Inspection on 24/10/05 for St Raphaels

This inspection was carried out on 24th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Raphaels 17/10/08

St Raphaels 24/10/06

St Raphaels 02/06/06

St Raphaels 05/04/05

St Raphaels 15/12/04

St Raphaels 14/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 St Raphaels The Butts Brentford Middlesex TW8 8BQ Lead Inspector Mr Gavin Thomas Unannounced Inspection 24th October 2005 11:25 St Raphaels DS0000022900.V254867.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 Raphaels DS0000022900.V254867.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 Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Raphaels Address The Butts Brentford Middlesex TW8 8BQ 0208 560 3745 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Francis Taylor Foundation Sister Clare Casey Care Home 19 Category(ies) of Learning disability (19) registration, with number of places St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service User aged over 65 not by reason of old age Date of last inspection 5th & 6th April 2005 Brief Description of the Service: St Raphaels is situated in a quiet residential area in Brentford. It is close to the Brentford High Street and within easy reach of Hounslow and Chiswick town centres. There are good public transport links close by. The home is one of two on the site, managed by the Frances Taylor Foundation. The other home, Maryville, is for older people and is inspected separately. There is also, on the site, a convent and six flats for Sisters of the Order and staff. The large, well maintained gardens are available to all service users within the complex. There is a Roman Catholic church incorporated in Maryville. The establishment is for nineteen service users with learning disabilities and is arranged in three units. Two units are situated over two floors in Fatima House. St Raphael’s is a large house, which is detached from Fatima House. St Raphael’s has an enclosed courtyard garden. St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five hours and fifteen minutes. During this time, the inspector met with the Registered Manager, two Support Workers, four service users and the Finance Officer. Service users were on holiday from day centres and college. Service users were doing tabletop activities such as puzzles and drawing. It was evident from conversations with service users that they continue to enjoy living at St Raphael’s. One service user said they are very happy at the home. They like the staff and made particular reference to about their positive relationship with the two staff on duty at the time of the inspection. Services users spoke positively about the wide range of day and evening activities they attend. What the service does well: What has improved since the last inspection? The Registered Manager now has part-time administrative support. The home was also in the process of setting up computerised systems including care plans and risk assessments. Although only five out of the twelve requirements made at the previous inspection were fully met, the Registered Manager provided evidence to demonstrate that work had been done towards implementing ten out of the twelve requirements. This included care planning, staff training and developing health and safety records. St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 6 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 Raphaels DS0000022900.V254867.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 Raphaels DS0000022900.V254867.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 Good systems were in place for the assessment and admission of prospective service users. EVIDENCE: An admissions and assessment procedure was in place. This was examined by the Inspector at the previous inspection. The assessment process was satisfactory. Service users representatives are informed in writing of the outcome of the assessment and if the home is suitable in meeting the needs of the service user. Contracts had been devised between the home and service users. The content of the contracts was in keeping with the criteria as set out in Standard 5.2 of the National Minimum Standards for Adults (18-65). The Registered Manager said that the home was in the process of arranging for contracts to be signed by service users representatives. Where possible, service users were also offered to sign their contracts. St Raphaels DS0000022900.V254867.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&9 Although care planning processes had improved, there were elements of care plans examined which still require further details relating to service users assessed needs to maximise consistency of care and service users’ independence. EVIDENCE: The Registered Manager said that care plans are now being generated electronically. A considerable amount of work has been invested in developing care-planning systems. However, it was noted from the care plans examined, that further details are required in service users’ care plans to ensure that all staff are given sufficient information to support service users. This applies to supporting service users both in and out of the home. Care plans must be more specific for service users who have sensory needs and those who require assistance with personal care. The Registered Manager confirmed that serviced users reviews are now being held every six months. The outcomes of reviews were not being recorded. A record of reviews must be implemented to demonstrate any changes required to service users’ care plans and how these changes are to be met. St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 10 Risk assessments were in place for all service users. Risk assessments examined were generic. The same outcomes applied to all service users. All risk assessments must be tailored and recorded in accordance with service users individual needs. The Registered Manager confirmed that there were no concerns with regards to service users’ attempting to abscond from the home. St Raphaels DS0000022900.V254867.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): 15 & 16 Good systems were in place for enabling service users to maintain positive relationships with relatives and significant others. EVIDENCE: The home supports service users in maintaining contact with relatives and significant others. Service users maintain contact with relatives and significant others by phone, post and direct contact. Approximately six service users currently visit relatives away from the home. The home also encourages service users to maintain contact with relatives who live abroad. One service user informed the Inspector that they enjoy spending time with their relatives including family holidays. The Registered Manager explained that relatives and significant others are invited to the home to celebrate special occasions such as birthdays and other calendar events. St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 12 Service users are supported and encouraged to maintain friendships outside of the home. This includes drama groups, youth clubs and discos. One service user said they enjoy meeting up with friends at college. Facilities are provided in St Raphael’s and Fatima House for service users to meet with visitors in private. Bathroom and toilet doors were lockable from the inside and outside. The Registered Manager confirmed that service users receive their mail unopened. The home operates a non – smoking policy. St Raphaels DS0000022900.V254867.