Inspection on 19/01/06 for Touchwood

This inspection was carried out on 19th January 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Touchwood 29/08/07

Touchwood 16/03/07

Touchwood 18/11/05

Touchwood 10/01/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Touchwood 13 Somerset Road Christchurch Dorset BH23 2ED Lead Inspector Heidi Banks Unannounced Inspection 19 January 2006 11:35 th DS0000059217.V277484.R01.S.doc Version 5.1 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 DS0000059217.V277484.R01.S.doc Version 5.1 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. DS0000059217.V277484.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Touchwood Address 13 Somerset Road Christchurch Dorset BH23 2ED 01202 487575 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) touchwoodcare@aol.com Principle Care Ltd Andrew James Milnes Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000059217.V277484.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user (as known to the Commission for Social Care Inspection) under the age of 18 may be accommodated. 18th November 2005 Date of last inspection Brief Description of the Service: Touchwood is a small care home situated in a residential area close to the centre of Christchurch. The home was first registered in April 2004 and provides support, accommodation and personal care to a maximum of 5 people with learning disabilities. The registered provider is Principle Care Ltd; which is a private organisation owned by the responsible individual Mark Hulme and the registered manager of Touchwood Andrew Milnes. The house is domestic in size and is in-keeping with neighbouring properties. There is a large garden at the rear and ample parking on the front driveway. The home provides five bedrooms, all with en-suite bathrooms. One bedroom is situated downstairs, the remaining four bedrooms are upstairs. There is a lounge with dining area and a kitchen. There is also a fully equipped laundry/utility room, a staff sleepin room and a small office. DS0000059217.V277484.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on a weekday for a duration of four hours. The inspector was assisted by Pam Taylor, Deputy Manager, staff and service users during the inspection. The inspector returned to Touchwood on 9th February 2006 to meet with the Registered Manager, Andrew Milnes, for two hours to complete the inspection process. The purpose of the inspection was to assess those key standards that had not been assessed at the last inspection in November 2005 and to go through the recommendations and requirements made at that time. There are currently four service users living at Touchwood. There is one vacancy at the home. During the inspection the registered manager, Andrew Milnes, was meeting with the Social Worker of a prospective new service user. During the course of the inspection three residents returned to the home following their morning activities for their lunch. One service user was attending college all day. There were three members of care staff on duty and the part-time cook at the home was preparing lunch. Information for this report was obtained from discussion with the Registered Manager and Deputy Manager, conversations with two service users and a member of staff, inspection of service user records and medication records and a guided tour of the home with access to one of the residents’ bedrooms with their permission. The inspector was pleased to receive four comment cards from service users, one comment card from a relative of a service user, three comment cards from Care Managers and one from a General Practitioner. Comments from these will be reflected throughout the report. What the service does well: The service strives to promote the involvement of service users in decisionmaking about the support they receive and the running of their home. This enables them to have some control over their lives and the environment in which they live. Service users are supported to access a wide range of educational and social activities and pursue their personal interests with a focus on promoting their independence. They are encouraged to maintain contact with their families and friends and are also supported to meet new people through their various activities, enabling them to develop their own networks if they so wish. Service users’ rights and responsibilities are acknowledged in working practices, in their service user plans and risk assessments and weekly house meetings enable service users to contribute their ideas about activities, menu planning and the running of the home. There was evidence that their personal DS0000059217.V277484.R01.S.doc Version 5.1 Page 6 preferences and dietary needs are catered for at meal times so that service users enjoy their meals and their individual health and nutritional needs are met. Good working relationships between the home and specialist health care services means that service users’ health care needs are monitored and met and changes in their health are responded to promptly. The home also communicates well with service users’ Care Managers, one commenting ‘the standard of care and support provided at Touchwood is very good. I have found the staff to be committed to enhancing the quality of the lives of people living at Touchwood. Communication is good and I am kept informed of any issues relating to the service users I am responsible for’ Systems are in place to promote the protection of service users from abuse and self-harm. Staff receive training in physical intervention to promote service users’ safety. The Registered Manager has been in post since the home opened in April 2004 and service users benefit from his ability to run the home well. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000059217.V277484.R01.S.doc Version 5.1 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 DS0000059217.V277484.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: DS0000059217.V277484.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Service users are involved in making decisions and choices about the way they are supported and aspects of the running of the home to enable them to exercise some control over their lives. EVIDENCE: There was evidence to demonstrate that service users are involved in many aspects of their care including support with preparing for reviews, signing up to their care plan and risk assessment and signing to indicate they have received their medication. Every service user has an allocated key worker and this enables them to build a positive working relationship with a member of staff with whom they can discuss aspects of their care. House meetings are held on a weekly basis during which service users are supported to make choices about their activities for the week ahead and also contribute ideas for the weekly menu. Although the home strives to ensure that service users make choices about the support they receive and the running of their home three out of four service users indicated in their comment cards that they wish to be more involved in decision-making within the home. DS0000059217.V277484.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 16 and 17 Service users are encouraged to access appropriate activities and pursue their interests so that they can develop their knowledge and skills and work towards independence. Service users are encouraged to build and maintain relationships with their peers and family and lead ordinary lives in their community. Service users’ rights and responsibilities are recognised by the home and they are encouraged to make choices and decisions about issues that affect them as individuals and as a group. Service users are offered a healthy diet to meet their individual needs and have some choice as to what is on their weekly menu. EVIDENCE: There is a Day Care Manager who works across Principle Care homes who is responsible for identifying suitable vocational and educational courses for service users to meet individuals’ needs and preferences. The weekly timetable indicated that service users are given support to access a wide range DS0000059217.V277484.R01.S.doc Version 5.1 Page 11 of educational and social activities. There is a focus on supporting service users to work towards independence and access their local community. There was evidence of service users attending a local college of further education, community centres and arts centres to access courses which interest them with appropriate levels of support from staff. The Deputy Manager reported that one service user is attending a ‘Building Independence’ course where there may be a work experience option in the final year. Other courses attended by service users include ‘Worldwise’, Pottery, Essential Skills, Literacy, Drama and First Aid. Service users are encouraged to attend mainstream courses where they want to. Social activities include the gym, snooker and swimming and are clearly tailored to the needs and wishes of the individual. There was evidence that service users’ contact with their families is promoted through home visits, acknowledgement of family birthdays and events. One relative indicated via a comment card that he feels welcomed at the home and is able to visit his relative in private. One service user who has a sister living abroad is being supported to undertake a literacy course so that he is able to maintain contact with her. The Deputy Manager stated that service users are encouraged to build relationships with people they meet outside of the home and are able to invite people to visit the home if they wish. Discussion with staff, observation and examination of service user records showed how staff promote service users’ involvement in making decisions and choices about their everyday lives. This is achieved through weekly house meetings and comprehensive service user plans and reviews to which service users’ needs and wishes are central. Individual risk assessments detail agreed restrictions, for example restrictions to other service users’ bedrooms, cupboards which may contain harmful substances and when service users may be accompanied. Every service user is issued with keys to their bedroom door and front door and all four service users responded via their comment cards that their privacy is respected by staff. Service users are kept informed of changes within the home, such as the possibility of a potential new service user coming to look round, and minutes of the weekly house meetings indicated that service users’ views are taken into account with regards to activities. Service users are encouraged to take responsibility for their home environment by being allocated to help with household tasks. There is a part-time cook at the home. A copy of the weekly menu was seen to offer service users a range of meals. Each service user is enabled to choose a meal that they would like to appear on the menu for the coming week. Individual dietary needs are catered for with attention paid to service users who may need to gain or lose weight for the benefit of their health. Service users have free access to the kitchen and can help themselves to drinks at any time. It was noted that meal times are promoted as a social occasion where service users and staff eat together. Service users appear to enjoy their mealtimes and have a good relationship with the cook. DS0000059217.V277484.