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Inspection on 05/01/06 for St Anne`s Alcohol Services - Leeds

Also see our care home review for St Anne`s Alcohol Services - Leeds for more information

This inspection was carried out on 5th 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 found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users are given clear information about what to expect and what is expected of them when they enter the home. There are regular meetings between the manager and service users which keep people informed and allow them to express their views. Daily records are detailed. The structured programme of rehabilitation provides focus and end to aim for. A daily timetable helps people to use their time productively and to develop new skills and interests. Service users were satisfied with the food and enjoyed the opportunity to make their own drinks and snacks. Ex service users work in the home as volunteers, run health education groups and an `in touch` group for other ex service users. This provides support for people after they have completed the rehabilitation programme.

What has improved since the last inspection?

The organisation has employed a group therapist and has been able to reintroduce this service one day a week. Four nurses have been recruited, one to take on the role of clinical nurse manager and who will deputise in the absence of the manager. Once all the nurses are in post the home will have a permanent team. The home has come to a service agreement with the CMHT pharmacy who have agreed to continue to provide for their medication needs.

What the care home could do better:

The care plans for people going through the 13 week rehabilitation programme were pre printed. This made them general in content with no evidence in the care file to show the programme of care agreed with each individual and no agreement about risk management. The organisation is aware of the benefits of a more permanent arrangement for GP support and is making efforts to generate interest from across the city. The nurses felt that some aspects of the medication system could be improved. When the limited communal space is in use service users who smoke have to stand outside in all weather. The dignity and privacy of people on the detoxification programme could be compromised by groups pf people gathering in the entrance hall outside the nurses office. It is appreciated that the organisation hopes in the long term to be able to use the rooms in Ashton House. In the meantime this area should be thoroughly cleaned to combat any lingering odours. Some redecoration work is needed in the food storage area of the kitchen. There must be photographic proof of identity for staff employed in the home.

