Inspection on 18/08/08 for The Squirrels Care Centre

This inspection was carried out on 18th August 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Squirrels Care Centre 20/08/09

The Squirrels Care Centre 20/02/09

The Squirrels Care Centre 30/08/07

The Squirrels Care Centre 04/07/06

The Squirrels Care Centre 10/10/05

The Squirrels Care Centre 05/05/05

The Squirrels Care Centre 13/12/04

The Squirrels Care Centre 17/06/04

The Squirrels Care Centre 08/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE The Squirrels Care Centre Warley Road Great Warley Brentwood Essex CM13 3HX Lead Inspector Michelle Love Unannounced Inspection 18th August and 9th September 2008 10:00 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 The Squirrels Care Centre DS0000018113.V370520.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 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. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Squirrels Care Centre Address Warley Road Great Warley Brentwood Essex CM13 3HX 01277 224308 01277 261353 thesquirrels@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited 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) Vacant Post Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Personal care to be provided to no more than fifty eight service users over 65 years. Total number of service users for whom personal care is to be provided shall not exceed 58. 30th August 2007 Date of last inspection Brief Description of the Service: Ashbourne (Eton) Ltd., which is part of Southern Cross Ltd., owns the Squirrels Care Centre. The home provides personal care and accommodation for up to fifty-eight older people. The home is a large listed building and is situated in extensive grounds in a rural location some distance from shops and public transport. The home provides transport to both staff and visitors. There are car-parking facilities at the front of the property. The home provides single and double bedrooms and all rooms have en-suite WC facilities. There are two lounges and a large separate dining room Passenger lifts provide access to all upper floors. As at 30th August 2007, the deputy manager advised that the fees for accommodation range from £421.54 to £669 per week. Extras to the fees include hairdressing, chiropody, personal toiletries, magazines and newspapers. Information about the services provided at the home is located within the homes main reception area. Inspection reports are available from the home and from the CSCI website www.csci.org.uk The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This was an unannounced key inspection. The visit took place over two days by one inspector and lasted a total of 14.15 hours, with all key standards inspected. Additionally, the registered provider’s progress against previous requirements from the last key inspection was also inspected. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment. This is a self-assessment document detailing what the home does well, what could be done better and what needs improving. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used throughout the main text of the report. Prior to the inspection surveys were forwarded from us to the home for distribution to residents next of kin, healthcare professionals and staff who work within the care home. It was disappointing and of concern that surveys sent to the home were forwarded to residents families, however in nearly all cases, the incorrect template had been forwarded and many people returned these to us having not completed the document and feeling puzzled by the above distribution methods. Where these have been returned to us with comments, these have been incorporated into the main text of the report and following the inspection some people who provided their telephone numbers were contacted. It was equally disappointing that no surveys were completed and returned to us by staff working within the care home. The deputy manager, operations manager, project manager, senior and care staff team assisted the inspector on both day’s of the inspection. Feedback on the inspection findings were given throughout and summarised at the end of each day with the deputy manager/operations manager on the first day of inspection and the project manager/operations manager on the second day of inspection. The opportunity for discussion and/or clarification was given. The main text of the report highlights a number of shortfalls. As a result of concerns relating to care planning/risk assessing, meeting the healthcare needs of some people and inadequate medication practices and procedures, an Immediate Requirement Notice and Serious Concern Letter were forwarded to the registered provider and to the management team of the care home. Additionally, 2 safeguarding referrals were made to Essex County Council Safeguarding Team. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Practices and procedures for the safe handling, administration and recording of medicines must be improved to ensure that residents are protected and safeguarded. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 7 Further development is required in relation to care planning and risk assessing processes, so as to ensure that individual plans of care are comprehensive, up to date, reflective of people’s current care and healthcare needs and ensure that the care provided to residents, meets their specific requirements. People living at the care home and/or their relatives need to be more involved in the care planning process. Appropriate staffing levels at the home must be maintained so as to make sure that residents needs are met at all times and are in line with people’s dependency levels. Further development is required to ensure that robust recruitment procedures for staff are adopted so as to ensure residents safety and wellbeing. Further training and personal development is required for staff to ensure that they have the skills and competence to meet resident’s needs and to deliver good care. Particular attention must be provided for those conditions associated with the needs of older people. New staff employed at the care home must receive a structured induction. The management team of the home must also ensure that all staff working at the care home receive regular supervision. 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 Squirrels Care Centre DS0000018113.V370520.R01.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 The Squirrels Care Centre DS0000018113.V370520.R01.