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): 18 & 19 Overall, the home does well in meeting service users care and support needs. However, the way in which support needs are recorded needs to be more specific to maximise consistency and continuity of care. EVIDENCE: Services users are supported to maximise their independence and privacy. Where possible, service users are encouraged to make decisions and take control of their lives. One service user confirmed that they are offered a variety of choices. These include food, clothing and activities. The home currently has all female service users. Same gender staff provides personal and intimate care and support. The majority of service users have daily routines and attend college and various external activities. Daily routines are flexible when colleges and day centres are closed for holidays. This was observed at the time of the inspection. As stated in standard 6, although care plans indicate the types of support service users require for personal care and hygiene, in some cases, these details must be more specific to ensure consistency and continuity of care. St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 14 The Registered Manager explained that the Hounslow Community Team for People with Learning Disabilities (CTPLD) continues to provide on going support for service users. Service users have an annual health check and on going primary health care treatments. Service users health needs were set out in their care plans. The Registered Manager confirmed that all service users were registered with a GP. The Registered Manager also reported that there were no concerns with regards to service users accessing primary health care treatments. Health care appointments were recorded on service users files. St Raphaels DS0000022900.V254867.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): 22 & 23 Satisfactory systems were in place for service users safety and protection. The home has done well in developing the complaints procedure and complaints monitoring. EVIDENCE: A complaints policy and procedure were in place. The Registered Manager said that the complaints procedure was recently revised and distributed to relatives and significant others. A simplified version of the complaints procedure was available for service users. A record of complaints was in place. Two complaints were recorded for 2005. Both were in relation to incidents involving service users at their day centres. Complaints are monitored via monthly Regulation 26 visits. An adult protection policy and procedure was in place. The Registered Manager said that there were no concerns regarding service users safety or protection. A staff training course in adult protection was scheduled for December 2005. The home has now obtained a copy of the Department of Health – No Secrets guidance document. St Raphaels DS0000022900.V254867.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, 25 & 30 The accommodation is very well maintained and pleasantly decorated. EVIDENCE: The home was very well kept and clean throughout. The furniture, window coverings and fixtures in both houses were judged to be of good quality. The décor in both houses was bright and cheerful. The roof had been removed from the courtyard garden for safety reasons. The Registered Manager explained that part of the wall in the courtyard garden was also removed for safety reasons. The Registered Manager said that a replacement roof/sheltered area would be erected in the courtyard garden within the next financial year. The home is conveniently located for easy access to Brentford High Street and public transport routes. Off road parking spaces are provided for staff and visitors. The grounds of the home were pleasant and very well maintained. St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 17 Major maintenance finance projections were included in a five year business plan. The Registered Manager explained that on going repairs and renewals are carried out as and when required. In addition to the five year business plan, the home should devise and implement a planned maintenance and renewal programme. All service users are accommodated in single bedrooms. One service user offered the Inspector to view their bedroom. The Inspector was accompanied by the service user and the Registered Manager to view the bedroom. The service user said they were very happy with the accommodation and was pleased to have en suite shower and toilet facilities. The service user confirmed that they were consulted on the colour of the bedroom and selecting the furniture. The bedroom was personalised, well kept and pleasantly decorated. A policy on the control of infection was in place. This policy has been revised and updated since the previous inspection. Laundry facilities are situated on the ground floor of Fatima House and St Raphael’s. Both laundry rooms are situated away from food preparation areas. The home is now in receipt of documentary evidence to confirm that the washing facilities and services comply with the Water Supply (Water Fittings) Regulations 1999. Records examined confirmed this. St Raphaels DS0000022900.V254867.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): 32, 33, 34 & 35 The home has a well-established staff team who have developed positive relationships with the service users. Recruitment and selection processes were satisfactory. However, recruitment checks must be carried out as required under Schedule 2 of the Care Homes Regulations. EVIDENCE: The home has a stable team. At the time of this inspection, there were fourteen staff in post. The staff team consisted of eleven Support Workers and two waking night staff. One domestic staff was due to commence employment in November 2005. Three Support Workers are based in St Raphael’s and eight are based in Fatima House. The home had vacancies for two part time carers. These are additional posts, which have been created in addition to the numbers of permanent staff. Both posts will be advertised within the next financial year. One service user made very positive comments about their relationship with two staff on duty at the time of this inspection. Two staff have achieved the NVQ Level 2 in care. One member of staff was working towards