CARE HOME ADULTS 18-65 St Anne`s Alcohol Services - Leeds Ashton House 186 Woodhouse Lane Leeds West Yorkshire LS2 9DX Lead Inspector Sue Dunn Unannounced Inspection 5th January 2006 11.00 St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 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 St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Anne`s Alcohol Services - Leeds Address Ashton House 186 Woodhouse Lane Leeds West Yorkshire LS2 9DX 0113 2434486 0113 2451526 detox@st-annes.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) St Anne`s Community Services Mr Jonathan Philpott Care Home 27 Category(ies) of Past or present alcohol dependence (27) registration, with number of places St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 Brief Description of the Service: Leeds Alcohol Service provided by St Anne’s is situated in St Marks House, a large two storey detached Victorian house. Three of the 20 beds are currently used for acute detoxification and 17 for rehabilitation. This has been a reduction in the overall service due to the withdrawal of funding by the PCT. Offices, medication room and training rooms remain in the adjoining Ashton House. The purpose of the service is to provide acute nursing care and a structured programme of rehabilitation for people with alcohol related illnesses and associated problems. The care home is well located in the university area of Leeds within walking distance of the city centre. A fence around the property creates safe sitting areas for the service users. There is a small area for visitor parking in front of the building. All bedrooms are below the minimum size requirement but all offer single accommodation and are regarded as fit for purpose. St Marks House has two lounges, dining room and a games room, which offer communal space. A bedsitting unit offers a stepping stone for people preparing to move back out into the community. Meals are provided from a central kitchen in St Marks House with facilities to enable people to make their own drinks and snacks. The service has a trained nurse on duty for 24 hours working in partnership with a team of experienced alcohol support workers. The registered manager, who is not a nurse, has overall responsibility for the service. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced inspection carried out by one inspector. The purpose of the inspection was to ensure the home was operating and being managed in the interests of the service users. There were 16 people in the rehabilitation unit and two working through the detoxification process on the day of the inspection. There have been three additional visits to the home since the last inspection due to the reorganisation of the service following funding cuts. Two were to look at the changes to the premises and one to attend a monitoring meeting. The manager and organisation have made adjustments to the way the home operates in an effort to continue to provide a service following funding cuts. The situation is improving as a permanent team of nurses including a clinical nurse manager have now been appointed. There are still concerns about the reduced number of beds available for detoxification. What the service does well: Service users are given clear information about what to expect and what is expected of them when they enter the home. There are regular meetings between the manager and service users which keep people informed and allow them to express their views. Daily records are detailed. The structured programme of rehabilitation provides focus and end to aim for. A daily timetable helps people to use their time productively and to develop new skills and interests. Service users were satisfied with the food and enjoyed the opportunity to make their own drinks and snacks. Ex service users work in the home as volunteers, run health education groups and an ‘in touch’ group for other ex service users. This provides support for people after they have completed the rehabilitation programme. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 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 St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 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): 2,5 The pre admission assessment process is suitable for the service provided. EVIDENCE: A member of the home’s staff completes an initial contact form to gather factual information about the referral. An appointment is then made for the person to attend a meeting at the home to discuss his/her needs and what will be expected. A more comprehensive assessment is done on admission which includes details of personal circumstances, problems and drinking patterns. Each person who remains for rehabilitation signs a licensing agreement which sets out the terms and conditions of occupancy. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 9 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): 6,7,8,9,10 Residents are treated with dignity and their privacy and rights are supported as long as this does not place other people at risk. Staff show an awareness of the residents’ needs but this is not fully evidenced in the care files. The home has good systems for consultation with residents. EVIDENCE: People who enter the home for the detoxification programme follow a standard pre printed care plan process of interventions which start with 15 minute observations and move into different phases of care as the person is recovering. The two care files inspected for people on the rehabilitation programme also had a pre printed standard care plan format. However, as there was no detail of the planned weekly programme of activities agreed with each individual in the files there was no point of reference to know how each person’s plan of care was progressing. The residents have a copy of this but a copy must also be included in each file with comments to provide evidence that particular areas of risk have been identified and to show what has been agreed to minimise risks. Regular progress records were good but did not show what St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 10 alternatives had been organised when planned events had been cancelled due to staff sickness. The manager has regular meetings with residents which inform people of changes and to allow people to express their views. People who sign up to the rehabilitation programme are expected to participate in all aspects of life in the home, including cleaning. The rehabilitation programmes are structured towards this end. The home provides clear guidelines for behaviour which are aimed at helping people to take control and responsibility for their own lives and stop drinking. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 11 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): 11,12,14,16,17 Residents are expected to be part of the decision making process and become involved in activities which help them make changes to their lifestyle. The staff, with the help of volunteers, offer health and emotional support and training opportunities. A good, varied and nutritious diet is provided which takes account of different tastes. EVIDENCE: Residents spoke of and were seen to be involved in activities which helped them to manage their time. This can involve domestic tasks, social activities, computer skills, voluntary work and college. One part of the programme is designed to help people to learn basic cooking skills. A period of leisure time is set aside at the end of each day which people can use as they choose. A Christmas party was enjoyed on 21st December but was said not to have attracted the number of guests as the previous year. The Christmas period was seen as a relaxed time which gave opportunity for people to develop their social skills St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 12 A group therapist visits the home for one day a week. The approach and helpfulness of this was said to be less effective than when a counsellor/therapist was part of the staff team. The manager has tried to compensate for this by introducing a ‘named worker’ for each resident who is available to talk to and give support between sessions. The menu offers a choice, which is based on feedback from residents. One person said the food ‘can’t be faulted’. It was described as ‘very good’ and ‘plentiful’ with fresh fruit always available St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 13 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): 19, 20 Residents physical and emotional care needs are met but this is not fully evidenced in the care files. The home is making efforts to find a more permanent source for medical support as the present arrangements are satisfactory but not ideal. EVIDENCE: Ex service users visit the home as volunteers and for support through the ‘in touch’ group. This continues to be seen as a valued part of the service. The named worker system gives each service user a member of staff they can approach for support. The staff were described as very understanding and helpful. The nurse talked through the