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 and 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect that they will be properly assessed prior to admission and assured that their care needs can be met. EVIDENCE: We were advised by both the deputy manager and home’s administrator that since the last inspection both the Statement of Purpose and Service Users Guide had been reviewed and updated. A copy of both documents was provided to the inspector on the first day of inspection, however it was noted that some elements were inaccurate and required further amendment e.g. the name of the administrator and contact details of the Commission for Social Care Inspection. A copy of both revised documents, were provided to the inspector on the second day of inspection, however our contact details remain incorrect and require further amendment. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 10 There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective residents’ needs. In addition to the formal assessment procedure, supplementary information is sought from the individual resident’s placing authority and/or hospital. As part of the inspection process two care files for the newest people to be admitted to The Squirrels were examined (one respite and one permanent). These showed that one pre admission assessment was completed prior to the person’s admittance to the care home and the other pre admission assessment was completed on the same day as the person was admitted to the care home. No rationale was recorded as to the latter. Relatives surveys returned to us, advised that people did not always feel that they were given sufficient information from staff/management team of the home, in order to make decisions on behalf of their member of family. If this is the case, this requires reviewing. Both pre admission assessments were noted to be detailed and comprehensive. It was positive to note that a letter confirming that the home could meet the resident’s needs was evident within each person’s care file. However, there was little information to show that this process had been conducted with either resident and/or their representative or that the person admitted on respite had been offered an opportunity to visit the care home prior to admittance. The deputy manager advised that prospective residents and their relatives are afforded the opportunity to visit the home prior to admission. The Statement of Purpose records under the heading of `admission criteria`, “An invitation to visit the home and perhaps stay for a meal will be offered”. The AQAA details under the heading of `what we do well`, “Prospective residents and families are invited to view the home prior to admission and the home will inform prospective clients in writing if the home can meet their needs prior to admission”. Residents spoken with at the time of the inspection were unable to confirm as to whether or not they had been involved within the pre admission process or if they or their representative had received information about the home, detailing the services and facilities provided. The Squirrels Care Centre DS0000018113.V370520.R01.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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents can be sure they have an individual plan of care in place, however significant and serious shortfalls in care planning, risk assessing and medication practices means that residents cannot be assured that their needs will always be met or that their health and wellbeing will be maintained or proactively managed. EVIDENCE: At this inspection a random sample of 4 care files were examined. Records show there is a formal care planning system in place to help staff identify the care needs of individual residents and to specify how these needs are to be met by care staff, however not all areas of identified need were recorded within each person’s care plan and in some cases there was limited information recorded as to how staff were to proactively manage the person’s specific care needs. Additionally, formal assessments relating to dependency, manual handling, pressure area care, nutrition and continence are also completed for individual people. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 12 Care records show that further development of the care planning and risk assessment process is required as shortfalls identified, potentially place residents at risk of not having all of their care needs met and provides staff with inaccurate and not up to date information about individual residents. Particular attention must be afforded to individual’s nutritional needs, refusal of medication and the management of people’s inappropriate or aggressive behaviours. The AQAA details under the heading of `what we do well`, “Care plans are comprehensive and understandable which are reviewed monthly by senior care staff and audited regularly by the home manager and deputy manager”. The document also recorded that service users are consulted regarding their health care needs. The above statements did not concur with the inspector’s findings. The care file for one person showed that over an 8 month period their weight had reduced by approximately 10KG and they were at high risk of malnutrition. Although staff had completed a malnutrition screening tool, weight recording chart, nutritional risk assessment, risk assessment and care plan, these had not consistently been updated to reflect the person’s change of needs. There was no evidence recorded within the person’s care plan, daily care records or professional visitors record to show that the above was being proactively managed or that healthcare professionals had been sought for advice and/or interventions. This, lack of a thorough assessment and monitoring of the resident’s nutritional needs, means that care staff did not have sufficient and accurate information to deliver the appropriate care and support to minimise the risks identified by the assessment. As part of the inspection process, nutritional records for this person were also inspected. These showed that the resident on occasions refused food, however the care plan/risk assessment had not been updated to reflect the above and some gaps were noted whereby staff had failed to complete nutritional intake records/daily nutritional choice sheets or show that alternatives to the menu had been provided. Records showed that the latter was not an isolated case. The care file for another resident showed that they too were at risk of poor nutrition and over a 5 month period had a weight loss of approximately 5KG. As above there was evidence to show that neither the care plan, risk assessment or other associated records had been reviewed regularly or updated to reflect the change in the person’s care needs. Additionally there was no evidence to show that the person had been referred to a GP and/or healthcare professional. A sample of `Daily Nutritional Choice` records were inspected and these showed many occasions in June 2008 and July 2008 when the resident refused to eat any meals. Although we recognise that for a period of 8 days the person was in hospital, records show that 1 week prior to going into hospital, the person only ate 3 biscuits, drank 2 cups of tea, ate half a plate of Irish stew/vegetables and half a bowl of mince pie and custard. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 13 Following the inspection and as a result of the above raised concerns, the registered provider has devised and implemented a new protocol entitled ‘Weight Recording Instruction’. It was also of concern that 3 staff spoken with during the first day’s inspection advised the inspector that currently no residents within the home were at risk of poor nutrition. It is clear that staff working within the home do not know the needs/areas of concern of some people living in the care home. The care file for one of the above people case tracked also recorded that they exhibited inappropriate and/or aggressive behaviours towards others. There was evidence to indicate that these behaviours had been present for some considerable time, however a care plan and risk assessment was only devised on 8/8/08. The archived file for this person was also checked, however no evidence was available to show this had been written prior to the above date. The deputy manager when spoken with could not confirm that a care plan had been completed prior to the above date. This is of concern as a letter from a healthcare professional dated 30/6/08 to the person’s GP and copied to the resident, clearly recorded that the person’s physical aggression “may put other residents in the home at risk”. This lack of information meant that care staff did not have sufficient and accurate information so as to deliver the appropriate care and support to minimise the risks. The staff training statistics provided to the inspector, show only 3 of staff as having attained and/or undertaken training relating to dealing with challenging behaviour and no staff have received training relating to care planning. The AQAA details under the heading of `our plans for improvement in the next 12 months`, “To provide care plan training for staff to continue to improve individual care plans”. It is evident that care plans for individual residents are not used as a working document and there is a lack of understanding around the concept of person centred care. As a result of the above a Serious Concern letter was forwarded to the registered provider detailing the above. The issues as described above were also forwarded to Essex County Council Safeguarding Team for their attention and action. The Essex Safeguarding Team spoke with a representative from Southern Cross Healthcare (Operations Manager) and no further action was required. Regulation 26 reports from February 2008 to August 2008 made reference to care planning processes and systems, “improving to continue work to make person centred”, “still need work on person centred carediscussed with manager”, “looked at four, all paperwork in place” and “x3 looked at. Information from professional visitor sheet not always carried over”. Of those care plans inspected there was little evidence to suggest that these had been devised with the resident and/or their representative. This is disappointing as the Statement of Purpose makes reference to residents and their families being encouraged to participate within the care plan process. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 14 Staff, were observed interacting with residents in a respectful and dignified manner when carrying out tasks. Several residents made positive comments about staff, but recognised that staff were very busy doing other jobs and were unable to spend time with them. During the inspection staff, were observed to interact positively with individual residents however routines at the home are task based and not person led e.g. when staff were serving resident’s their meals, little verbal interaction was noted and staff were observed to walk through dining/lounge areas without speaking to residents. Relatives spoken with also confirmed that they wished for staff to engage more with people living in the home. The majority of medication is managed through a monitored dosage system (blister pack). Administration of medication to residents was observed during the first day’s inspection. During the morning this was seen to be satisfactory, however during the afternoon the senior on duty was observed to administer medication to residents in the dining room, however the trolley was left open and unattended on several occasions. This is not in line with Southern Cross Healthcare’s own medication policy, which states, “The trolley if left unattended, even briefly, must be locked at all times”. During the morning the room, which is used to store medication was observed to be left unlocked and easily accessible to residents, staff and other visitors to the home. Although both medication trolleys were secure and locked, upon entering the room a box containing a variety of medications were noted to be placed on the floor. The senior on duty when questioned as to the above stated that the room had been left unlocked by the District Nurse visiting the home. Medication records were not up to date, with gaps in recording and information. This refers specifically to no record of some medicines having been given to the resident when they were due, as the entries on the Medication Administration Record (MAR) had been left blank and not signed/initialled by staff. Where some residents consistently and/or regularly refuse medication, no evidence was available to show this was under discussion with the person’s GP or under review. On the second day of inspection, it was noted that the registered provider had since the first day’s inspection, drafted the company’s training officer/project manager to oversee the management of the home and they confirmed that the majority of people living at The Squirrels, require a medication review to be undertaken. Additionally there was no evidence to show that staff administering medication, were following the registered provider’s own medication policy and procedures in relation to refusal of medication e.g. adopting various strategies (going back to the resident at a later time and/or gentle persuasion). Following the inspection and as a result of the above raised concerns, the registered provider has devised and implemented a new protocol entitled ‘Refused Medication’. Additionally the GP of 3 residents were also contacted in relation to their continued refusal of medication. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 15 Records also showed that as part of good practice procedures, several handwritten MAR records were observed to not be double signed by staff, so as to evidence that the information recorded was correct and accurate. Additionally for some people, it was evident that their medication was not administered in line with the prescriber’s instructions e.g. the MAR record for one person detailed their Co-Amoxicillin was prescribed as 1x tablet to be taken 3x daily, however the MAR record on one day showed this as being administered on 4 occasions. It was of serious concern that the MAR records for one person between May 2008 to August 2008, showed many occasions whereby they did not receive their Warfarin medication as the MAR record recorded `E` (refused/destroyed). The most serious issue related to the MAR record for one 28 day period. This showed the resident as not receiving the above medication on 10 out of 28 occasions and this included 5 consecutive days and 3 consecutive days. On inspection of the person’s care file and associated records, there was little evidence to show that staff were proactively managing the above or that advice had been sought from the person’s GP or anti coagulant clinic. The home’s medication policy and procedure details, “If a service user refuses to take their medication for a long or sustained period e.g. 2 to 3 days consecutively then the doctor must be informed immediately”. The document also states that failure to adhere to procedures could lead to disciplinary action being taken. Issues relating to the above were recorded within the medication audit conducted on 25/6/08 stating, “No” to “When a service user does refuse their medication on 3 or more occasions is their GP contacted. Do staff members record this on the service users MAR sheet and daily progress notes”. As a result of the above concerns an Immediate Requirement Notice was issued and a referral made to Essex County Councils Safeguarding Team for action. The Essex Safeguarding Team spoke with a representative from Southern Cross Healthcare (Operations Manager) and no further action was required. The AQAA details under the heading of `what we do well`, “All medication is administered in accordance with regulations”. This does not concur with the inspector’s findings. On the second day of inspection the Operations Manager advised that issues highlighted had been addressed. Both the Operations Manager and Project Manager, were advised that this area would be examined at the next inspection. Further gaps were noted in relation to the management of medication within the care home. Handwritten MAR records did not always include the quantity of medication received, who by and the date commenced. Records showed in some instances that prescribed medication was being administered as PRN (as and when required medication). The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 16 It was positive to note that where appropriate, some residents are actively encouraged to maintain independence by managing their own medication. On inspection of one person’s care file, a care plan had been devised detailing that the person chooses to self medicate and is provided with a lockable facility to store their medication. An assessment was in place confirming that the resident was deemed competent to administer their medication and this was regularly evaluated. The deputy manager advised that both she and senior staff at the care home administer medication to residents. The training matrix shows that those staff, who administer medication have up to date administration of medication training, however not all staff members were observed to have evidence that they are regularly assessed as to their continued competence. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 17 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, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities programme at the home does not meet the social care needs of all people living at the care home. Not all residents have their nutritional needs met and this means that some residents do not receive a varied and balanced diet, which could affect their health and wellbeing. EVIDENCE: From discussions with the deputy manager the inspector was advised that the newly appointed activities co-ordinator had been in post for only 4 weeks at the time of the inspection. The activities co-ordinator is employed for 25 hours per week, Monday to Friday. The activities co-ordinator has a £100 per month budget to spend on materials/projects and to fund external entertainers. The inspector was advised that the latter is very positive, however the cost of some external entertainers means that there is little budget left to fund other projects and/or community outings. Following discussions with the activities co-ordinator, it was disappointing to learn, they received no induction into their role and had “been left to their own devices”, to gather information from residents about their personal likes and The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 18 dislikes pertaining to their social care needs. The activities co-ordinator stated that people’s likes and dislikes have been documented within an activities folder and a Recreational Activities Record has been devised and implemented for all residents, so as to record activities undertaken. A monthly timetable of events and activities is devised for residents and activities, and includes arts and crafts, bingo, quizzes, sing-a-long, religious observance, memories and reminiscing, music and ball games, stories and poems and pamper and nail painting. The activities co-ordinator was advised to consider devising the activity programme in larger print and/or pictorial format so as to ensure that people living at the care home are enabled to make an informed choice. The activities co-ordinator advised the inspector that it has been disappointing that some planned community based activities have been cancelled/not taken place as a result of no driver being available to drive the home’s minibus. Although we recognise that the minibus is used for the transport of staff to and fro the workplace, this must not be to the detriment of residents and them not having their social care needs met. The activities coordinator also advised that many residents require a lot of encouragement and motivation to participate within community based activities as a result of not having been out of the care home for such a long time. The AQAA details under the heading of `what we could do better`, “Organise a more varied activity programme to include more external activities”. The activities co-ordinator demonstrated a willingness and enthusiasm to provide an innovative programme of activities for people living in the care home. The inspector was advised that she has undertaken no training relating to activities, but hopes this can be provided for the future. The AQAA details under the heading of `our plans for improvement in the next 12 months`, “access further training for the activity co-ordinator, to develop a more varied activities programme”. Relatives’ surveys returned to us recorded, “More activities