CARE HOMES FOR OLDER PEOPLE
Stretton Nursing Home Stretton Nursing Home Manor Fields Burghill Hereford Herefordshire HR4 7RR Lead Inspector
Sandra J Bromige Unannounced Inspection 13th December 2005 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stretton Nursing Home DS0000062332.V272937.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Stretton Nursing Home Address Stretton Nursing Home Manor Fields Burghill Hereford Herefordshire HR4 7RR 01432 761611 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) Stretton Care Ltd Care Home 50 Category(ies) of Dementia (50), Dementia - over 65 years of age registration, with number (50), Old age, not falling within any other of places category (50), Physical disability (50), Physical disability over 65 years of age (50), Terminally ill (50) Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 1. Registration is for 50 places on condition that: a) Alterations to the 4-bedded room to create 2 en-suite twin rooms will be commenced within 3 months of registration b) In the meantime no new service users will be accommodated in the room c) The room will be taken out of use when no longer occupied pending commencement of the upgrading. 2. The registration categories for the Home will be transferred as existing on the conditions that Stretton Care Ltd conducts a full review of the service and the statement of purpose in respect of the Home (and hence the necessary categories of registration) within 4 months of registration. 3. During the 4 month review period referred to in Conditions 2 above, service users with care needs associated with dementia illnesses may only be admitted to the Home where these are secondary to the person`s physical care needs. 4. The Responsible Individual will arrange training for himself in respect of local procedures for the protection of vulnerable adults within 3 months of registration. (It is recommended that this be done through the local POVA co-ordinator). 5. Stretton Care Ltd will make arrangements for the Manager to have supervision at least six times a year by someone suitably qualified and trained. These sessions must result in a report to the Provider on the quality of clinical nursing practices in the Home. 6. Stretton Care Ltd will arrange a review of the skills, training and experience of the registered nurses and care assistants employed at the Home. The review, together with an action plan to rectify any deficits identified, will be submitted to the Commission for Social Care Inspection within 3 months of the date of registration. 7. Stretton Care Ltd will review the staffing arrangements to assess their adequacy to meet the needs of the service users. The review, together with an action plan to rectify any deficits identified, will be submitted to the Commission for Social Care Inspection within 3 months of the date of registration.
Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 5 8. Stretton Care Ltd will review progress on requirements detailed in the inspection report from the inspection carried out during September and October 2004. The review, together with an action plan to rectify any deficits identified, will be submitted to the Commission for Social Care Inspection within 3 months of the date of registration. 9. Stretton Care Ltd will carry out a review of the premises (including fire safety arrangements), adaptations and equipment at Stretton Nursing Home. The review, together with an action plan to rectify any deficits identified, will be submitted to the Commission for Social Care Inspection within 3 months of the date of registration. 10. Stretton Care Ltd will carry out a review of the heating, surface temperatures of radiatiors and pipes, water temperature controls and Legionella precautions at Stretton Nursing Home. The review, together with an action plan to rectify any deficits identified, will be sumitted to the Commission for Social Care Inspection within 3 months of the date of registration. 11. The Responsible Individual for Stretton Care Ltd will be present on site at Stretton Nursing Home for the equivalent of 4 working days a week for a minimum of one month from the date of registration in order to establish a working relationship with the Manager and the staff team. Date of last inspection 11th October 2005 Brief Description of the Service: Stretton Nursing Home provides nursing care to 50 people. A range of registration categories are in place allowing a service to be provided to people with physical care needs, those arising from dementia illnesses and people who have terminal illness. The accommodation is provided in a single storey building which is situated in a peaceful rural location just outside Hereford. The building is operated as two wings with independent staff teams and separate communal rooms. Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place between the hours of 10.15 –16.30 hrs on the 13th December 2005. The focus of this inspection was to follow up the requirements and recommendations from the last inspection report. Information has been obtained through observation of parts of the premises, meals, care practice and practice of ancillary staff. Information was also gathered from looking at residents and staff records, and other records in the Home. A number of staff, residents and relatives were spoken with. The Home has been without a registered manager since the end of November 2005 and the Provider is currently advertising for a replacement manager. Since the last inspection a meeting has taken place with the Provider of the Home to discuss with him the findings of the last inspection and the concerns of the Commission about the Home’s non-compliance with National Minimum Standards. The Provider has since submitted an action plan with timescales to show how he will meet the requirements made by the Commission and to ensure that the standards in the Home are improved. The Provider has been very co-operative with the Commission. Since the last inspection in October 2005, two complaints have been received by the Commission about the Home. The complaint investigated by the Commission was alleging poor care practice and about the quality of the food in the Home. Two elements of this complaint were upheld, one partly upheld and two were unresolved. A complaint about a health & safety issue and staff attitude has been referred to the Provider for investigation. What the service does well:
