Inspection on 03/08/05 for Tramways

This inspection was carried out on 3rd August 2005.

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

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

Other inspections for this house

Tramways 16/09/08

Tramways 12/10/07

Tramways 19/04/06

Tramways 17/01/06

Tramways 19/01/05

Tramways 26/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Tramways Tramway Road Brislington Bristol BS4 3DS Lead Inspector Sandra Jones Unannounced 3 & 5 August 2005 9:30 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 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 Stationary 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. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tramways Address Tramway Road Brislington Bristol BS4 3DS l 0117 3009637 0117 9709301 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Aspects & MilestonesTrust To be appointed Care Home 14 Category(ies) of LD(E) Learning dis - over 65,14 registration, with number LD Learning disability,14 of places Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 14 persons aged 65 years and over with Learning Disibilities for personal care only May accommodate up to 14 persons aged 40 to 65 years with Learning Disibilities for personal care only Date of last inspection 19/1/05 Brief Description of the Service: Tramways is registered to accommodate up to fourteen adults with learning disabilities. The care home is operated by Aspects and Milestones Trust and at present there are two acting managers. The property was purpose built and arranged on one level, designed into two separate units accommodating seven people, linked by a passage, with a shared kitchen. It is situated in an industrial estate close to the Bath Road and within walking distance of shops, amenities and bus routes. Each unit has their own staffing with a manager, senior and home support workers. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted with a second inspector on the first day of the three-day inspection. Since the last inspection in January 2005, three visits were conducted to the home and three immediate requirements have been issued. Two immediate requirements were issued, one to each house, during a monitoring visit and one during this inspection. Enforcement action will follow for non-compliance of the requirement on risk assessments. Through Regulation 37 notifications, houses 1 and 2 have kept the CSCI office informed of any occurrences, events and accidents. The managers and external manager have regular contact with the CSCI to ensure the home continues to develop the standards of care. A manager for each house has been appointed and will be undergoing a “Fit Persons” process. A further registration will also take place to register each house separately. What the service does well: On the second day of the inspection, the managers and senior staff were not present. It was conducted in house 1 with a support worker bank and agency staff. Residents and staff were observed interacting and residents were clearly familiar with the support staff. Residents were observed making choices and staff empowering residents to make these choices. Although staff must be forewarned on the balance between friendly and respectful as some of the residents are their seniors. Respect that comes with their age must be shown. Members of staff at the home have specific knowledge of the residents and have taken steps to ensure there is social inclusion for the residents accommodated. Good interaction with residents is maintained; they join residents at meal times, have refreshments together, 1:1 time and share a genuine interest in their wellbeing. Members of staff welcome visitors to the home. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 6 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. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 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 standard(s) These standards were not examined at this inspection. EVIDENCE: Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 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 standard(s) 6, 7 & 9 Person Centred Plans (PCP) must be clearer in terms of action plans to ensure the individuals needs are met. Documentation must evidence decisions made by residents. Risk assessments must be completed and any further non-compliance of this requirement will lead to enforcement action. EVIDENCE: It is evident from the case records that Person Centred Plans (PCP) are being developed, through a review day with staff, residents and facilitator. A holistic approach to assessing the persons physical, social, emotional and communicating needs is being adopted which incorporates the persons likes, dislikes and preferred routines. The information is supplemented by “What makes me happy”, What makes me sad”. A “Listen to me” format is used to describe the manner in which the person communicates. It identifies gestures, vocal sounds and behaviours, with the staff’s actions to be taken. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 10 While daily diaries report preferred routines in terms of times to rise and retire, decisions made by residents that based on the assessments on communications are not included in the diaries. Care plan reviews are organised by South Glos. Local Authority, for people from the authority placed, by them at the home. While PCP are comprehensive in that staff contribute information about the person, it is difficult to establish the needs and actions to be taken. Action plans that draw information gathered through PCP and care reviews must be developed, which include dates and signatures. A keyworker system is in operation and it was understood that the aim is for 1:1 with the resident and staff member, although staff are currently having more key residents whilst recruitment takes place. Monthly review questionnaires are in place and must be reviewed to establish their purpose and usefulness. At present residents are restricted from leaving the building and entering the corridor that links both homes. The keypads will be removed from the passageway as a result of the risk assessment completed. A risk assessment must be completed for the front door to ensure the actions are consistent with the level of risk. Through consultation with the staff, it transpired that to prevent one resident from entering other residents rooms, bedroom doors are kept locked in house 1. Risk assessments for locking bedroom doors must be completed. Despite previous requirements (26.11.03, 26.5.04 & 19.1.05) to complete risk assessments for activities that may involve an element of risk and manual handling, this requirement remains outstanding. Risk assessments are inadequate and require reviewing. For example, listening monitors are used in a resident’s bedroom that has epilepsy. However, the records demonstrate that this individual has not had a seizure at night. Therefore a monitor is not necessary in a bedroom at night. A follow-up visit will be conducted to confirm that risk assessments have been completed. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 11 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 standard(s) 13 & 16 Members of staff have recognised the pertinence of social inclusion and residents are more visible in the community. Risk assessments must be completed to evidence that residents rights are respected. EVIDENCE: It was understood from the manager that there is funding allocated to remove the fence that isolates residents from the local community. In removing the fence residents will see and be seen by members of the public. Additionally the front of the house will be made secure to enable residents to move freely in and out of the house. During the inspection members of staff were observed taking residents to the local shops and cafes as part of their daily routines. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 12 All residents are registered on the electoral roll. Since the last inspection, bedroom keys were hung from hooks at the top of doorways, making it impossible for residents to reach their keys. Furthermore members of staff would have to assist residents with developing their skills to use the key and to understand the concept it represents. As this is not a meaningful practice the keys must be removed. Generic risks assessments must be completed to demonstrate that residents are not able to used their bedroom keys. Case records detail the persons preferred mode of address. One resident has a nickname and the staff reported that this individual would not respond unless the nickname is used. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 13 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 standard(s) 19 & 20 Residents health is monitored by the staff and where appropriate referrals are made. Records must support that advice given by outside professionals is followed. Staff are competent to administer medication and safe handling practices are in place. Risk assessments and GP’s consent must be sought for concealing of medication. EVIDENCE: Through conversation with the member of staff on duty, the staff observations that led them to question cataracts for one resident were explained. This evidences that staff monitor residents health and make referrals where appropriate. Referrals for hospital and other specialist appointment are made on behalf of the residents. For example speech and language, physiotherapy and district nurse. Although documentation did not evidence that advice given by these professionals were followed, comments indicated that action was taken by staff. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 14 Narrative story telling group, designed for people with profound and severe learning disabilities took place for a period of nine weeks. It is unclear whether the group was not successful or whether the group was for a specific period of time. Documentation kept in case records evidenced that residents access NHS community facilities. The staff arrange for residents to regularly visit the dentist, chiropodist and optician. Residents are invited for routine screening, which were declined for residents that would be distressed by the procedure. The home uses a monitored dosage system, which is received weekly and signed appropriately. Any medication, which is given on an “as required” basis, is kept separately. Records showed that staff are not using medication to control behaviours. It is only used when there is an appointment with an outside agency. This is seen as good practice. One resident has medication concealed and signed consent from relatives is in place but not from the GP. A risk assessment that evidences that this practice is regularly reviewed is not in place. From discussion with a member of staff, it was reported that although the medication is concealed the resident is told each time its administered. A risk assessment that evidences this practice is appropriate must be completed along with signed consent from the GP. Discussion with staff showed their competence at dealing with any adverse effects when medication is altered or reduced. Records showed that all staff have read the medication policy. Drug profiles were written with possible side effects. All administration charts since 3/7/05 were signed appropriately with no gaps. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 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 standard(s) 22 The home seeks feedback. The records must evidence the investigation conducted, the outcome and the level of satisfaction where a complaint is made. Consideration must be given to enabling residents to make complaints. EVIDENCE: There were two complaints received at the home since the last inspection. A neighbour complained about soil left on the road. The actions taken by the staff and the complainant level of satisfaction were not recorded. Complaints log book must include the investigation, the outcomes and the complainants level of satisfaction. One member of staff discussed how residents were able to complaint when some are unable to communicate. It was reported that members of staff had made complaints on behalf of a residents and it was acted upon. Consideration must be given to ways to enabling residents to express their dissatisfaction with the standards of care at the home. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 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 standard(s) These standards were not examined at this inspection. EVIDENCE: Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 & 36 The home is relying on bank and agency staff to cover vacant house. The suitability of agency staff working at the home is not evidenced. Members of staff benefit from individual supervision but this should be more frequent which must occur six weekly. EVIDENCE: The rota in place indicates that three staff are rostered throughout in day in each house. With one person awake in each house at night. From the rotas in place, it is evident that the home must rely on bank and agency staff to maintain staffing levels. Thirteen bank staff were listed for cover in the first week in August. At the time of the inspection there was one permanent member of staff in each house, the other four staff were agency and bank. At night all staff are either agency or bank. On the previous evening there was no cover, as the agency member of staff did not turn-up for duty. The bank staff on duty found cover and remained on duty until cover was found. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 18 Members of staff reported that the process for covering vacant hours was altered by the Trust. It was reported that Trust office must be informed of vacant shifts and bank staff are allocated shifts at the home. Where bank staff cannot cover the shifts, the home is given authorised to contact agency staff. Feedback from staff regarding these arrangements were that on-call managers do not fulfil the same role, the service only provides clinical guidance and not advise on staffing. Reports also indicated that at times the agencies are contacted at very short notice. From the information received from managers, authorisation has been given, for Trust staff to seek staff from five specific agencies. There is confirmation from these five agencies that CRB checks are obtained for their staff. While the agencies assure that CRB’s are obtained there is no confirmation that they only employ staff with clear CRB’s. There are no other processes followed at the home to establish the agency staff’s suitability to work with vulnerable adults. Agencies are not required to provide copies of their staff’s CRBs that work in Trust homes, provide specific information about the recruitment process or inform the home of the name of the person allocated to cover the shifts at the home. Staffing levels were checked and concerns were raised about the night cover. Within the reports of significant events, from house 2 staff had to assist in house 1, with four other incidents in that week, leaving the residents in house 2 unsupervised. Members of staff reported that four residents routinely get up before the day staff cone on duty. The current staffing arrangements must be reviewed. It was reported that on one occasion personal care was conducted on the floor because assistance from house 2 could not be summoned. Staff records were examined and training records indicated that statutory training was provided. Supervision records showed that sessions are constructive and monitor performance. Actions relating to their key worker residents were acknowledged. Members of staff were positive about the sessions. Supervision must be more regular. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 41 & 42 Records of cash held in safekeeping are accurate and up to date. Steps must be take to ensure the safety of the residents at the home. Staff made positive comments about the future management of the home. EVIDENCE: Permanent staff were consulted on the style of management used at the home. A member of staff in house 1 reported that there was a good sense of team in house 1 and the manager was good. It was further stated that the staff at the home are clear on their position and responsibilities and there was good communications with senior staff. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 20 In terms of the appointment of senior staff, staff reported that prior to these appointments, the atmosphere was tense because of the implication to colleagues. Staff are pleased with the appointments and feel able to focus on the provisions of care. Staff believe that since there was a good response to the recruitment drive a team can be developed. Facilities for the safekeeping of cash and valuables exist at the home and residents have cash in safekeeping. Cash balances are checked at each handover, which are doubly signed. Receipts for purchases made on behalf of the residents tallied with the recorded balances. Fire safety records were examined and indicated that checks are conducted at the stipulated frequencies. The Fire policy was dated 25/6/03 and reviewed 2/2/05. However, the manner in which each resident would react in an evacuation situation was not stated. Members of staff believe that they did not evacuate, when fire bells were sounding. Although it was stated that the noise would wake residents and vagueness was conveyed on the individuals reaction. An immediate requirement was issued for the staff to revise the fire policy. It must include a detailed response from the staff to each resident. As a result of the policy, sleeping cover has been reinstated until there is a comprehensive assessment of the fire procedure. Additionally, records show that only 12 staff have attended fire training since November 2004, raising the concern for residents in the event of a fire at night. Work Place risk assessments completed on 24/12/04 state that individual fire risk assessments must be completed. This has not been completed. Records examined indicate that the staff conducts monthly checks. It was noted a bath has not been functioning since 9/5/05 and remains out of order. Staff stated that this is due to the spare part needed to be ordered from Sweden and assurances were made that the bath would be functioning soon. Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 x x 1 x Standard No 31 32 33 34 35 36 Score x 1 x 1 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tramways Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x 3 1 x Version 1.40 Page 22 D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Standard 9 Regulation Requirement Timescale for action 30.11.05 2. Standard 6 3. 4. 5. Standard 19 Standard 20 Standard 22 6. Standard 34 Regulation Risk assessments must be 13 (4) completed for activities that may involve an element of risk. Previously required (26.11.03, 26.5.05, 19.1.05). Generic risk assessments must be conducted particularly for manual handling, locking bedroom doors and keypads for leaving the home. Regulation PCPs must be cleared in terms 15 of the action plans. They describe the means of communicarion and decion making which must be signed and dated Regulation Documentation must evidence 13(b) that professional advice sought is followed by the staff. Regulation Signed consent from the GP 13(2) must be sought for concealing medication. Regulation Records of complaint must 22 include the investigation conducted, the outcomes and the complainants level of satisfaction. Regulation The suitability of agency staff to 19 work with vulnerable adults must be sought before they cover vacant hours at the home D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 30/12/05 30/10/05 30/10/05 30/10/05 30/10/05 Tramways Page 23 7. 8. Standard 36 Standard 42 Regulation 18(2) Regulation 23 (4)&(5) Members of staff must have six supervisons sessions per year. a)A review of the fire procedure must be conducted. b)Members of staff must attend fire training and fire drills at the stipulated frequencies, c)individual fire risk assessments must be completed in line with the WorkPlace assessments 30/10/05 30/11/05 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 Standard 22 Good Practice Recommendations Consideration to enabling the residents to make complaints Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 300 Aztec West Almondsbury South Gloucestershire BS32 4RG 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 Tramways D05_D56_Tramways_S26641_V241861_030805_Stage 4.doc Version 1.40 Page 25 - 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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