Inspection on 06/09/06 for Valley House

This inspection was carried out on 6th September 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Valley House 25/03/06

Valley House 19/07/05

Valley House 16/10/04

Valley House 14/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Valley House Elham Valley Road Barham Canterbury Kent CT4 6LN Lead Inspector Nicki Dawson Unannounced Inspection 6 and 8th September 2006 13:25 th Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Valley House Address Elham Valley Road Barham Canterbury Kent CT4 6LN 01227 832230 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) Family Investment (Five) Limited Post Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th March 2006 Brief Description of the Service: Valley House provides residential care for up to 8 adults with a learning disability. It is situated in the beautiful rural setting of Elham Valley vineyards. There are no amenities in the immediate area, but the small village of Barham is a few miles away. Buses provide links to Canterbury and Folkestone. A small parking area is available at the home with further parking nearby. The home is owned and managed by Family Investment Limited. The families of residents buy shares in the company. Family Investment Limited also operate a pottery and tearoom on the same site. The home manager, Annette Norton, has been in post for a year and is in the process of applying for registered manager of the home. The home is on two floors. It has recently been extended to provide two additional en-suite rooms. It has eight single rooms with en-suite shower facilities. There is a bathroom with toilet and shower facilities on the second floor and a shower room for visitors on the ground floor. The communal space consists of a main lounge and dinning room. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Wednesday 6th September at 1.25pm and took 6 ½ hours. The inspector spoke with all eight residents who live at the home and joined them for their evening meal. Discussion took place with two support staff and one senior support staff on duty at the home. The inspector also looked around the main areas of the home and was invited to view a number of resident’s bedrooms. Time was also spent looking at records kept at the home. The inspector returned by appointment at 1.30pm, for 2 hours on Friday 8th September to meet the home manager. Two relatives of a resident were also met on this occasion. What the service does well: What has improved since the last inspection? What they could do better: The home should have written a guide for residents about the services and facilities provided by the home, called a ‘service user guide’ 4 years ago and this still has not been done. There should be enough information on every new resident who comes to live at the home to make sure that staff know how to help them. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 6 The records used to record whether medication has been given to a resident are not being filled in properly. This could mean that a resident has not received the medication that they should have done, which may put their health at risk. Not all staff records are kept in the home that should be. The manager needs these records to ensure that competent staff have been employed in the home. 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. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents do not have all the information they need to make an informed choice about where to live. Not all prospective residents have their needs fully assessed before moving into the home. Prospective residents have opportunities to visit the home before deciding if it meets their needs. EVIDENCE: The home has produced a ‘statement of purpose’ that sets out the aims, objectives and philosophy of the home, together with the services and facilities provided for residents. The home has been required, since the National Minimum Standards came into effect in April 2002, to produce a ‘service user’s guide’, which clearly sets out for residents, the services and facilities that they can expect if they move to the home. The home produced this guide in a draft format over 6 months ago but has yet to give a copy to each resident, in a format that is easy to understand. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 9 Records were inspected which related to the assessment of three potential resident’s suitability for living in the home. Two potential residents had a detailed assessment, which staff said was helpful in ensuring that their care needs were met. For the third potential resident, there was limited information and staff said that it was not sufficient in order to fully understand the residents support needs. All three potential residents had the opportunities to visit the home, including overnight stays, before deciding whether the home met their needs. Staff undertook an assessment of residents’ independent living skills during this time. A resident contract was sampled which sets out the terms and conditions of residence at the home. It does not currently include the fee, although it states that this is available from the organisation. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s care plans and risk assessments have improved and now include clear guidelines as to how staff support residents assessed needs. Residents continue to be involved in decision making in the home and to be consulted on and participate in all aspects of home life. EVIDENCE: The way that resident’s care plans are written has been changed since the last inspection. They now contain all the information necessary for staff to be able to support residents as needed. The plans are updated regularly and any changes are highlighted. Staff said that care plans were easy to understand and use on a daily basis. Residents are involved in any changes to their care needs. Residents are supported to take risks and these are clearly recorded in individual risk assessments. To minimise the risk for the resident, there is a Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 11 checklist which staff use before the activity is undertaken. One such example is of a resident learning to use the bus independently. Residents said that they were able to make choices as part of their everyday lives. For example, residents said that they took turns to choose what to eat at mealtimes and they stated that they are free to change their day activities. Residents said that they were able to make their views known at residents meetings. These take place monthly and are recorded. There are clear records kept of all money transactions involving the residents in the home. Residents are encouraged to save money for activities, holidays and transport so that everyone has sufficient money to participate. Whilst there is no evidence to suggest that any money belonging to a resident has been used inappropriately, the current systems in place need to be reviewed. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents continue to enjoy a full and stimulating lifestyle with a variety of options to choose from. Residents have the opportunity to develop and maintain important personal and family relationships. Residents are actively supported to be independent and are involved in all areas of daily living in the home. Mealtimes are relaxed and residents are supported and given guidance on a balanced diet. EVIDENCE: Staff encourage residents to participate in their share of the household tasks and to be as independent as possible. Each resident is allocated one day at Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 13 home a week to attend to their household tasks. As mentioned previously, individual plans are in place to develop residents’ independent living skills. Family Investment has developed a range of day opportunities for the residents. There is a pottery, vineyard and teashop in the area surrounding the home and a workshop situated in Barham. The residents are actively involved in these activities and said that they were pleased with their activity programmes. They explained that if they were not happy with an activity they could change to one that they prefer. Some residents also take part in work opportunities in the community. Residents have opportunities to participate in a range of leisure activities, including the Special Olympics, swimming, keep fit, going to the cinema and shopping. Residents had recently come back from their summer holidays organised by the home. Some resident’s can travel independently. The home has use of one car and on occasions a mini bus. Residents are able to develop and maintain relationships with friends and family. Some residents spoke about the friends they had made that live at other Family Investment houses. Relatives said that they were able to visit the home when they wished. Residents, who wish, have a key to their room to maintain their privacy. It was observed that at times some residents chose to spend time in their rooms. This choice was recognised and respected by staff and other residents. The inspector joined the residents for their evening meal. Staff and residents sat down together to eat like a large family and the inspector was made to feel part of the occasion. Some residents prepared the meal, others helped to clear the table and others to wash up. The menu indicated that residents are given choices at mealtimes and that a well-balanced diet is provided. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way that they prefer and require. Residents’ physical and emotional needs are met. The systems in place for the administering of medication need to be strengthened to ensure that residents are safe at all times. EVIDENCE: Residents staid that staff were there to help them with any personal support that they required. Staff ensure that residents regularly access relevant health care professionals. All health care appointments and the outcomes are clearly recorded. These records have been reorganised to enable staff to find the relevant information more speedily. Resident’s emotional needs are recognised, recorded in their care plans and professional support accessed where appropriate. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 15 Selected aspects of the ordering, storage and administration of medications were inspected, including the administration of medicines. The home has a comprehensive policy on the administration of medication and residents are able to self-medicate where appropriate. Staff have attended training on the administration of medication and knew what to do if any medication error was made. Generally the administration of medicines complied with the home’s procedures, with two important exceptions. In respect of three residents there was at least one occasion when staff had not signed the medication record sheet to indicate whether the medicine had been administered or refused. It was impossible to check whether the medication had been given by undertaking an audit since staff had not recorded the date that the box of medicine had been opened. Secondly, staff were aware that any handwritten entries on the medication record sheet should be countersigned to check the accuracy, but had not done so. The home is required to ensure that systems are in place to audit the medication administration sheets on a regular basis. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel that their views are listened to and acted on. Staff demonstrated their ability to deal appropriately with any suspicion of abuse. EVIDENCE: Residents said that if they had a problem they would speak to a member of staff or take it to the regular resident’s meeting. Staff demonstrated that they would encourage discussion and action, before a problem developed into a formal complaint. The complaints procedure is on display in the home and staff understood how to put it into practice. Staff demonstrated through discussion that they would take any suspicion of abuse seriously and report it to the home manager. Most staff have been on training courses and learnt how to protect vulnerable adults from abuse. The home has a ‘whistle blowing’ policy and staff said that they felt confident in using it if the need arose. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 17 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): 24, 25, 26, 27, 28 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Valley House looks and feels like a family home. The home is clean. EVIDENCE: Valley House is situated in a beautiful rural location and many of the upstairs rooms have views across the vineyard and surrounding countryside. The local amenities can be accessed by public or house transport. The home has recently been extended upstairs to provide a further two ensuite bedrooms. Downstairs, one bedroom has been extended and ensuite facilities added. All residents benefit from a bedroom with ensuite facilities. The inspector viewed a number of resident’s rooms by invitation. Each resident has a single room and all but one, has ensuite toilet and shower facilities. Bedrooms have been decorated according to individual tastes and to a good standard. A number of bedrooms have been redecorated and the residents Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 18 concerned were very pleased with the results. Rooms contain items that are important to the residents. Downstairs there is a large living room a dining room that has been extended, a kitchen and laundry area. The garden has been laid to lawn, with a seated area. The home was clean, bright and inviting on the day of the inspection. The majority of staff have been on a training course about how to minimise the spread of infection and they demonstrated that they had sufficient knowledge in this area. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 19 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): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and effective staff team supports residents. Staff files require reorganisation to ensure that there is an effective recruitment procedure in place in the home. Staff are well supported by the home manager. EVIDENCE: Through discussion and observation, staff demonstrated that they understood the main values of the home and were clear about their roles and responsibilities. There was a good rapport between staff and residents and staff showed that they had a good understanding of residents’ individual needs. The National Minimum Standards are that 50 of staff, including bank staff should have completed NVQ 2 by 2005. This has not been met since there is a relatively new staff team at the home. One staff has achieved NVQ 2 and two staff are planning to start NVQ 2. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 20 The number of staff on duty during the day and evening has been adjusted since the last inspection, to take into account the additional two residents in the home. There are two members of staff available during the afternoon and evening and at the weekend. These staffing ratios ensure that there is sufficient staff on duty to give residents the choice as to whether to go out or stay at home. Staff records kept in the home did not contain all the information that is necessary to ensure that proper procedures are in place for the recruitment of new staff. The manager said that she has checked that the missing information has been obtained and that it is currently held in the main office. The manager agreed to audit staff files to ensure that all the relevant information is kept in the home. The training records of the whole staff team indicate that most staff has received training in the required areas. A new staff member stated that they had undertaken the relevant skills for care induction training when commencing employment at the home, although a copy was not in their staff file. Staff said that they were well supported by the home manager and received regular supervision and an annual appraisal. The manager explained that supervision is not always recorded and agreed to do this in future. There are regular, recorded staff meetings. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by a home manager whom people feel comfortable with. Resident’s views are listened to and acted upon. Residents live in a safe environment. EVIDENCE: The home manager, Annette Norton has been in post for 1 year. She has working in care settings for people with mental health and learning disabilities for 13 years, including 4 years as a house leader. She obtained the City and Guilds Advanced Management for care in 1998. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 22 Residents, staff and relatives praised the management approach of the home manager. One person described her as, ‘brilliant’ and another that they, ‘couldn’t have done it without her’. She has a clear management direction and everyone who expressed a view, said that she was approachable and supportive. The home uses various methods to gain the views of residents, staff and stakeholders about the quality of care provided at Valley House. Staff meetings are held and the home’s policy states that there are shareholders meetings and an annual general meeting. Residents said that their views were sought and listened to during regular meetings and in addition they complete a quality service questionnaire yearly. A selection of policies and procedures were sampled. Staff said that the homes policies and procedures were accessible and that they knew where to find a piece of information if it was required. An inspection of records indicated that there is a system in place to ensure the regular maintenance of the services and facilities in the home. Staff now take part in fire training and regular fire drills to ensure the safety of residents. The first aid box is well supplied and the majority of staff have training in first aid. Records indicate that any accidents that occur are recorded and dealt with appropriately. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 23 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 2 2 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 3 27 4 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 4 3 3 X 3 X Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 24 YES 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. 2. Standard YA1 YA2 Regulation 5 (2) 14 (1) (a) (b) 13 (2) Requirement Timescale for action 08/03/07 3. YA20 The service user guide should be completed and a copy given to each resident and the CSCI. The needs of a resident should 08/10/06 be fully assessed and recorded in writing before they move into the home The appropriate code must be 15/09/06 made on the MAR sheet when administrating all medications (previous timescale of 19/07/05 and 01/04/06 not met) The date should be recorded when a new box of medication is opened. All handwritten entries on the MAR sheet should be countersigned to ensure accuracy. A system should be put in place to ensure that no.3 is put into practice To audit staff records kept in the home to ensure that they contain all the information in schedule 2 4. 5. YA20 YA34 13 (2) 19 schedule 2 08/10/06 08/11/06 Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 25 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. 2. 3. Refer to Standard YA5 YA7 YA36 Good Practice Recommendations Residents statement of terms and conditions should include the amount of fees payable To review the current systems in place for residents’ activities, holiday, and transport funds. Staff to receive formal recorded supervision six times a year. Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Valley House DS0000023287.V303537.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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