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 Service users are supported to access generic and specialist health care services to meet their individual physical and emotional health care needs. Service users are encouraged to sign for their medication to promote their independence. Service users are generally protected by the home’s policies and procedures but a review of some aspects of the procedure will further protect service users. EVIDENCE: Inspection of service user records showed that there is substantial multidisciplinary team involvement to ensure that service users’ needs are met. This includes regular input from specialist services such as Psychiatry, Psychology and Community Nursing. It was noted that one service user had experienced weight loss and had been appropriately referred to a dietician whose recommendations have been implemented with a positive effect. A system for the monitoring of sleep and eating patterns was also in place for a service user who requires this, information from which is shared on a regular basis with the specialist health care team. The home maintains record sheets of health care appointments for every service user. DS0000059217.V277484.R01.S.doc Version 5.1 Page 13 The home maintains positive working relationships with service users’ Care Managers evidenced by comments made in comment cards; ‘Touchwood provides a high standard of care to my service user. Their staff understand the needs of the service user and have an excellent reputation of effective management of service users with behavioural difficulties’; ‘Continues to be a positive placement and meets the needs of the service user well’. Medication procedures were reviewed. Medication is kept in a secure cupboard in the office of the home. There is a medication policy in place which covers safe administration, administration of over the counter medication, disposal of medication and refused / missed medication. The Registered Manager confirmed that procedures for taking verbal messages regarding medication and obtaining written confirmation had not been included. At present medication is delivered by the pharmacy to another Principle Care home in the area. The Day Care Manager has the responsibility of bringing the medication for service users at Touchwood to the home on a weekly basis and then re-dispenses them into a weekly dosette box for administration by staff. Re-dispensing is not considered good practice because of the potential risk of error. The home has a list of non-prescribed medicines used. Supplies of nonprescribed medicines were checked against this list and were found to be correct. The home prints a weekly Medicine Administration Record (MAR) chart for each service user. Separate charts are used to record the administration of short courses of medicines and non-prescribed household medicines. Sensitivity to certain medicines had been recorded on one service user’s MAR chart. The Registered Manager confirmed that where a service user had no allergies to medicines, ‘none known’ had been recorded in the appropriate area of the MAR chart. Both the service user and staff member sign the MAR chart to indicate that medication has been administered. A sample of dosette boxes and MAR charts were checked and no gaps were found. An individual’s PRN medication plan was discussed with both the Registered Manager and Deputy Manager. Through discussion it was evident that there are safeguards are in place around the appropriate administration of PRN medication in that staff on duty will contact the Duty Manager should PRN medication be required to obtain authorisation to administer. The Registered Manager confirmed that he often makes contact with the Community Specialist Health Care Team regarding administration of PRN medication to keep them informed and seek guidance as appropriate. This procedure has not been clearly documented as part of the individual’s care plan. DS0000059217.V277484.R01.S.doc Version 5.1 Page 14 The Registered Manager reported that only staff who have been in employment for more than one month are permitted to administer medication. Administration of medication is covered in the home’s induction process and covers safe storage, respecting dignity, reporting errors, refusal of medication, aspects of administration and recording. The Deputy Manager stated that staff receive in-house training which involves observation and giving medication with supervision before they are able to administer medication independently. Training records showed that approximately one third of all staff have completed a safe handling of medicines course with a local college. DS0000059217.V277484.