are required for all residents regardless of their ability”, “A little more stimulation is required for the residents such as simple quizzes or music and movement etc”, “there could be more activities” and “more activity for all residents regardless of their ability”. There is an open visiting policy whereby visitors to the home can visit at any reasonable time. People spoken with confirmed that they are made to feel welcome by care staff. The lunchtime meal was observed within the main dining room on the first day of inspection. Each table was laid with a tablecloth, vase of flowers, jug of juice and condiments. It was disappointing that only 1 table had a choice of either water or orange juice and that no residents were asked if they wished to have an alternative. When this was discussed with the deputy manager, the inspector was advised that this was most unusual and on most days, two The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 19 choices of drink are readily available for residents. However, on the second day of inspection the same as detailed above was noted and residents spoken with confirmed that they were not always offered a choice of drinks. Menu’s depicting the choices available on any given day were placed on each table. Consideration should be undertaken to devise the menu in larger print and/or pictorial format so that people living at the home can make an informed choice. For those people who require a pureed/liquidised meal, items were portioned separately, however one member of care staff was observed to mix these together prior to assisting the resident to eat their meal. Consideration should also be given by staff to advise residents as to what the pureed/liquidised meal consists of. This will ensure that people who require such a diet are informed of what is being presented to them. Within the previous section of the report (Health and Personal Care), information is recorded about the nutritional needs of two residents. Information recorded details that not all people living within the care home have their nutritional care needs met. People were brought into the dining room from just before midday, however the first person to be served their meal, did not receive this until 12.35 p.m. and the last person did not receive their meal until 12.50 p.m. Consideration should be made to cut down the time people spend sitting in the dining room, waiting for their meal. The serving of the lunchtime meal was observed to be well organised and systematic and staff, were observed to work well as part of a team. Where people were assisted and given support to eat their meal by staff, this was observed to be done with sensitivity and due care. Further efforts must be made by staff to interact verbally with residents. Comments from residents in relation to the meals provided were positive and included, “the food is so good here, you can’t help but feel hungry, I’ve got a good appetite” and “the food is lovely, there is always a choice”. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 20 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate systems are in place to ensure that residents are safeguarded and that any concerns raised are dealt with proactively, however people living in the care home, cannot be assured that staff working with the care home have the skills and competence to deal with people who display aggressive and/or inappropriate behaviours. EVIDENCE: A copy of the home’s corporate complaints policy and procedure was observed to be displayed within the entrance hall/foyer. Records showed that since the last inspection, the management team of the home had received 3 complaints. Evidence indicated there is a clear audit trail available within the home evidencing the specific details of the complaint, details of any investigation and action taken. Relatives spoken with confirmed that should they have any areas of concern, they knew who to address their complaint to and felt assured that action would be taken by the management team of the home. Since the last inspection, there has been 1 safeguarding referral, which was initiated by the management team of the home. It was of concern that actions taken by the home, recorded that the member of staff implicated in the safeguarding issue would be “working under supervision”, however on inspection of their recruitment file, there was no evidence to support the statement and/or action taken by the registered provider. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 21 Staff spoken with demonstrated an awareness and understanding of safeguarding policies and procedures and stated that should an issue arise, this would be highlighted to the person in charge. The AQAA details that Action on Elder Abuse cards have been distributed to all families, residents and staff, and are available in the foyer of the home. It was positive to note that these were readily available for people. The training matrix showed that all staff working in the home had received safeguarding training within the past 18 months. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 22 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements are required to the home environment so as to ensure that people living in the care home are provided with an environment that is comfortable, homely and safe. EVIDENCE: A full tour of the premises was undertaken on the second day of the inspection with both the project manager and the maintenance person. A random sample of resident’s bedrooms were inspected and all were seen to be personalised and individualised with many personal items on display e.g. ornaments, photographs etc. On both days of inspection, the home was observed to be clean, tidy and odour free. The person in charge of the home, should consider sufficient numbers of side tables being placed beside armchairs in lounge areas, so as to enable people to place personal possessions and other items e.g. cups and saucers somewhere safe, rather than holding them or trying to The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 23 secure them on their laps. On both days of the inspection, insufficient numbers of side tables were observed to be available for residents use. This potentially poses a risk to individual’s health and safety and was highlighted at the previous key inspection. The AQAA details that redecoration within the home is being undertaken and prior to the inspection, new chairs, flat screen televisions purchased to both lounge areas, flooring in the dining room had been replaced and new carpets had been laid within the lounge areas and corridors. The project manager advised that a further refurbishment programme is planned whereby curtains and other carpets will be replaced and fitted and decorating to be undertaken. On inspection of the premises some areas of the home were observed