medication system. She and the clinical support nurse feel that the system has improved and is safe but identified some areas which could be improved further when the new deputy nurse manager starts work. Examples were given of confusion between nurses about how the medication sheets should be completed and the storage of medication which people bring into the home. This was described as ‘a grey area’. With the exception of inhalers none of the service users manages their own medication whilst in the home. This is an area for further consideration, subject to a St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 14 satisfactory risk assessment and plan, for people who are preparing to leave the home The home is in the process of completing a service agreement with The Mount pharmacy for their medication requirements. Medical input for support on admission continues to be provided by a locum doctor. The home liaises with the person’s own GP and relevant medical details are faxed to the doctor. All the GP’s in Leeds have been invited to an open day in February in an effort to generate interest in providing a service. People in the rehabilitation unit visit their own GP’s for non emergency treatment and prescriptions which are then photocopied by the home before the medication is collected. This allows the nurses to keep track of the full range of medication each person is on. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 15 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): Not inspected EVIDENCE: St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 16 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): 24,28,30 Systems are in place for the upkeep and maintenance of the building. Some decorative work was needed in the kitchen The bedrooms are ‘fit for purpose,’ though below the minimum space requirements, but the amount of communal space does not compensate for the number of people having to make use of the space. EVIDENCE: The building was not inspected on this occasion but the communal areas seen, which were used by residents, were cleaned to a satisfactory standard. The dining area looked festive with Christmas decorations The integration of people on the detoxification programme into St Marks House continues to be necessary, but not ideal. Two of the bedrooms used for this purpose open onto the main entrance hall. It was evident that there are times when people congregate in this area waiting to speak to a nurse. This leads to a risk that the privacy and dignity of people going through the detoxification programme may be compromised. Communal space has been reduced by the loss of space in Ashton House. It was noted that when the TV lounge, which is the designated smoking area, is in use for planned programmes, people who want to smoke have to stand St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 17 outside the back door. There is a loss of heat from the nearby lounge and no protection in bad weather. The food storage area in the kitchen is in need of redecoration as the paintwork near the ceiling and around the fan needed cleaning and was starting to flake. The fan in this area and the radio needed a thorough clean. There was a faint, but unpleasant, odour lingering in Ashton House. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 18 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): 31,33,34, The skills and experience of the alcohol support workers has provided continuity and back up for the temporary nursing team who have in turn developed their skills. The staff training programme covers topics which help staff to understand and meet the needs of the service users. New staff should receive training as soon as possible which is specific to the needs of the service and the service users. EVIDENCE: The manager described the hard work and loyalty of the alcohol support workers as ‘fantastic’. He said they had used their experience and knowledge to support the agency nurses and provide a partnership for the benefit of the service users. A group therapist has been providing a service to the home for one day a week since mid November to fill the gap left when the last clinical nurse manager left. The service users had mixed feelings about the effectiveness of the present arrangements, which the manager had been made aware of. The recruitment and selection process and documentation for two nurses soon to join the team was found to be satisfactory. Some of the nurses who have St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 19 been employed by the agency have applied for permanent positions in the home. The staff files must include a photograph of each person employed. This was not available. The manager said that the training planned for alcohol support workers is on medication and mental health. The 4 nurses appointed to join the permanent staff team have limited or no experience of working in substance misuse settings. All will be doing the St Anne’s induction training and the homes induction training. All will do a one day alcohol awareness course and will attend training at the Addiction unit on motivational interventions. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 20 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): 37,38,39,41,43 The manager has the skills and knowledge to provide effective leadership and is in the process of obtaining the necessary qualifications to back this up. Staff are well motivated, residents are consulted and their interests are safeguarded though this is not fully evidenced in the care files. The organisation continues to strive to provide a service despite funding cuts beyond their control. EVIDENCE: The registered provider and manager have worked hard to try to continue to maintain a much-needed service for people with alcohol related illness following cuts in funding. It is acknowledged that the present arrangements, are not ideal but, have been necessary for the survival of what is a reduced detoxification service. This has created a waiting list. The manager plans to complete the NVQ4 in Management and Care by March 2006. He will then start a Diploma course in addiction to update his knowledge and skills in this area of care. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 21 The deputy nurse manager, who has been appointed to provide clinical support for the nurses, will also be required to undertake the NVQ4 award in management and develop his knowledge of substance misuse in relation to the care setting. This role is currently being covered part time by a trained nurse from another home in the organisation. The manager provides a firm but open style of management in which service users are consulted and kept informed, as far a possible, about matters affecting the running of the home which may affect their care. The records seen were up to date and securely held. More detail is needed to show evidence of individual care programmes and, if necessary, risk management plans discussed with each resident. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 3 Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 4 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x 2 x 2 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score 3 x 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Anne`s Alcohol Services - Leeds Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 2 x 3 DS0000001352.V273522.R01.S.doc Version 5.0 Page 23 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 YA41YA6 Regulation 15 Requirement There must be evidence in care files of the care plan arrangements agreed with each individual Arrangements must be made to allow sufficient communal space within the home to compensate for the size of the bedrooms and allow a suitable space for people who smoke All areas of the building must be kept free from unpleasant odours and the kitchen storage areas decorated to a satisfactory standard The staff files must contain photographic proof of identity and care files enough detail to provide assurances that the needs of individual service users are being met. Timescale for action 31/02/06 2. YA28 12, 23.(2) e,g,h 31/08/06 3. YA30 23.(2)d 31/02/06 4 YA6YA41YA34, 17 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 24 No. 1 2 Refer to Standard YA20 YA28 Good Practice Recommendations The guidance on medication and its recording should be reviewed and include systems to risk assess and support people towards managing their own medication The present arrangements for using rooms in St Marks House for nursing care should be kept under review. The staff should ensure that the privacy and dignity of people using the detoxification service is not compromised by groups congregating in the entrance corridor adjacent to their rooms. Staff training should include training updates for nurses on medication 3 YA35 St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 St Anne`s Alcohol Services - Leeds DS0000001352.V273522.R01.S.doc Version 5.0 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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