The Home is located in its own extensive grounds in a peaceful rural area. It is a single storey building, which makes its accessibility good for residents using wheelchairs. The Home receives a lot of visitors and the staff make visitors welcome in the Home. The staff were seen to maintain resident’s privacy by knocking on doors before entering the room and making sure that the door is closed when helping the resident with personal care such as washing, dressing and going to the toilet. Residents’ seen appeared comfortable, appropriately dressed for the current climate, and the staff had nicely shaved the men who needed assistance. The resident’s clothes were nicely laundered. Relatives spoken with were all very satisfied with the care and told the inspector that it is “home from home” and the “staff are marvellous”. One resident said the staff are “very good. They are pretty good if you call your Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 7 bell and the night staff are around all time”. The residents know the Provider and see him on a regular basis. Staff were observed assisting residents to eat their lunch in a discreet and unhurried manner. Plenty of adapted crockery for serving meals to physically disabled residents was in use. What has improved since the last inspection? What they could do better:
The Statement of Purpose must be reviewed, as it does not contain the information that is required for prospective residents. Care planning must be further improved so that staff know what to do for each resident and they provide an accurate record of the care given by the staff. The individual care plans must to be reviewed to ensure that the information is
Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 8 up to date. The residents’ and/or their relatives must be consulted about the content of the care plans. Their agreement to the care plan must be obtained. Residents’ must be given the choice of having a same gender carer to carry out intimate personal care. This must be recorded in the residents’ care plan. Activities and interests for residents on an individual basis must be provided by the Home. Staff must find out what each individual resident likes to do or about any hobbies they may wish to carry on with whilst living at the Home. This information must be written down to ensure that all staff know what individual activities the resident enjoys and when they may wish to engage in these activities. The meals provided at lunchtime must be reviewed. Residents must be asked the type of food that they enjoy and must be offered a choice of meal at lunchtime that is suitable, wholesome and nutritious. An identified toilet must be properly cleaned. Staff must be employed correctly to protect the residents at the Home. The owner and manager must establish a system to gather views of the residents, staff, relatives, visitors, visiting professionals and other stakeholders of the community. This information must be used as part of their review of the quality of the service. Hot and cold water storage temperatures must be monitored and recorded as part of the Home’s control and management of Legionella. 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. Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The Statement of Purpose and Service User guide is inadequate and does not provide sufficient information for prospective residents so that they can be clear about all aspects of the services the Home provides, including terms and conditions of residence. EVIDENCE: Revised information has been sent to the Commission since the last inspection. A letter has been sent to the Provider on the 1st December 2005 outlining the information that is outstanding for the Statement of Purpose and Service User guide. The Provider’s action plan received following the last inspection confirms that this document will be completed by the 14th December 2005. Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 Progress has been made on improving arrangements to ensure that the health care needs of residents are identified and met. Further progress is now needed to ensure that there are no shortfalls in identifying residents care needs that may potentially place them at risk. Residents’ are not being given the choice of receiving care from a same gender carer so that their dignity is respected at all times EVIDENCE: Two identified care records were seen during this visit. The standard of the recording in the care plans is much improved. Records are being reviewed on a monthly basis. Further improvements are needed to ensure that they accurately reflect the current care needs of the resident as an identified resident was prescribed a food supplement due to having a poor appetite and this had not been included on the Medication Administration Records or in the resident’s care plan. The mobility care plan had not been updated to show the current care needs of an identified resident and an identified problem with elimination of urine had no documentary evidence that it had been followed up by the nursing staff. Moving & handling risk assessments must be fully completed when reviewed to show the score and risk rating and acute care plans need to be reviewed at
Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 12 least monthly or more often as required. One section of a care plan had not been reviewed since December 2004. There is no information showing that the care plans are being written with the involvement of the resident or their next of kin or that they agree to the content. Male and female carers are employed by the Home. A female resident when asked what changes she would like to see at the Home responded by saying that she would like to have female carers only for any assistance with personal care. Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Improvements have been made to the quality, variety & choice of food served in the Home since the last inspection. A varied menu is still not being provided at lunchtime to enable the residents to exercise choice and control over what they eat. Group activities are being provided by the Home 2-3 days each week for the enjoyment and stimulation of residents. Individual programmes of activities are not in place for residents to meet their individual social care needs and interests. EVIDENCE: A board is now in place in one dining room in the Home showing the menu for lunch, teatime, and supper, including any activities in the Home for that day. Lunch on the day of the inspection was Shepherds pie, brussel sprouts, cauliflower followed by a dessert of lemon tart and custard. The menu did not show any alternative choices available for lunch, although the cook reported that alternatives are available. Residents’ when asked did not know that they could ask for an alternative meal at lunchtime. The Inspector was told, “the food is quite good” there is “no choice, if you don’t like it you go without”. The menus for suppertime have been revised and residents have been consulted about the choice of food that they would like to see on the menu at suppertime. A comments & complaints book has been set up by the cook for the care staff to record any comments made by the residents each mealtime. This is good practice.
Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 14 Group activities are now being provided in the Home 2-3 days each week. On the afternoon of the inspection the Home were holding there carol service followed by sherry & mince pies. The event was very well attended. Residents’ said that they “enjoy the bingo each month, the chocolate tasting & Christmas gift demonstrations”. “There is plenty to keep you occupied” and “they can see what is on by the posters” and “staff also tell them”. A programme of group activities is now in place in the Home. Residents attendance at various activities are being recorded in their individual care plans. There is no evidence of any individual programmes of activities for residents being in place at the Home. Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The Home is failing to protect residents from potential harm. EVIDENCE: Since the last inspection the Provider and 13 staff at the Home have received adult protection training from the local coordinator for Protection of Vulnerable Adults in Herefordshire. Further training is now required for all remaining staff. Robust recruitment procedures are not in place for the protection of residents living in the Home. Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 26 All residents do not have access to a call bell to ensure that they are able to call for assistance when needed. The majority of the Home is clean, pleasant and hygienic. EVIDENCE: Call bells are available in all rooms in the Home. Two identified residents did not have access to the call bell when sat in a communal lounge area as the inspector was asked to find staff to take them to the toilet. The standard of hygiene in an identified toilet needs attention. This has been brought to the attention of the Home on two previous occasions and the nurse in charge of the Home was advised and shown the lack of cleanliness of this toilet at the conclusion of this inspection. Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 29 Sufficient staff are provided to ensure that the health care needs of the residents are being met. The procedures for the recruitment of staff are not robust and do not offer protection to residents living in the Home. EVIDENCE: On the day of the inspection there was a registered nurse and 4 care staff on duty in the Corridor unit for 22 residents and a registered nurse and 2 care staff on duty in the Woodlands unit for 15 residents. An additional carer should have been on duty, but had called in sick that morning. Catering and domestic staff were also on duty. An administrator and a maintenance person were also at work in the Home. Two staff files show that recruitment practice remains poor: • Both staff member had started work in the Home prior to receipt of the PoVAfirst check. • There was no application form for one employee. • Only testimonial style references had been accepted for both of these staff. One reference had been translated into English by the recruitment agency and a handwritten note indicates that they were unable to understand the entire document. • There was no information to show that the authenticity of these ‘To whom it may concern’ testimonials had been checked and there was no information to show the Home had verified the reason why they had left their previous employment. • There was no evidence to show that either of these staff had been interviewed by the Home.
Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 18 • • There is no documentary evidence of their qualifications There was no evidence to show that a gap in a curriculum vita had been explored. Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 Further improvements have been made in the Home in order to promote and safeguard the health, safety and welfare of the residents using the service. EVIDENCE: Since the last inspection the Provider has reviewed the Home’s fire risk assessment and sent a copy to the Commission. All wheelchairs in use on the day of the inspection were fitted with two footrests which were seen being used by staff at all times when transporting residents’. A maintenance programme for wheelchairs has been set up and they are now being cleaned and checked on a regular basis with records being maintained of this work. The Provider has written to the Commission advising that a contract has been set up with a specialist company for the management and control of Legionella in the Home and the first visit is due to take place in January 2006.
Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4, 5 Requirement Timescale for action 14/12/05 2 OP1 2 OP7 3. OP7 4 OP7 The Statement of Purpose and Service User guide must include all the information set out in Schedule 1 and Regulation 5 of the Care Homes Regulations 2001 and Regulation 5a (Care Homes (Amendment No. 2) Regulations 2003. Timescale of 30/11/05 not met. 6 A copy of the revised Statement of Purpose & Service User guide must be forwarded to the Commission. 12, 15 Care plans must be established as true working documents and used as tools to inform care staff as well as registered nurses about the individual needs of each resident and how these are to be met. Timescale of 30/11/05 not met 12, 13, 15 The care plan for each person must be reviewed to ensure that all information is up to date. Timescale of 30/11/05 not met. 15 Residents and/or their next of kin must be consulted about the content of the care plan. Their
DS0000062332.V272937.R01.S.doc 31/12/05 31/01/06 31/01/06 31/01/06 Stretton Nursing Home Version 5.0 Page 22 5 OP10 12 6 OP12 12, 16 7. OP15 12, 16 agreement to the content of the care plan must be sought and recorded. Residents’ must be given the choice of same gender carers when carrying out intimate personal care. Activities must be provided in the Home on an individual basis. Residents must be consulted about the type of activities they would like and this must be recorded in their individual care plans. Brought forward amended as timescale of 31/10/05 only partly met. Menus must be provided that are suitable, wholesome and nutritious and a choice of food must be available for residents each mealtime. Timescale of 30/11/05 partly met. All staff must receive training on the Herefordshire procedures for adult protection. The standard of cleanliness in an identified toilet must be improved. Timescale of 31/10/05 not met The registered Provider must ensure that recruitment practice at the Home fully complies with statutory requirements with regard to references, Criminal Record Bureau checks and Protection of Vulnerable Adult checks. Timescale of 21/10/05 not met Staff must not be employed to start work in the Home unless all documents required under Regulation 19 & Schedule 2 have been obtained. Timescale of 21/10/05 not met. Staff must not commence
DS0000062332.V272937.R01.S.doc 31/12/05 28/02/06 31/01/06 8 9 OP18 OP26 13 23 28/02/06 23/12/05 10 OP29 19 31/12/05 11 OP29 19 31/12/05 12 OP29 19 31/12/05
Version 5.0 Page 23 Stretton Nursing Home employment until a minimum of a Protection of Vulnerable Adult first clearance has been obtained alongside all other elements of Regulation 19 & Schedule 2. The identified staff must be supervised at all times until receipt of Protection of Vulnerable Adult first clearance. Timescale of 21/10/05 not met 13 OP33 12, 21, 24 The registered Provider must establish systems for reviewing the quality of the service provided at the Home including consultation with residents, relatives and staff. Brought forward not assessed. 13 Hot and cold water storage temperatures must be monitored and recorded as part of the control and management of Legionella. Timescale of 30/11/05 not met 31/01/06 14 OP38 31/01/06 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 Stretton Nursing Home DS0000062332.V272937.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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