to be tired and worn e.g. skirting boards require repainting, some doors both within communal areas and in some resident’s bedrooms require replacing as they are not closing properly and in some cases have holes in them. The project manager was advised to ensure that we are notified of the refurbishment plan, the time frame and the impact (if any) this will have on the people living in the care home. One relative survey returned to us recorded, “The fabric of the home could be improved somewhat, including the ceiling in my [name of relative] room”. The maintenance person advised that a new part is required for one of the home’s boilers. We must be notified in writing when this part has been fitted and the heating system within the home has been tested and is deemed to be in full working order. A new fire sprinkler system has been installed throughout the home. The project manager was advised that once the system has been fully installed, consideration should be undertaken to have the system checked by the local Fire Service. Health and safety issues were highlighted on the second day of inspection whereby no restrictors are fitted on the windows in the dining room and hot water temperatures emitting from a random sample of resident’s wash hand basins were noted to exceed 43° centigrade (46° to 51°). The maintenance person at the home is employed for 40 hours per week, Monday to Friday, however these hours are flexible to cover evenings and weekends. A random sample of safety and maintenance certificates showed that fire systems within the home, fire alarm/emergency lighting testing and fire drills were serviced/tested regularly. Records relating to the emergency lighting showed in July and August 2008 that the emergency lighting within 4 bedrooms was not working as a result of a “wiring error” and that the service were waiting for the external contractors to “come back and rectify”. We must be notified in writing when the above is fully operational. Other certificates were also inspected in relation to the call alarm facility, hoists, passenger lift, The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 24 gas, electrical and portable appliance testing. All were seen to be in date and no remedial works outstanding. On inspection of the training matrix, this showed that the maintenance person has up to date training relating to manual handling, fire safety awareness and fire drills. There was no evidence to indicate they had up to date training relating to health and safety, COSHH (Control of Substances Hazardous to Health) or infection control. On inspection of the laundry area, this was seen to be organised and well managed, however on inspection of quality assurance surveys (completed November 2007), it was clear that there had been a few problems. One comment recorded included, “Main problems at the moment is loss of underwear which seems to disappear in the wash even when marked. Stockings are impossible, although my [relative] likes to wear them-there is no way to keep track of them”. If this is an issue, systems within the home need to be reviewed to ensure that items of clothing belonging to individual residents are not mislaid. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 25 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, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The level of staffing and staff deployment restricts the ability of the service to deliver person centred care and to ensure that people’s needs, can be met and that they are safe. Inadequate recruitment procedures and insufficient evidence of training for some people mean that residents are not safeguarded and staff working at the care home may not have the necessary skills to meet the assessed needs of residents. EVIDENCE: The deputy manager advised the inspector that staffing levels at the home are 7 staff between 07.15 a.m. and 14.15 p.m., 6 staff between 14.15 a.m. and 21.15 p.m. and 4 waking night staff between 21.15 p.m. and 07.15 a.m. each day. In addition to the above, there is an administrator between 09.00 a.m. and 15.00 p.m. Monday to Friday, chef/weekend chef between 08.00 a.m. and 17.00 p.m. each day and a maintenance person 09.00 a.m. to 17.00 p.m. Monday to Friday. The inspector was also advised that the maintenance person’s hours are flexible so as to encompass weekends and evenings as and when required. The gender mix of male/female staff to the gender mix of residents at the home is very positive. On inspection of 4 weeks staff rosters, records show that staffing levels relating to care staff as detailed above are not being maintained. We have not The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 26 received any Regulation 37 notifications advising us of the staffing shortfall and measures undertaken to deploy staff to the home. Manager’s daily audits, which were implemented since 27/8/2008, confirm that staffing levels have not always been attained. On the first day of inspection the deployment of staff within communal areas were at times not appropriate to meet the needs and numbers of residents, as people were at times left unsupported for periods of time. The manager’s audits make reference to some staff arriving late for the commencement of their shift or staff not turning up for duty and the impact on residents being that on a number of occasions, individual’s call alarm facilities were not answered for between 4 minutes and 21 minutes. This is unacceptable and potentially places residents at risk of not having their basic care and/or healthcare needs met. The project manager advised the inspector that she intends to meet with individual members of staff to discuss their role and to spend time working alongside staff, observing their practice. One quality assurance survey returned to the home from a relative concurred with the inspector’s findings and stated, “There appears at times to be a lack of staff on duty, particularly at weekends”. Of those relatives surveys returned to us, comments recorded, “There often seems a shortage of staff, especially at weekends”. In contrast relatives surveys returned to us recorded positive comments about staff and these included, “My [relative] has dementia and is unable to tell me anything about their care. They seem contented and appears to be happy enough, and likes the care staff”, “The staff are very calm and caring when my [relative] are not at their best”, “I am often at The Squirrels visiting my [relative] and am quite happy that they are in a safe, caring environment,” “The staff at this home are very friendly and helpful at all times” and “The carers are always approachable and friendly”. Additionally the staff rosters show that some staff are working long days e.g. one member of staff was observed to work 5 consecutive long days. This is not good practice and potentially places staff and residents at risk. It is positive that several members of staff have been employed at the care home for a significant period of time, providing consistency and stability to residents. The AQAA details, under the heading of `how we have improved in the last 12 months`, “retention of regular staff to continue consistency in care for service users”. A random sample of staff files (5) were examined including those for newly recruited staff. Staff files were well organised and presented, with the majority of records as required by regulation available. However gaps were noted in relation to one reference for three employees not being from their most recent employer, no proof of identification for one person and the Criminal Record Bureau (CRB) check for two people being issued after they commenced employment and no evidence of a POVA 1st check having been undertaken. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 27 Although there was evidence of an induction for 4 out of 5 people case tracked, records showed in two cases that the inductions were not commenced until one week after a person had commenced employment and for the other employee, records showed this was not commenced until nearly a month after they had started employment at The Squirrels. As stated previously, no induction had been undertaken for the activities co-ordinator. The AQAA details under the heading of `what we do well`, “Staff have references and CRB check before taking post” and “We follow a rigorous recruitment procedure to ensure we employ capable staff who are capable of providing excellent care to our residents”. The deputy manager advised that she has attained NVQ Level 3 and three members of staff have achieved NVQ Level 2. The inspector was advised that under the previous manager, all senior staff and some care staff have signed to state that they are interested in undertaking this qualification, however nothing has progressed further. The number of staff with NVQ Level 2 or above does not meet the recommended level as recorded within the National Minimum Standards for Older People. The training matrix and record of training statistics shows that the majority of staff have up to date training relating to fire safety awareness, basic food hygiene, moving and handling and safeguarding. Records show that there are significant gaps pertaining to fire drill training, COSHH, health and safety, infection control and those conditions associated with the specific needs of older people i.e. pressure area care, sensory impairment, nutrition, continence awareness, diabetes etc. The AQAA details under the heading of `what we do well`, “staff trained to the needs of service users” and under the heading of `what we could do better`, “To seek more varied training for staff to increase knowledge”. It also states that within the next 12 months, “to register staff onto NVQ courses to meet with requirements”. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 28 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, 32, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst management arrangements within some aspects of the service are either good or adequate, shortfalls and deficits identified could potentially affect positive outcomes for residents. EVIDENCE: The manager has not been at the care home since the beginning of July 2008. As a result of the manager’s absence the home, has been managed in the interim by the deputy manager until recently. On the second day of inspection, it was noted that Southern Cross Healthcare had placed a project manager in the home. The project manager advised the inspector that her remit is to provide support to the existing deputy manager until a permanent manager is appointed. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 29 Records showed that since the last inspection, the previous manager in November 2007 conducted a quality assurance survey to seek both residents and relatives’ views about the quality of the services provided at The Squirrels. Comments recorded were mixed and have been included within the main text of the report and in the relevant sections. In addition to the quality assurance surveys, the management of the home conduct a variety of audits, which are completed by the management team of the home and by the operations manager who has responsibility for The Squirrels. It is positive to note that some of the audits have highlighted issues requiring further development as detailed within the main text of the report, however there is little evidence of an action plan and steps taken by the management team of the home to address the shortfalls and deficits identified. Again, comments relating to these have been recorded within the relevant sections of the report. It is evident from this inspection that there are a number of identified shortfalls and deficits, which need to be addressed urgently. Areas which require further development relate to care planning/risk assessments, proactive management in meeting individual resident’s care needs and healthcare needs, ensuring that residents receive a range of activities which meets people’s social care needs (community based), ensuring medication practices and procedures in the home are safe, staffing levels appropriate to meet residents dependency needs, sustained training and development of staff particularly around those conditions associated with the needs of older people and developing consistent staff supervision. The management team at the home must demonstrate a proactive approach to addressing and sustaining good practice, so as to ensure residents continued safety, wellbeing and positive outcomes. All sections of the Annual Quality Assurance Assessment were completed. We recognise that the assessment form was completed and submitted to us in May 2008, however the information recorded does not give an accurate account of the current situation within the service as some elements provide little and/or no evidence to support the claims made within it. The home’s administrator advised that records relating to residents finances are computerised. Although monies are pooled, each resident has their own individual bank account. The inspector was advised that statements are sent out with invoices every 4 weeks and people’s records detail the amount withdrawn/deposited and any interest incurred. Weekly audits are undertaken and these are reconciled every month. Where possible and appropriate, residents are encouraged to maintain independence by managing their own finances. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 30 A random sample of staff supervision records were inspected and these showed that supervisions are not being conducted in line with regulatory requirements and recommendations. No supervision records were available for 4 people who commenced employment at the care home in January 2008 and where issues have been highlighted, there was no evidence to show action taken. The AQAA details under the heading of `what we do well`, “Staff supervisions are carried out on a regular basis” and under the heading of `how we have improved in the last 12 months`, “planned supervisions”. The statements made within the AQAA do not reflect the inspector’s findings. The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 31 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 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 1 X 2 The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? YES 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(1) Requirement Care planning at the home must identify, and be effective in meeting all residents’ assessed needs and ensure that these are regularly updated/reviewed to reflect the most up to date information. Risk assessments must be devised for all areas of assessed risk so that risks to residents can be minimised. Records must be explicit, detailing the specific risk, how this impacts on the person and steps taken to reduce the risk. Ensure suitable arrangements are in place so as to ensure that resident’s health and welfare are promoted and any issues are promptly addressed and proactively managed. This refers specifically to ensuring that where people require support, records are updated, staff have the skills to recognise when to contact healthcare professionals and to provide appropriate interventions. Timescale for action 01/10/08 2. OP7 13(4) 01/10/08 3. OP8 12(1)(a) 18/08/08 The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 33 4. OP9 12(1)(a) 13(2) 5. OP9 17(1)(a) Schedule 3(3)(i) 6. OP9 13(4) 7. OP12 16(2)(m) and (n) 8. OP18 13(6) 9. OP19 23(2)(b) and (d) 10. OP19 13(4) Residents must be protected from harm by having their medication administered safely and in accordance with the prescriber’s instructions so as to ensure their health and wellbeing. Ensure that when medication is not administered to residents, records clearly record this, the rationale why they are not and any action taken to address the above, so as to ensure people’s health and welfare. Ensure that the medication trolley is not left unattended and medication easily accessible to residents and others. This will ensure unnecessary risks to residents’ health and wellbeing is averted. Ensure that people living at the care home have the opportunity and encouragement to access and participate in community activities so as to ensure people have their social care needs met. Ensure that all staff receive, appropriate training relating to dealing with challenging behaviour. This will ensure that staff, feel confident, have the skills to deal effectively with issues raised pertaining to the above and residents are protected from harm. Ensure that the premises, is kept in a good state of repair and that all areas of the home are reasonably well decorated. This will ensure that people living in the care home, live in an environment that is homely and comfortable for their needs. Ensure that all areas of the home are free from risks to residents’ health and safety. This refers specifically to the need for DS0000018113.V370520.R01.S.doc 18/08/08 18/08/08 18/08/08 01/10/08 01/01/09 01/01/09 09/10/08 The Squirrels Care Centre Version 5.2 Page 34 11. OP27 18(1)(a) 12. OP29 19 13. OP30 18(1)(c) and (i) 14. OP30 18(1)(c) and (i) 15. OP36 18(2) window restrictors fitted to the dining room windows and hot water emitting from wash hand basins not exceeding 43° centigrade. Ensure there are sufficient staff, on duty at all times, so as to meet the needs of residents and to ensure their safety and wellbeing. Ensure that robust recruitment procedures are adopted at all times for the safety and wellbeing of residents and that all records as required by regulation are sought. Ensure that staff, receive appropriate training to the work they perform. This refers specifically to those conditions associated with the needs of older people. This will ensure that staff, have the competence, confidence and ability to meet resident’s care needs and people living at the care home will feel reassured that their care needs will be met by suitably trained staff. Ensure that all staff newly employed to the care home receive, a structured induction. This will ensure that staff, feel supported and able to carry out their role. Ensure that staff, receive regular supervision so that they feel supported and residents know that staff are appropriately managed. 18/08/08 18/08/08 01/01/09 18/08/08 18/08/08 The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 35 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 Complete minor amendments as required within the Statement of Purpose and Service Users Guide. Ensure that information recorded within both documents is accurate and reflective of the services and care practices provided. Record within the pre admission assessment process, evidence that prospective people/representatives are offered an opportunity to visit the care home prior to admission and that they are consulted/involved within the assessment process. Ensure wherever possible that residents and their representatives are consulted regarding the care planning processes. Ensure that nutritional records for people living in the care home are fully completed. Ensure as part of good practice procedures that handwritten MAR records are double signed by staff. This will ensure that information recorded/transferred is correct and accurate. Ensure that MAR records detail the quantity of medication received, the name/initial of the person completing the documentation and the date the medication commenced. Ensure as part of good practice procedures that all staff, who administer medication to residents, are regularly assessed as to their continued competency. Consider devising the activity programme in larger print and/or pictorial format, so as to enable people to make an informed choice. Consider devising the menu’s for residents, in larger print and/or pictorial format, so as to enable people to make an informed choice. Ensure that people living in the care home receive a choice of drinks throughout the day and at mealtimes. The person in charge should prepare a plan as to how the recommended level of 50 of staff working at the care home attain NVQ 2 or equivalent will be achieved. DS0000018113.V370520.R01.S.doc Version 5.2 Page 36 2. OP3 3. 4. 5. OP7 OP8 OP9 6. 7. 8. 9. 10. 11. OP9 OP9 OP12 OP15 OP15 OP28 The Squirrels Care Centre The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 37 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 The Squirrels Care Centre DS0000018113.V370520.R01.S.doc Version 5.2 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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