Inspection on 06/09/07 for The Leys

This inspection was carried out on 6th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Leys 02/10/08

The Leys 18/12/06

The Leys 14/10/05

The Leys 09/05/05

The Leys 28/02/05

The Leys 19/08/03

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 The Leys Park Lane Sharnbrook Bedfordshire MK44 1LX Lead Inspector Andrea James Unannounced Inspection 6th September 2007 10:00 The Leys DS0000014926.V350173.R01.S.doc Version 5.2 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 The Leys DS0000014926.V350173.R01.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 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. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Leys Address Park Lane Sharnbrook Bedfordshire MK44 1LX 01234 781982 T/F 01234 781982 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) Lansdowne Care Services Mr D A Diemer Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th December 2006 Brief Description of the Service: The Leys is a large six-bedded bungalow and self contained two-bedroom flat set in countryside on the outskirts of Sharnbrook. The home can provide residential care to eight adults with learning disabilities including those with physical disabilities. The home is staffed over a twentyfour hour period and is adjacent to a day care facility. All accommodation is on one level and there is ramped access to the buildings. Sharnbrook is about fifteen minutes drive from both Rushden and Bedford and there is a bus service to both towns. The service has its own transport, which assists service users in accessing facilities in both the village and nearby towns. The fees for this home vary from £1,050.00 to £1,782.67 per week. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out on the 6th of September 2007. The inspection was carried out by Andrea James, with the full cooperation of the Registered manager. The inspection process lasted for duration of 6 hours. The inspection process followed a case tracking methodology where a sample of three people using the service was case tracked. The inspector inspected their files and where possible spoke to the users and the care staff involved in their care package. The inspection report also consists of information received from the AQAA (Annual Quality Assurance Assessment), surveys and other evidence collected by the Commission since the last key inspection. The inspector would like to thank the people using the service, care staff and the registered manager for their co-operation in the inspection process. What the service does well: The home provided a safe and comfortable environment for people using the service. They encouraged feedback from users and their relatives through regular family days and other forums. The home used various external agencies to support them in the service they provided to users. The home had a stable staff team that ensured the users were able to maximise their independence in the way they lived their lives. The users spoken to all said they enjoyed living at the Leys. One user said “ staff treats me well”, he explained that they took his temperature when he had a cold and helped him to clean his room. The people using the service explained that they were able to access the community to pursue leisure activities. The manager said all staff were drivers and they had access to three buses, so users could pursue any activity they liked, to include various day centres and college placements. Care staff explained that they also took users to visit their relatives on a regular basis. The home was also good at the way they order and administered medication to the users. They are very careful about making sure they order everything each user needed and then keep records of when they had given them out so everyone knew that it has been done. This is considered good practice because it means all users receive medication when they should to maintain their health. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The service should ensure that: • • People using the service do not pool money for the use of the transport. Evidence of satisfactory and up to date Criminal Record Bureau Checks are available in the home for inspection. All medication kept in the home including PRN are clearly labelled with prescribers instructions. • 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. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 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 The Leys DS0000014926.V350173.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Systems were in place that ensured perspective users were provided with sufficient information that enabled them to choose whether or not they wanted to use the service and they received satisfactory assessments, as a result users were able to make an informed decision about using the service. EVIDENCE: The home had a Statement of Purpose and Service User Guide, which was available to all users of the service. The home carried out full assessments on all potential users that were reviewed and updated on a regular basis. The inspector viewed a user’s file that had recently moved into the home. The files contained an initial assessment documentation with guidelines and objectives for meeting the needs identified in the assessment documentation. The records suggested this user was able to have an average of 130 hours where he visited the home for tea stays and overnight stays that formed a part of his transition to the home. There was evidence that he received a review of his care and the family were involved in the settling in period. On the day of the inspection the user The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 9 appeared unsettled and the manager and family members were seen to work together for the benefit of the user. The assessment and objective documentations were signed and dated by key workers and managers and where possible users were consulted about the service delivery. The home has had new contracts for people using the service but most users found it difficult to understand and therefore were reluctant to sign. The home has involved advocates and family members to assist in the process. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8&9. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. Satisfactory systems were in place that enabled people using the service to have their needs and choices met through effective care planning, risk assessments and consultation, as a result users were able to maximise their independence in achieving their personal goals. EVIDENCE: The home had effective care planning procedures for people using the service. The care plan documentations inspected suggested that the needs of the people using the service were reviewed on a monthly basis with the involvement of the user and various external professionals. The key workers ensured that the needs identified were highlighted using objectives and clear guidelines that should ensure consistency among the staff team. Staff spoken to appeared knowledgeable about the needs of people using the service. There was evidence that one user who had the ability was responsible The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 11 for writing her review and communicating her needs which were reflective in her care plan documentation. The documents suggested that users were also enabled to take calculative risks in maintaining their independence as individuals. All users engaged in activities outside the home. The inspector was able to speak to several of the users who attended the near by day centre. Other users attended colleges and various community resources. The manager said all the staff were drivers and as a result users were able to access the community more readily. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,16 &17. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Good systems were in place that ensured people using the service were able to maximise their independence in the way that they chose, as a result users lived a fulfilled lifestyle. EVIDENCE: The home separated 2 of the users who lived independently in a flat near by. These users more than the others clearly had opportunities for personal development and could live with less staff support. One user spoken to had the potential to move on and this was identified by the home. As a result various guidelines and contracts were implemented to enable the user to take calculated risks. Other users in the group home were also given opportunities to develop. One user said he enjoyed washing up and helping with food preparation. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 13 People using the service were able to participate in community activities. Some also maintained links through local general Practitioners, therapists, phyciatrist, family and similar peers. Staff spoke of links with the local community and the home is known in the area enabling residents to participate in a variety of social and educational facilities. The home described throughout its literature the importance of integration into community life; the users who were able use local pubs, shops and parks on a regular basis and the home owns transport to assist in this. Users also helped with caring for the animals at the home, which included ponies, goats and chickens. Entries made within the care records described the social and leisure activities the resident’s had received. Records viewed on the day of inspection indicated that activities that had been provided for example were shopping trips, walks and going out for a pub meal/drink. One person spoke of the contact with their family, they could visit family members at their own home. Documents seen within the individual care records of the users gave clear guidance to staff in how they should support the people using the service in maintaining these close relationships with the family members. A choice of meals was available over the week; menus submitted by the home reflected a varied diet and staff informed the inspector that users were involved in setting the menus in the home and on occasions assisted in the homes ‘ shopping’. The kitchen was seen to be clean and tidy. Users through discussion and through feedback from returned comment cards confirmed that they were satisfied with the food at the home. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Satisfactory systems were in place that ensured users received the personal health care needs they required in the way they chose, however further development was needed to ensure all procedures for medication safeguarded people using the service, as a result users needs could be compromised. EVIDENCE: There were documentary evidence that suggested the home accessed outside healthcare professionals and services as required; in order to meet the healthcare needs of the people using the service. The home was supported by a variety of health and medical advisors through a local clinical resource centre. Medical visits were being recorded separately to daily notes, and a variety of healthcare monitoring charts were in use. The home had satisfactory policies and procedures for receiving, administering and disposing of medication. All staff received medication training both in house and yearly from the pharmacist. The manager informed the inspector that only shift leaders administered medication. The day-to-day medication procedures were satisfactory but further development was needed to ensure The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 15 PRN medication was clearly labelled and in date. There was also a need to ensure tablets kept are not pooled but labelled with users names and dosage from prescibers. Care staff spoken to informed the inspector of the procedures in place that ensured users privacy and dignity were maintained. These were also documented in the care plan documentation. One user spoken to said he liked the way the staff assisted him when having a bath, as they washed his hair and his back. Staff assisted one user who came home for lunch in an appropriate manner. The staff were observed to treat the user in the way that he required. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home had satisfactory complaints and safeguarding procedures in place that protected people using the service, however further development was needed to ensure users are not at risk of financial abuse. EVIDENCE: The homes complaints procedure was noted to give guidance on how to complain, to whom and the timescale for response by the home. One complaint had been received since the homes last inspection. Documentary evidence was seen that showed that the home had responded to the complainant. The home also encouraged users and their relatives to voice their concerns in an open forum, namely in family days or questionnaires. Staff spoken to said they were aware of the complaints procedure, some users when asked said they would complain to the staff or the manager if they were not happy about something. The home had clear safeguarding procedures and the manager had made several (7) referrals regarding a particular user whose behaviour was challenging the service but to date the external forces have failed to act accordingly. The manager was due to have a meeting to decide how best to manage the user in his best interest and that of other users and staff. The manager informed the Commission for Social care inspection of the stages by forwarding copies of the referrals sent to social services. The current position is The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 17 that the home was able to provide a one to one staffing to protect other users but this was due to be withdrawn on the 18th of September 2007. The manager was confident that if satisfactory procedures were not implemented that the home may not be able to meet the users needs. The home had satisfactory finance procedures and most of the procedures for handling users finances were clear , however the home pooled users money for purchasing diesel for the transport. The manager was not able to give a clear audit trail as to how much usage was given to each user and as a result the system needed to be reviewed to ensure fairness to all users. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 &30. People who use this service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The environmental standards were welcoming and comfortable for people using the service. They were all of a satisfactory decorative state and as a result users were able to live in a good environment. EVIDENCE: All accommodation was provided on the ground floor with easy access to all buildings for the people using the service. The home was situated just outside of the village of Sharnbrook in a rural setting. There was a large amount of outdoor space available to the users and this was well kept. Up to six users shared a lounge and dining room in the main building, at the time of this visit five users were living in this part of the home; two other users shared a twobedded bungalow providing its own self-contained accommodation. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 19 One user showed the inspector their individual room. This contained numerous items that helped in creating a homely and personal space for the user. The people using the service indicated that they were happy with their room, which contained photographs, pictures, television, music equipment and ornaments. All areas of the home were safe and users were able to use specialist equipment to access all areas of the home. All the areas seen at the site were noted to be clean and tidy and free from offensive odours. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34, 35 &36. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence, to include a visit to the service. The systems in place for training, recruiting and supervising staff were of a high standard however further development was needed to ensure satisfactory clearances are maintained on all staff files, as a result users best interests could be compromised. EVIDENCE: The home had a stable staff team with a core of 12 staff. The manager was in the process of recruiting two new members of staff. The processes for recruiting were satisfactory and in line with policies and procedures. A check of staff files undertaken to look at recruitment practices suggested that files contained satisfactory proof of identity and references, however two files seen suggested Criminal Record Bureau checks were not available, as a result users safety could be compromised. The training and development procedures in place were satisfactory and all staff records seen suggested that mandatory training was undertaken. There The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 21 was also a system in place that highlighted future training needs for individual care staff. All staff spoken to said they had obtained their NVQ in care. The manager said they had ear marked breakaway training as one that care staff needed in meeting the changing needs of people using the service. The home had systems in place that ensured staff received regular supervision in accordance with the National Minimum Standards. Staff spoken to said they received supervision, one staff was in the process of her supervision when the inspector arrived at the service. The manager had evidence to suggest that care staff also received annual appraisals. The staff appeared to interact well with the people using the service and those spoken to were knowledgeable about the changing needs of the users. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 &43. People who use this service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Effective management systems were in place that ensured the smooth running of the home as a result users best interests and safety were maintained. EVIDENCE: The home appeared to have effective management systems that were underpinned by satisfactory policies and procedures. The manager have been in the home for more than 4 years and had a vast knowledge and understanding of the needs of the people using the service. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 23 The home also had a deputy manager and senior carers that managed in the absence of the manager. The home had satisfactory quality assurance procedures that ensured areas of the home were monitored and updated on a regular basis. The inspector was provided with evidence to suggest users and their relatives received regular opportunities to voice their opinions of the service delivery through open days and questionnaires. The manager also responded to individual relatives giving feedback about any issues raised. There was evidence that regulation 26 visits took place and the manager carried out monthly checks on care plans and the environment. The home could make improvements in this area to ensure the results are evaluated and published in the service user guide and that a policy for quality assurance is implemented that ensured a systematic and cyclical approach is adopted in monitoring all areas of the home. The health and safety procedures in the home were satisfactory. All fire procedures inspected were found to be of a satisfactory standard and procedures for fire risk assessments were reviewed and up dated on a regular basis. The home had various daily checks that ensured the safety of people using the service, these included fridge temperature checks, socket lead checks and other health and safety checks. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 2 3 3 3 3 3 The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Arrangements must be made to ensure PRN medications are clearly labelled with the prescibers instructions for individual users of the service. Arrangements must be made to ensure tablets are not polled together, namely paracetamols. Arrangements must be made to ensure users do not pool money for the purchase of diesel, in ensuring users are protected from financial abuse. Arrangements must be made to ensure all recruitment procedures ensure the safety of people using the service. Therefore evidence of satisfactory Criminal Record Bureau checks must be available for inspection. Timescale for action 30/10/07 2 3 YA20 YA23 13 (2) 13 (6) 30/10/07 30/10/07 4 YA34 19 (1) 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 26 No. 1 Refer to Standard YA39 Good Practice Recommendations Arrangements should be made to ensure quality assurance procedures are improved that shows evidence of users views that are collated and published. The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 The Leys DS0000014926.V350173.R01.S.doc Version 5.2 Page 28 - 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!