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Systems are in place at the home that promote the protection of service users from abuse, neglect and self-harm. EVIDENCE: There is a policy in place at the home on abuse which contains information on the categories of abuse, signs of abuse and guidance on whistleblowing and reporting procedures. Adult protection and the prevention of abuse is covered with staff in their inhouse induction programme and covers the importance of immediate reporting. There was evidence that ten staff out of thirty-four had undertaken a one day course in abuse awareness organised by Social Services. The Registered Manager and Deputy Manager reported that staff aim to raise awareness of abuse with service users by discussing scenarios with them at house meetings and by ensuring that they have the contact details of the Commission for Social Care Inspection on their individual key rings should they need to talk to an inspector about any concerns. All four service users indicated on comment cards that they feel safe at Touchwood. Physical intervention may be used at the home to respond to physical aggression by service users. Staff at Touchwood receive two days’ training in Non-Violent Crisis Intervention from a Director of Principle Care Ltd who has undertaken a Trainers’ Course in this intervention strategy. The Registered Manager confirmed that no staff member is permitted to use physical intervention until they have undertaken appropriate training. The home notifies the Commission appropriately when incidents occur and physical intervention has been used. DS0000059217.V277484.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: DS0000059217.V277484.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 35 Further development of the home’s training programme for staff will ensure that all staff have training in areas specific to the service user group and access to NVQ training. EVIDENCE: The home’s training programme for staff was discussed with the Registered Manager. There is an in-house induction programme in place and all new staff are now undertaking Learning Disability Awards Framework (LDAF) modules as part of their induction. The staff training record showed that staff undertake Emergency First Aid training every three years and that staff have also attended Non-Clinical Manual Handling training. Some staff have undertaken Basic Food Hygiene training. Staff receive training in Non-Violent Crisis Intervention. Although there was evidence that a small number of staff have attended training in Equal Opportunities, Autism and Epilepsy, there was limited evidence of training for all staff in specific issues relevant to the service user group, for example, mental health, challenging behaviour and sexuality. The Registered Manager reported that training is mainly ‘on-the-job’ and bi-monthly staff meetings have been used to watch videos on issues relevant to the service user group. The Registered Manager stated that the home has recently identified a training provider to support them with the delivery of accredited training and that these options are currently being explored. Ten staff out of thirty-four have either achieved or are working towards an NVQ qualification. DS0000059217.V277484.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 The Registered Manager understands his role and responsibilities and service users benefit from his ability to run the home well. EVIDENCE: The Registered Manager has been in post since the home opened in April 2004. As well as being the Registered Manager he is also one of the Directors of Principle Care Ltd. He is currently studying for his NVQ Level 4 qualification in Care and is committed to updating his own knowledge and skills in order to meet the needs of the service user group. DS0000059217.V277484.R01.S.doc Version 5.1 Page 19 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X 3 X X X X X X DS0000059217.V277484.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement The home’s quality assurance system must be fully implemented. This requirement is carried forward from the previous inspection. Timescale for action 1 YA39 24 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Guidance from the Royal Pharmaceutical Society should be followed with regards to the receipt, recording, storage, handling, administration and disposal of medicines. It is recommended that the home’s procedure for redispensing medicines be reviewed and risk assessed. Medicines should be given directly from the container in which the pharmacy supplied them labelled with the doctor’s prescription directions. When MAR charts are printed in the home or handwritten, a second competent person should sign to confirm that all the details of prescribed medicines are correct. Records should be kept to identify staff responsible for filling and checking dosette boxes. DS0000059217.V277484.R01.S.doc Version 5.1 Page 21 1 YA20 2 YA32 3 YA35 Procedures for taking verbal messages regarding medication and obtaining written confirmation should be added to the medicines policy. A clear, written plan around PRN medication should be put in place detailing the procedure to be followed by staff / Duty Manager when administering / authorising PRN medication. 50 of all care staff in the home should obtain a care NVQ Level 2 or above. This recommendation is carried forward from the previous inspection. The home’s training and development programme should be reviewed to ensure that all staff receive training in Equal Opportunities, including disability equality and race equality training. All staff should be able to access training that is linked to the home’s service aims, service users’ needs and individual Plans. DS0000059217.V277484.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000059217.V277484.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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