Inspection on 02/06/08 for Tavey House

This inspection was carried out on 2nd June 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Tavey House 4 Grove Road Whetstone Leicester Leicestershire LE8 6LN Lead Inspector Helen Abel Unannounced Inspection 09:50 2nd June 2008 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 Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tavey House Address 4 Grove Road Whetstone Leicester Leicestershire LE8 6LN 01162848606 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) marscsl@gmail.com MARS CARE SERVICES LIMITED Banu Lokat Care Home 12 Category(ies) of Dementia (12), Mental disorder, excluding registration, with number learning disability or dementia (12) of places Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated can be 12 New service 2. Date of last inspection Brief Description of the Service: Tavey House is a detached property that is set back from Grove Road in Whetstone Road in Leicestershire. The service is for 12 residents over 65 years and over with varying degrees of dementia. There is a stair lift for access to the first floor. There are 8 single rooms and 2 twin rooms. There is one shower with toilet, one single toilet and two en-suites on the ground floor. There is one communal bathroom with toilet and three en-suites on the first floor. All rooms are fitted with washbasin and an emergency call system. Residents are encouraged on admission to bring with them ornaments, pictures and any other items to make them feel at home. Pets are not encouraged. Inspection reports will be placed in the hallway. Fees range is from £320.61 to 446.47 with the average at £345. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three people and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. People who live at Tavey House prefer to be called “residents.” Planning for this visit included: Assessing the service history of the home including the reporting of significant events, and surveys received from residents and staff. The Annual Quality Assurance Assessment (AQAA) was made available following on this inspection. This was an unannounced inspection for a new service. The visit started around 10.00 in the morning and lasted around five hours. The home’s Registered Manager was present throughout the visit and the Registered Provider arrived shortly after and assisted with the inspection process. The visit included a selected tour of the building, inspection of records and indirect observation of care practices, and the serving food at a mealtime. The Inspector spoke with five residents, one member of staff and the Registered Provider and Registered Manager. The quality rating for this service is 1 star. This means the residents who use this service experience adequate quality outcomes What the service does well: Each resident is allocated a key worker to work closely with them. There is adequate planning and organisation to meet resident’s health and personal care needs. Residents told us: “I watch the racing and football. I order a paper and read this each day. My family is made welcome and offered a drink”. “I choose what I want to wear each day.” “I love every meal. They are good cooks here.” Residents have the opportunity to experience a range of preferences and activities and receive varied and balanced meals. Residents have been involved in the decision making to choose final designs and colour schemes of carpets, curtains and easy chairs. These items are soon to be purchased. All bedrooms and bathrooms viewed were personalised with Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 6 resident’s belongings and cleaned to a high standard. The home was fresh and airy with no odours. The Registered Manager is at the home most days on shifts with staff providing care to the residents. The Inspector observed warm and friendly interactions between staff and residents. Residents told us, “ The staff are very good” “ I am well looked after by the staff” What has improved since the last inspection? What they could do better: Care plans to be updated. These improvements will help provide better health and personal care for each resident. Any staff that have responsibilities for administering medicines must receive accredited medication training. This will protect resident’s health care needs. To ensure protection of residents - a controlled drugs cupboard should be purchased in line with new legislation around the safe storage of controlled drugs. Providing adult protection training for care staff will help to prevent residents being harmed or placed at risk of harm. Wheelchair footrests must be provided for the safety and welfare of the individual when using a wheelchair (unless specified by the resident) and should be recorded in their risk assessment. Procedures and practise around infection control to be improved for the health and safety of residents. Resident’s needs to be met by care staff being employed in sufficient numbers and with the appropriate skill mix to work at Tavey House. To ensure residents are supported and protected by the homes recruitment policy and practices, all staff must be properly recruited and fit to work at the home. Staff recruitment records must be held in the home. This will ensure residents best interests are safeguarded. To enable prospective residents to make an informed choice about admission to the home the Statement of Purpose and Service Users Guide to be updated; and copies kept in the home. To ensure residents are kept protected and their complaints are taken seriously, the complaints procedure should be updated. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 7 To minimise risks to residents the laundry area must be made secure, as easy access to cleaning agents could be a potential hazard to residents. A staff training plan to be developed to promote and make proper provision for the health and welfare of residents at Tavey House. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 8 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 Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process meets the needs of people admitted to the home, prior to admission; but additional written information would enable prospective residents to make an informed choice about moving into the home. EVIDENCE: The Statement of Purpose and Service User Guide is in the process of being updated. The Inspector gave some guidance around this. The Registered Provider Mr Jawa agreed to include in the Statement of Purpose a summary of the complaints procedure, revise the staffing structure, include room sizes and ensure his name is included as a point of contact as the Registered Provider. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 10 He agreed in future copies of the Statement of Purpose and Service User Guide will be held in the home. There have been no new admissions since the Registered Provider brought the home in March 2008. The admissions procedure is clearly outlined in the Statement of Purpose. This information will help new residents make a choice about whether or not the home is suitable and able to meet individual and particular needs. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is adequate planning and organisation to meet resident’s health and personal care needs. EVIDENCE: Each resident was allocated a key worker to work closely with them. Care plans included a photograph of the individual, daily records, some risk assessments and some health records. Risk assessments and monthly reviews need updating and to start a regular weighing programmes for residents. These improvements will help towards better health and personal care, which each resident will receive. The Registered Provider showed the Inspector new blank care plan formats that will be used over the next few weeks by care staff. They had room for sufficient detail that will cover every aspect of care Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 12 required for residents. The Inspector recommended including information around sexual orientation, dietary needs and allergies. The Registered Manager is responsible for the administration of medication and medication records which were in satisfactory order. The Registered Manager must undertake some accredited medication training to ensure residents are well protected. The Registered Provider is currently in discussions with the Community Pharmacist around purchasing a new storage cupboard for medicines. The Inspector recommended a controlled drugs cupboard be also purchased as new legislation has been introduced around the safe storage of controlled drugs. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to experience of a range of preferences and activities; and receive varied and balanced meals. EVIDENCE: Residents were observed sitting together in the lounge, watching television and in the afternoon colouring and drawing. Residents had recently been to visit a garden centre and had been to the local pub for lunch. Residents are able to follows their religious beliefs and attend services when they wish with support from carers. Residents told us: “ I watch the racing and football. I order a paper and read this each day. My family is made welcome and offered a drink”. “I choose what I want to wear each day.” Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 14 The Inspector observed residents were dressed individually smartly and comfortably ladies with tights and stockings and accessories and men with shirts and pullovers and trousers. Residents had hot drinks mid-morning of tea, coffee and biscuits. The Inspector suggested residents are allowed to choose their biscuit from a plate (where possible). The Registered Provider confirmed a new large teapot would be purchased this would ensure drinks are served hot to residents. A resident was late for breakfast and was provided with a tray of breakfast with a small teapot of tea, toast and butter served separately for spreading. One resident was observed setting the dinner table, with mats and cutlery. Equipment such as plate guards to help individual residents independence were in place. Residents are offered a choice at each mealtime and meals are freshly prepared. Residents spoken with confirmed the meals were good. Residents told us: “I love every meal. They are good cooks here.” “ Good meals.” “Lovely meals here.” The Inspector suggested some improvements around portion sizes, offering gravy boats and condiments on the table. In addition to ensure staff sit down with residents when assisting them at mealtimes in line with good practise. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Residents tell us they are satisfied with the service and feel they would be able to complain to staff. There are reduced opportunities for training staff around adult protection and has the potential to put residents at risk. EVIDENCE: Two residents confirmed on a survey, “If the food is not good, I will make a complaint to the person in charge.” “No complaints to make at all.” Another resident told the Inspector, “They are good here, no complaints.” The Registered Provider agreed to make a complaints record in case a complaint is received. To date no complaints have been received, or made by outside agencies. The home is reminded to update their complaints procedure in the Statement of Purpose and Service User Guide. The Registered Manager has received adult protection training and is aware of the local reporting adult protection procedures. Care staff have not received any recent adult protection training. Providing such training will help to prevent residents being harmed or placed at risk of harm. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with clean and comfortable surroundings; however failure to attend to the control of infection has left residents at risk. EVIDENCE: The home is under major refurbishment over the next 3 months with new ground floor carpets being fitted and easy chairs purchased and paint work and repairs being undertaken. Residents have been involved in the decision making to choose final designs and colour schemes of carpets, curtains and easy chairs. A resident was keen to tell the Inspector about the different changes happening in the home. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 17 The wall lighting in the main lounge needs some adjustment as this area appeared dark in the morning whilst six residents were sitting there. The Registered Provider will be replacing light bulbs accordingly. The Registered Provider will be redecorating the central fireplace in the lounge and make it the centre of interest so that the lounge is brighter and more comfortable for residents to spend time in. All bedrooms and bathrooms viewed were personalised with resident’s belongings and cleaned to a high standard. The home was fresh and airy with no odours. A resident was observed being moved around without footrests on the wheelchair. Footrests must be provided unless specified by the residents and should be recorded in the residents risk assessment. This will ensure the residents safety and wellbeing. The laundry area must be made secure, as this area was open when the Inspector visited with easy access to cleaning agents that could be a hazard to residents. Procedures around control of infection were inadequate with staff wearing the same aprons for personal care, cleaning and food preparation duties. This has the potential to spread infections to residents and staff. The Registered Provider accepted and agreed to rectify this immediately. