCE: Four service users case files were case tracked. All of them were well maintained and there is evidence that the home reviews the care it provides at least on a monthly basis. Service users are assessed for their risk of developing pressure sores, falling, and moving and handling, whilst this is pleasing to see, the home is currently not using a recognised screening tool to assist them in making these judgments. For instance one service user was assessed as high risk of developing pressure sores but the manager was unable to demonstrate how they had come to this decision, this was the same when assessing their risk of falls. The home does not routinely screen service users for their risk of becoming malnourished upon admission or thereafter, this was discussed with the manager who will ensure that this is done in the Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 11 future, this means that all service users who are potentially at risk will be identified at the earliest opportunity and appropriate action taken. All other care records were well kept and up to date, wherever possible they demonstrated that the service user had been involved in the planning of their own care. The registered manager ensures that all of the service users receive medical attention whenever they require it, it was pleasing to see that on the morning of the inspection one service user was feeling unwell the staff arranged for the doctor to visit her the same day. Service users said “if we need the doctor Ann always calls one”, “they’re very good at getting us sorted out”. One relative said “if she has any health problems the doctor is always called quickly”. Medication practices within the home are of a good standard with only minor shortfalls for the staff to address, for instance the temperature in the treatment room must be recorded on a daily basis to ensure that all medication is stored at the recommended temperature. Staff need to make sure that when they are administering creams and lotions for service users that this is recorded onto the MAR sheet, if service users choose to administer their own creams then this must be risk assessed inline with the self administration policy. The home has good systems in place for the ordering, receipt and disposal of medication, this system could be further improved by staff signing to say they have received and checked medication rather than the current practice of ticking the book. Staff also need to record the amount of medication received onto the MAR sheet. Controlled drugs are administered safely and the controlled drugs register is kept up to date and completed appropriately. Service users were generally positive about the way medication is administered although one did comment “when staff are busy things can get overlooked like applying creams”. All of the service users who responded to the questionnaire sent out by the Commission said that they felt the staff treated them with respect and dignity at all times. When talking to staff they were able to give good examples of how they encourage service users to make choices about their care such as what time they want to get up in the morning, what time they want to go to bed in the evening, staff also stated that they use screens where necessary to protect the privacy of service users. Throughout the day staff were seen to be talking to service users in a friendly manner. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be consulted about the activity they take part in. Friends and family are welcomed at anytime. The home provides meals that are nutritious and balanced for all service users. EVIDENCE: The home does not have a dedicated activity coordinator, however it has recently employed the services of an Occupational Therapist who is working with the service users to develop an individual activity plan for them. This scheme will last for six months and has already begun with a review of each service users likes and dislikes. The assessment will also include an assessment of mobility, falls, leisure and social activities. In addition to this the home organises outside entertainment such as “keep fit”, bingo, singers and more recently an in-house pantomime. Service users commented “I’d like more trips out to the lights, (Walsall illuminations), and the pub. “I don’t really like to join in activity but there are plenty of things going on through the year”. The home has a hairdresser who visits the home on a regular basis to wash and set service users hair, although not all of the service users were happy with the current arrangement stating, “the home could do with a better hairdressing service, the current lady is not always available i.e school Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 13 holidays”. This was discussed with the manager who stated that the hairdressing service is unavailable during bank holidays and also for four weeks whilst the hairdresser takes her annual leave, during this time service users can choose to make their own arrangements if they wish to do so. The home encourages visitors at any time during the day but they are asked to consider service users needs particularly when visiting early morning or late evening. Service users do have the choice to meet with their relatives in the privacy of their own rooms should they choose to do so. It is acknowledged at the present time some service users and their visitors are finding the current arrangements a little cramped due to the building work that is taking place. Service users are encouraged to manage their own finances should they choose to do so, the home also takes positive steps to encourage service users to bring in their personal possessions from home prior to admission should they wish to do so. Usually service users and relatives are also informed about the local advocacy service who will act in their best interests however because of the building work and reorganisation this information was not on display on the day of inspection, the manager stated that this would be addressed as soon as possible. Mealtimes are usually a relaxed affair however there has been some changes again due to the building work, this has not affected the quality of the food and all of the service users spoken to said how much they enjoyed their meals. The home has a menu that is divided over four weeks and offers service users two choices daily for dinner and tea. Care staff have access to the kitchen at night to enable them to make service users supper and other snacks should they require them. “The food is excellent, there’s always plenty of choice” Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that their concerns will be listened to and acted upon. Service users will be protected from abuse. EVIDENCE: The home has good systems in place for dealing with complaints, since the last inspection the manager has dealt with two complaint investigations, one resulted in an adult protection referral. It was pleasing to see that throughout this process the manager worked with all of the involved agencies in order to ensure that the matter was thoroughly investigated. Most of the staff have now received training in adult protection issues, that includes recognising the signs of abuse and their role in reporting suspected abuse to the appropriate person. There are plans in place for the remaining staff to take part in this training in the near future. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and staff are currently managing well with a stressful situation, the existing part of the home is being maintained as well as can be expected during this building period EVIDENCE: The home is undergoing major building work and as a result there have been some alterations to the living arrangements for the service users. At present three bedrooms have been converted into a lounge for service users to use, the dining room has reduced in size and the outside of the building is largely inaccessible due to the extension building work. Although both service users and their relatives were consulted about the new building and the temporary changes to the environment, the manager has dealt with some concerns from relatives and service users. One commented “the situation at Pelsall Hall is far from satisfactory at present as the home is undergoing building work. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 16 Conditions are extremely cramped and dingy”. It is acknowledged that at present service users have limited space in the temporary lounge, it is felt that the registered manager and providers have taken steps to reduce the impact of these works on service users. It is anticipated that the new lounge should be completed and ready for use in early February. A partial tour of the building was undertaken due to the building work, a number of outstanding requirements are yet to be addressed but it is hoped that these will all be addressed once the building work is completed. The manager has been requested to seek the advice of a plumber/heating specialist regarding the recording of the flow and return of hot water and the two bedrooms identified during inspection whose hot water supply does not meet required temperature. The manager is currently updating the infection control policy for the home to ensure that staff are practising against current best practice guidance. The home provides liquid soap and paper towels in all toilets and bathrooms and staff reported that they have enough protective equipment such as gloves and aprons to reduce the spread of infection. The laundry continues to require updating but again this will be addressed once the building work has been completed. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that staff are appropriately trained and recruited in a manner that safeguards their interests. EVIDENCE: Since the last inspection the staffing levels have been reviewed, there are now extra staff available on duty but this does depend upon the number of service users in the home. A new deputy manager has also been recruited. The numbers of staff who have completed their NVQ level 2 exceeds the required 50 by 2005 and the staff group should all be congratulated on their achievement. Some care staff are now progressing on to their NVQ level 3. Staff files were examined to ensure that the home continues to recruit people safely and in a manner that protects service users. There were some minor shortfalls that were bought to the attention of the manager at the time of the inspection but generally all files contained the required information. New staff in post are given the opportunity to take part in an induction programme, however of the new workers files that were examined none of them had any documented evidence that an induction had taken place. Similarly there was no identified worker to support them during this time. It was evident however, whilst talking to staff that they had been given clear Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 18 instruction and training that meets the Skills for Care induction standards. This means that record keeping practices must be updated so that evidence of all induction activity is recorded. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that the home is run in their best interests and that staff will be appropriately trained to ensure their health and welfare is protected at all times. EVIDENCE: The registered manager is both qualified and competent to run the home and does so in the best interests of the service users. The home’s quality assurance systems are being developed and are now providing a systematic cycle of planning, action and review. Once a year service users and their relatives are invited to take part in a survey of the home progress, the results of which are then published for all interested parties to read. Some of the comments received from the last survey were Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 20 very positive and included “my family and I are satisfied with the care my mother gets”, “is cosy, clean and well fed very lucky to be in such a caring place”, “all the staff from the management to the kitchen are a credit to Greensleeves”, “how old do I need to be before I can move in”. The home has provision for the safe keeping of service users monies, it was pleasing to see that the home addressed the requirement from the previous inspection and is now recording two signatures for every transaction and receipts are being numbered. Records were seen and found to be an accurate account of service users monies. There are robust measures in place to ensure that the home practices safe working in relation to health and safety. Safety certificates were spot checked and found to be in order. Records of fire drills and fire training are up to date and the manager has a training matrix that highlights when staff are due for their mandatory training in health and safety, infection control, first aid and food hygiene. The manager must ensure that all COSHH products are stored securely. Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 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 2 X X X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 17 (1)(a) sch 3 Requirement The registered manager must ensure that all service users are screened for their risk of falls upon admission and a regular intervals after that. The registered manager must ensure that all service users are screened for their risk of malnutrition and pressure sore development upon admission and regularly after that Provide storage area for aids and equipment, including wheelchairs. Not met - Additional storage has been identified within the new extension. 4. OP26 12(1), 23(d) Provide a suitable regularly cleaned, washable floor covering and ensure an even floor level in the hairdressing salon. Not met will be addressed when the new extension is completed 01/04/07 Timescale for action 01/03/07 2 OP8 17 (1)(a) sch 3 (3) m,n 01/03/07 3. OP22 23(2) 01/04/07 Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 23 5. OP26 13(3) The laundry floor and walls must be continuous and easily cleanable. Not met will be addressed when the new extension is completed Gloves and aprons must be available for staff to use in the laundry area. The registered manager must ensure that a full employment history is available for all members of staff, any gaps must have a written explanation. The registered manager must ensure that a written record of induction for all new workers is available. Provide safe, secure, suitable (fire safe) storage of stacked paperwork etc in the hairdressing salon. Partially met, and will be fully addressed by the new extension. A record must be available of the storage and flow of hot water. The manager must seek the advice of the specialist plumber on how to record the flow and return of hot water. The two bedrooms identified with insufficient hot water supply must be addressed and made good. 01/04/07 6 7 OP26 OP29 13(3) 19 sch 2 (6) 01/01/07 01/03/07 8 OP30 18 (2) 01/03/07 9. OP38 13(4)(a), 23(4) 01/04/07 10. OP38 23 01/02/07 11 OP38 13 (4) All products relating to COSHH must be stored securely at all times. 01/03/07 Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Pelsall Hall DS0000020827.V319279.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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