NVQ Level 3 in care and four staff were working towards NVQ Level 2 in care. The Registered Manager said that the five staff were working towards a completion date in February 2006. St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 19 The home has a low staff turn over. The home does not use external agency staff. The numbers of staff on duty at any one time reflect the needs of service users. Service users accommodated in Fatima house have higher dependency needs as opposed to service users accommodated in St Raphael’s. The home is fully supported by external health professionals. Assessments are carried out and referrals are made for service users to access specialist health treatments including counselling, occupational health and neurological treatment. Specialist advice is sought from a relevant, national charitable organisation for service users who are displaying symptoms of disorientation and mild confusion. The Registered Manager confirmed that none of the current service user group have a clinical diagnosis of dementia or Alzheimer’s. Some service users attend the “Speaking Out” group, which is organised by the London Borough of Hounslow. A recruitment policy and procedure was in place. The Registered Manager said that this policy and procedure was being revised and updated at organisational level. Three staff files were examined for the purpose of this inspection. The majority of recruitment checks were in place. However, the following shortfalls were identified: • A recent photograph must be obtained of all staff. • Evidence of a CRB check must be obtained for one named staff. • The Registered Manager should obtain evidence to demonstrate that one staff member who is a non-UK passport holder, has been granted permission by the Home Office to take up employment in the UK. The Registered Manager explained that the Francis Taylor Foundation has now set up a training centre in Liverpool. Although organisational training programmes were in place, a training programme is still required for this establishment to indicate which staff are due to attend training and when. A dedicated training budget was in place. Individual staff training and development assessment and profiles were not in place. These must be devised and implemented. St Raphaels DS0000022900.V254867.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): 39 & 42 The home is making on going progress in developing quality assurance and monitoring systems. The home is required to ensure that fire safety procedures are in place. This includes a fire emergency plan, which had not been implemented since the previous inspection. EVIDENCE: Good progress was being made towards quality assurance and monitoring systems. Quality monitoring surveys had been distributed to service users, their representatives and significant others. The Registered Manager is required to publish the results of these surveys. Monthly unannounced visits are carried out as required under Regulation 26 of the Care Homes Regulations 2001. Copies of reports for these visits are supplied to the CSCI. St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 21 Health and safety and fire risk assessments were in place and reviewed periodically. There were no changes to the way in which these are recorded and monitored. The record of hot water temperatures had been updated since the last inspection. However, this record must still include the appliance tested and the signature of the staff taking the temperature. A legionella test was carried out in February 2005. The outcome was satisfactory. A fire emergency plan was not in place. This requirement had not been met from the previous inspection. As a result, an immediate requirement was issued at this inspection for a fire plan to be devised and implemented by the 24th November 2005. Records indicated that safety checks are carried out on gas and portable electrical appliances. A safety check had also been carried out on the electric hob in St Raphael’s since the previous inspection. Records examined confirmed this. St Raphaels DS0000022900.V254867.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 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 3 2 2 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Raphaels Score 2 3 x x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000022900.V254867.R01.S.doc Version 5.0 Page 23 Yes 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 YA6 Regulation 15(1)(2)(b) Requirement Service users plans must be written in sufficient detail to provide clear guidance to staff on actions to be taken to meet service users health and welfare needs. (Timescale of 31/07/05 Not Met). Reviews of service users plans must be recorded to demonstrate any changes and how these are to be met. All risk assessments must be tailored and recorded in accordance with service users individual needs. Identified goals for supporting service users with personal care tasks must be more detailed to ensure consistency and continuity of care. (Timescale of 31/07/05 Not Met). Recruitment checks must be carried out as follows: • A recent photograph must be obtained of all staff. • Evidence of a CRB check must be obtained for one named staff. DS0000022900.V254867.R01.S.doc Timescale for action 31/12/05 2. YA9 13(4)(a)(b)(c ) 12(1)(b) 31/12/05 3. YA18 31/12/05 4. YA34 19(1)(b)Sch2 (1)(7a,b 31/12/05 St Raphaels Version 5.0 Page 24 5. YA35 18(1)(a) 6. YA35 18(1)(a)(c)(i) 7. YA39 24(1)(a)(b)(2 )(3) The staff training programme must be more detailed indicating the types of training, timescales and staff nominated for the training. (Timescale of 31/05/05 Not Met). Staff training assessments must be devised and implemented. (Timescale of 31/05/05 Not Met). The outcomes of service users surveys must be published. The home must also seek the views of staff and significant others as part of the quality assurance and monitoring system. (Timescale of 31/07/05 Not Met). The record of hot water temperature tests must be revised to include the appliance tested and the signature of the staff taking the temperature. (Timescale of 06/05/05 Not Met). A fire emergency plan must be devised and implemented. (Timescale of 31/05/05 Not Met). 31/12/05 31/12/05 31/12/05 8. YA42 13(4)(c) 30/11/05 9. YA42 23(4)(c) (iii) 24/11/05 St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA24 YA34 Good Practice Recommendations The home should devise and implement a planned maintenance and renewal programme. The Registered Manager should obtain evidence to demonstrate that one staff member who is a non-UK passport holder, has been granted permission by the Home Office to take up employment in the UK. St Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Raphaels DS0000022900.V254867.R01.S.doc Version 5.0 Page 27 - 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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