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and staff training needs to be improved to adequately meet resident’s needs. EVIDENCE: Residents told us, “ The staff are very good” “ I am well looked after by the staff” The Inspector observed two staff on duty over the visit. The Inspector observed staff were warm and friendly and attentive to residents needs. For periods one staff member was working alone attending to residents needs. At these times cleaning and cooking duties were taking up more time, than time spent with the residents. The Registered Provider confirmed staffing levels will soon be increasing and had already been analysing busy and quiet periods in consultation with staff. There are no agency staff or trainees but one person is working as a volunteer. The Inspector advised a proper recruitment process in undertaken to ensure Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 19 residents are supported and protected by the homes recruitment policy and practices. Some recruitment records could not be examined as the Registered Provider held them outside the home. The Registered Provider was reminded recruitment records must be held in the home and is available for inspection. New Providers purchased the home in March 2008. Managers are in the process of drawing up a plan of training for staff and are compiling suitable training resources. Staff have not been on any recent training. One staff member confirmed in a staff survey: “I would like our manager to let us know how we work, and if they are happy with our work and how we can improve.” Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health and welfare is adequate with improvements being planned. EVIDENCE: The Registered Manager is an experienced qualified social worker and is also a Director of the home. She is at the home most days on shifts with staff providing care to the residents. Mr Jawa is the Managing Director and comes to the home regularly each week. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 21 The home is looking to develop a quality assurance monitoring systems to ensure the home is run in the best interests of the residents. The Registered Manager is responsible for leading quality care and monitoring the progress. The homes Annual Quality Assurance Assessment is in the process of being developed and will be sent onto the Commission for Social Care Inspection for review. Safe working practice checks were not examined. These aspects will be examined further at my next visit to the home. There are currently no resident’s monies being held by the home. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 22 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 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x x 2 x x x 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x x 2 x Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/a STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Care plans to include: updated risk assessments and monthly reviews; regular weighing programmes for residents. These improvements will help provide better health and personal care for each resident. Staff that have responsibilities for administering medication to receive accredited medication training. This will protect resident’s health care needs. Providing adult protection training for care staff will help to prevent residents being harmed or placed at risk of harm. Wheelchair footrests must be provided for the safety and welfare of the individual when using a wheelchair (unless specified by the resident) and should be recorded in their risk assessment. Procedures around control of infection were inadequate and have the potential to spread infection to residents and staff. Better procedures for infection control and understanding and DS0000071637.V364496.R02.S.doc Timescale for action 02/07/08 2 OP9 13 02/07/08 3 OP18 13 02/09/08 4 OP22 23 02/07/08 5 OP26 13 02/06/08 Tavey House Version 5.2 Page 24 6 OP27 18 7 OP29 19 8 OP37 17 practise – with the use of protective clothing, and improved hand washing is now required. Resident’s needs to be met by 02/07/08 care staff being employed in sufficient numbers/appropriate skill mix to work at Tavey House. To ensure residents are 02/07/08 supported and protected by the homes recruitment policy and practices. The identified person must be recruited properly and fit to work at the care home. Staff recruitment records must 02/07/08 be held in the home for all persons employed. This will ensure residents best interests are safeguarded. 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 Refer to Standard OP1 Good Practice Recommendations To enable prospective residents to make an informed choice about admission to the home the Statement of Purpose should be updated. To include: a summary of the complaints procedure, revise the staffing structure, include room sizes and ensure the Registered Provider is included as a point of contact; and to keep copies of the Statement of Purpose/Service User Guide in the home. To ensure individual’s needs are recognised and met, care plans and the delivery of care to include: Sexual orientation, dietary needs and allergies. To ensure protection of residents - a controlled drugs cupboard should be purchased in line with new legislation around the safe storage of controlled drugs. To ensure residents are kept protected and their complaints are taken seriouslyA Record of Complaints should be held and include details of investigations and any action taken. DS0000071637.V364496.R02.S.doc Version 5.2 Page 25 2 2 3 OP7 OP9 OP16 Tavey House 4 5 OP26 OP30 The complaints procedures should be altered to give the complainant the choice of the initial stage to go to the investigating body-the local social services department- now the lead agency for investigating complaints- as well as the home. Ensure the complaints procedure includes an assurance that they will be responded to within a maximum of 28 days. Ensure the correct name and address of the Commission for Social Care Inspection is included. To minimise risks to residents the laundry area must be made secure, as easy access to cleaning agents could be a potential hazard to residents. A staff training plan is developed to promote and make proper provision for the health and welfare of residents at Tavey House. Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tavey House DS0000071637.V364496.R02.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!