Inspection on 14/06/06 for Queens Lodge

This inspection was carried out on 14th June 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queens Lodge 07/02/08

Queens Lodge 12/12/05

Queens Lodge 30/08/05

Queens Lodge 07/12/04

Queens Lodge 23/04/04

Queens Lodge 11/07/02

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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 Queens Lodge 4 Goffs Park Southgate Crawley West Sussex RH10 6AX Lead Inspector Mrs S Rodgers Key Unannounced Inspection 14th June 2006 03:00 Queens Lodge DS0000014675.V293349.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 Queens Lodge DS0000014675.V293349.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. Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Queens Lodge Address 4 Goffs Park Southgate Crawley West Sussex RH10 6AX 01293 510734 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) Outreach 3 Way Mrs Margaret Lucas Care Home 20 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10) of places Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. A maximum of 10 service users may be admitted to Queens Lodge. Only service users under the age of 65 years to be admitted to Queens Lodge House. A maximum of 10 service users may be accommodated in South View. Only service users over the age of 65 years to be admitted to South View. Total number of service users not to exceed 20. That after the admission of the initial Service User Group no further persons under the age of 65 years will be admitted to South View. 12th December 2005 Date of last inspection Brief Description of the Service: Queens Lodge is a care home, registered to provide care (PC) for up to twentythree people in the Category LD, Learning Disability, including up to ten people over the age of sixty-five. The property is purpose built and is situated near to Crawley town centre. The home consists of two buildings; Queens Lodge provides short stay accommodation for up to thirteen people with a learning disability and Southview that provides accommodation for up to ten people over the age of sixty-five with a learning disability. In both buildings accommodation is provided on ground and first floor level. All bedroom accommodation is for single occupancy. There are lounge and dining facilities in both buildings. Outreach 3 Way is a charitable trust. The responsible individual on behalf of the trust is Mrs Vanessa Keen. The post of registered manger is a shared post Mrs Margaret Lucus has responsibility for managing the site known as Queens Lodge and Mrs Kathleen Philpott has responsibility for managing the site known as Southview. Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours. Preparation for this inspection focused the review of previous inspection reports, general correspondence and information contained in the pre inspection questionnaire submitted to the Commission. There has been one Adult Protection referral made by the management of the home since the last inspection. Appropriate procedures were followed and the Commission was informed with in the specified timescales as indicated in the Care Home Regulations 2001, Regulation 37. One complaint has also been received. The management of the home invoked the homes complaints procedure and has dealt with the matter with in the timescales stated. During the course of the inspection the inspector toured the home, spoke with residents within the communal areas of the home in order to gain a sense of how the home is being run and how they experienced staying/living at Queens Lodge and Southview. Staff were spoken with in order to gain a sense of the support and training they receive in order to carry out their jobs and to gain insight into how their knowledge of the aims and objectives of the homes philosophy of care. Due to the diverse needs of the residents not all were able to express their views however, residents who were able to communicate with the inspector indicated that they are happy when they visit Queens Lodge for a short stay they said comments like “ best thing I can do kariokie”, “ I enjoy getting to know people I did not know before”. Those living at Southview also told the inspector that they are happy living at the home. Comments such as “ I go out with the staff”, “ I get up at about 11am, can go out when I want”. The inspector was able to observe the interactions between residents and staff, both were relaxed and confident in each other’s company. Staff spoken with were knowledgeable with regards the care needs of residents. It was clear that they were aware of the homes philosophy of care i.e. to support resident to lead an independent life within their individual capabilities. There were two requirements identified at the last inspection. The quality assurance and quality monitoring audit has been completed. It was confirmed following the last inspection that staff identified as not receiving fire safety instruction had received training in the agreed timescales however this remains a requirement as it was noted that fire training for two staff at Queens Lodge has lapsed. Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 6 Two other requirements have been identified at this inspection. The providers are requested to provide an action plan by 29 July 2006 advising when compliance with the regulations will be achieved. Where standards have not changed from the previous inspections this report records that the findings were the same. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 7 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 Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 8 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): 1, 2 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose, Service User Guide and the admission process enables prospective residents and their representivites to make an informed decision as to whether the service can meet the needs of the individual. EVIDENCE: The homes Statement of Purpose and Service User Guide clearly advises prospective resident, relatives and placing social workers of the services provided. Both documents are in written text and symbol format. The inspector was advised that these documents are in the process of being reviewed. As identified previously for registration purposes Queens Lodge is registered as one service however within the home there is a division in services provided. 10 beds are registered for residents over the age of 65 years with a Learning Disability in the section known as Southview and there are 10 beds registered in respect of the section know as Queens Lodge for residents under the age of 65 years with a Learning Disability including one placement for a person with a learning disability and a Physical Disability. Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 9 Southview provides long term placements for resident and therefore there have been no recent admissions. However Queens Lodge provides short stay respite care and has regular admissions. Records of pre admission assessments were reviewed at Queens Lodge. Residents admitted for short stays have had an assessment of need carried out by the placing authority. These documents are placed on individual files and are used to formulate care plans that detail the needs of residents and how those needs are meet. At present all residents admitted to the home are funded by Social services and as such the placing authorities assessment of need is accepted as the pre admission assessment. However it was discussed with Ms Lucus, the manager of the section known as Queens Lodge, that if is possible it is good practice for the service to carry out its own assessment to ensure that they are fully aware of the individuals needs and that the placement will not affect unduly the dynamics of the resident group. Queens Lodge DS0000014675.V293349.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): 6, 7, 9 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents assessed needs and personal goals are reflected in care plans. Residents are assisted to make decisions about their own lives. Residents are supported to take risks. EVIDENCE: Four care plans were reviewed. Two care plans from Queens Lodge and two from Southview. Each gave detailed information on the personal, health and social needs of residents. Due to the varying degrees of learning disabilities of the current residents it is difficult to assess whether they know their assessed needs however, the care planning documentation demonstrates that each resident is consulted with regards their changing needs and personal goals. There was documentation to demonstrate that annual reviews take place for residents living at Southview however there was no evidence to demonstrate that care plans are reviewed and updated at 6 monthly intervals or on the request of resident. Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 11 The risk assessments seen at this inspection indicate that all residents are supported to lead an independent lifestyle with in a risk-assessed framework. Action plans to minimise risk are also devised and kept on individual care plans. The pre inspection questionnaire indicates that Mrs Philpot the registered manager in respect of Southvew is appointee for 3 residents. Each has an individual bank account. Mrs Philpot can withdraw money from individual accounts, as residents require money, a monthly audit/reconciliation of transactions are carried out. Records seen at this inspection of money held in safekeeping for residents were available and were in good order. Money is kept in individual lockable cash boxes and records of transactions and receipts are kept. Residents who are admitted for short stays at Queens Lodge do not generally take money with them however, should they take money to the home with them the same system used in Southview for holding money in safe keeping would be used. Queens Lodge DS0000014675.V293349.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): 12, 13, 15, 16, 17 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assisted to attend colleges, day centres and clubs. Acitvities are offered and residents are enabled to maintain contact with family and friends and access the local community. The views of residents are respected. Meals provided are varied. EVIDENCE: All residents are enabled to access colleges, clubs and day centres. The majority of residents who live in Southview choose not to go to college as they are of retirement age however should they wish to do so staff contact local colleges and arrange placements. People who visit Queens Lodge for short stays maintain the routines they have when they are at home, the service transports them to the day centre or college they are attending. Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 13 Residents are enabled to maintain links with the local community. Residents if they choose can attend the local gateway club. They also use the local amenities, residents regularly go to the local shopping centre, local parks and. pubs. Activities within the home environment include arts and crafts and music therapy. Residents spoken with confirmed that they are able to maintain contact with their families. Communication record sheets clearly record contact with family and friends. The inspector noted that staff respected that residents have rights, resident’s views were heard to be sought and permission to enter bedrooms was asked prior to the inspector touring the home. Residents who were asked confirmed that they liked meals provided, residents comments regarding meals were foods alright, Menus were seen that demonstrated that a varied diet is offered. Residents living at Southview devise the weekly menu with the aid of staff. Residents are encouraged to have regular fresh fruit and vegetables however due to residents likes and dislikes the inspector was told it was not always easy to maintain a truly balanced diet. A recent regulation 26 monthly report provided by the service did identify this issue. Queens Lodge DS0000014675.V293349.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, 19, 20 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Every effort is undertaken to ensure that residents receive support in the way they prefer. Systems are in place to promote the physical and health needs of resident. Systems are in place to promote the safe handling of medication. EVIDENCE: Care plan review documentation seen at Southview demonstrates that residents are consulted on how they wish to receive support. Each resident has a review. Residents are assisted to complete the review form 6 weeks prior to the review. The form is in pictorial and written text. Due to the profound disabilities of some of the residents it is difficult to identify their preferences. However as resident reaction to situations and new activities are monitored and recorded so that staff can identify a preference in the way a resident wants support, staff would evidence that preference by recording patterns of behaviour or incidents. Due to the service being provided at Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 15 Queens Lodge care plans clearly demonstrate that people staying for short breaks are facilitated to maintain the daily routines they would follow at home. All residents are registered with a local General Practitioner. Records of visits to the Doctors surgery are kept along with brief details of the outcome of the visit. Residents have access to other health professional such as dentist and opticians within the local community. Residents also have access to the Community Team for People with Learning Disabilities. Systems are in place for the receipt, recording, storage, handling administration and disposal of medication. The home has a contract with a local pharmacy. The Monitored Dosage System is used at Southview. The pharmacist dispenses medication into individual ‘ blister packs’. Due to the nature of the service residents admitted to Queens Lodge for a short break take their own medications into the home. Following an incident of medication allegedly going missing whilst a resident was staying at Queens Lodge a new system of recording the amount of medication being brought into and leaving the home has been implemented. Medication at Queens Lodge is dispensed for individual containers. Queens Lodge DS0000014675.V293349.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): The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and are managed in accordance with the complaints procedure. Systems are in place to promote the protection of vulnerable adults. EVIDENCE: A complaints procedure is in place. The procedure is in written text and symbol format. The procedure informs residents and their relative who they should address their concerns to in the first instance and timescales in which a response will be made. The procedure contains the address and telephone number of the Local office of the Commission for Social Care Inspection so that in the event that they are not satisfied with the outcome of the homes investigation they can contact Commission directly. A complaints book was available. There has been one complaint since the last inspection. Mrs Keen the Responsible Individual on behalf of the organisation instigated the homes complaints procedure and have kept the Commission informed of the outcome. Training records evidence and staff confirmed that they receive training in adult protection procedures. Staff are aware of the indicators of abuse and confirmed that they would report any suspected incidents of abuse to the Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 17 manager. The has been one Adult Protection procedure invoked since the last inspection. The manager and providers followed the Local Authority protocols Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 18 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, 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained. The standard of cleanliness through out the home was good. EVIDENCE: From touring the home the inspector was able to determine that the home is well maintained. All bedrooms are for single occupancy. Residents at Southview are encouraged personalise there rooms with their own belongings. Rooms at Queens Lodge are decorated and furnished to a good standard. Communal areas in both sections of the service are bright cheerful and welcoming. Systems are in place for the disposal of clinical waste. Laundry facilities are appropriate for the needs of current residents. The home is clean and free from offensive odours. Queens Lodge DS0000014675.V293349.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): 32, 34, 35 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent staff. Staff were relaxed, confident and knowledgeable with regards the needs of residents. A recruitment process is in place. EVIDENCE: The staff recruitment records for Southview were not reviewed, as there have not been any new employees since the last inspection. Recruitment records for Queens Lodge were reviewed. The recruitment process is managed from the head office. A new/vacant post is advertised in the local papers, application forms are required to be completed. Staff short-listed are invited for an interview. References and an enhanced Criminal Records Bureau check are sought. It was noted that one staff member employed only had one reference on file, the inspector advised Ms Lucus that although the recruitment process is dealt with at head office it is her responsibility as a registered manager to ensure that all the checks have been received prior to the person commencing employment. . Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 20 Queens Lodge DS0000014675.V293349.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, 39, 42 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home. A quality assurance and quality monitoring system is in the process of being completed. The health, safety and welfare of residents are protected EVIDENCE: Mrs Philpott manager of Southview and Ms Lucus manager of Queens Lodge have both obtained the National Vocational Qualification level 4 and Registered Managers Award. Staff confirmed that they feel supported by management. Regular staff meetings are held and all staff receive supervision that enables them to discuss care and training issues. Both staff spoken with formally and informally confirmed that they feel supported by management. Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 22 Records seen on the day of this inspection indicate that a quality assurance and monitoring system has been undertaken. The information gained from resident, relatives and other stakeholders has been collated and the findings from the internal audit have been collated. A report has been produced. Risk assessments are carried out and training is provided for ensuring safe working practices such as manual handling, fire safety, first aid, food hygiene and infection control are in place and understood. However it could not be demonstrated that all staff working in the section Queens Lodge have received fire safety instruction at the recommended intervals of 6 monthly for day staff and 3 monthly night staff. Maintenance records indicate that annual servicing of boilers, gas supply,water tempretures, maintence of window restictors and security of premises are undertaken. Records of accidents/incidents are maintained and were avilable. Queens Lodge DS0000014675.V293349.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Queens Lodge DS0000014675.V293349.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. 1. Standard YA34 Regulation 19 (b) Timescale for action Two references must be obtained 29/07/06 prior to a new member of staff commencing employment The provider must ensure that all staff receive fire training at the recommended intervals of 6 monthly day staff and 3 monthly night staff. The registered person shall keep the service users plan under review. 29/07/06 Requirement 2. YA42 23 3. YA6 15 29/07/06 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 Queens Lodge DS0000014675.V293349.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Queens Lodge DS0000014675.V293349.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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