Inspection on 29/10/07 for Westerley

This inspection was carried out on 29th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 but made no statutory requirements on the home.

Other inspections for this house

Westerley 14/11/06

Westerley 02/02/06

Westerley 12/09/05

Westerley 07/03/05

Westerley 04/11/04

Westerley 15/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Westerley 1 Winton Avenue Westcliff On Sea Essex SS0 7QU Lead Inspector June Humphreys Unannounced Inspection 11.30 29 &31 October 2007 th st X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westerley Address 1 Winton Avenue Westcliff On Sea Essex SS0 7QU 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) 01702 349209 01702 213192 westcliff@lwpt.org.uk The Leaders of Worship and Preachers Homes Simon Andrew Lee Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2006 Brief Description of the Service: Westerley is registered to provide care and accommodation for 21 older people. The home is managed and run on Christian faith, belief and values. The premises was converted from 2 hotels and extended in 2001. All rooms have ensuite facilities. There are 5 double rooms, which may be used as large singles. Some bedrooms have views of the Thames Estuary. There is a choice of 2 lounges and a separate dining area. There is a small patio area at the rear of the home. A prayer service with hymns takes place in the lounge each weekday morning. There is no off street parking and the driveway provides very limited spaces. The home is situated close to the main shopping areas of South end, Westcliffe and Leigh on Sea. There are good bus and train links to the area. The range of fees provided by the manager was £406 - £500.00 per week. There are additional charges depending on the type of bedroom available/requested and items of a personal nature. A copy of the home’s Statement of Purpose is displayed in the foyer. The Service User’s Guide and brochure is currently not available and the manager should be contacted for the updated version when available. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains the outcomes of the unannounced key inspection completed on the 29th and 31st of October 2007. Evidence gathered during the inspection included: • Observation of interaction between staff and service users, • Individual interviews with four service users, and four support workers • A detailed discussion with the registered manager • A look at relevant documentation maintained in the home. • Paper evidence received by the CSCI from the service since the last inspection on the 14th November 2006. Records and documents were looked at in detail, including a sample of care plans, two staff files and supervision records, the staff rota, complaints, medication and accident records. What the service does well: What has improved since the last inspection? Staff recruitment files seen were satisfactory, and all the necessary checks had been completed Staff have a greater understanding of the importance of storing COSH products appropriately. The manager has identified Safeguarding training for all staff. Administration and recording of medication has improved. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can expect a detailed assessment of their needs to be carried out prior to admission and to have opportunities to visit the home, however there is no up to date service users guide or brochure to assist them to make a judgement about the service. EVIDENCE: Prospective Service users and relatives do not have an up to date information booklet or service users guide available to look at prior to admission. A relative stated “a service users guide or brochure was not given to me when we visited”. The manager advised that this is in the process of being developed. The manager has the key role in completing pre-admission assessments. An inspection of the most recent assessment showed that it had been completed to a good standard, with no gaps left on the form. The service users care plan Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 9 is developed from the assessment and the inspector was informed that every effort was made to involve the person in the assessment process. The service user said “I visited the home several times before moving in, and I was made to feel most welcome.” All prospective service users visit the home, and spend time meeting the staff, and the people already living at the home prior to admission. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The level of detail in care plans for people who are highly dependent is inadequate and personal care needs are not always being met. Service users are helped to access a full range of healthcare facilities available to them; medication in the home is managed well. EVIDENCE: Although care plans were available and appeared to have been reviewed regularly, the care plans for those residents who had higher dependency did not reflect the level of care required. One resident was very confused, the inspector looked at her care plan and could not establish what her individual care needs were. The care plan did not state that this person required greater support than many of the other residents in the home. The home cares for several people who are more dependent then many other residents. One person is currently formally diagnosed with Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 11 dementia. Staff were observed communicating well with residents, reassuring and explaining what was happening. However concerns were raised from two relatives who felt the care provided was not always as good as it could be. One person said her mother was found to be ‘dirty’ on several occasions when she visited. She acknowledged that this was not always the case and that some staff were “excellent and went beyond their duty of care”. One member of staff also said “The new service users being admitted have greater needs, and the ones already here are getting older, and they also need more help with their basic care which is more demanding.’ Several of the more independent service users said ‘the home is catering for people who need lots of help, that’s not how it used to be.’ Although efforts have been made by the manager in improving practices there still remains some concerns. The inspector observed four sets of soiled underwear in the resident’s bedroom drawer, which indicated that the resident was not being monitored appropriately or their personal care needs addressed. A number of service users manage their own medicines including homely remedies i.e. cough linctus, lotions and creams. This has improved since the last inspection where concerns were expressed in relation to storage and recording. The manager has met with service users and staff to ensure that all medication is adequately stored and recorded. Two-service users medication was checked thoroughly and found to be correct, this included current controlled drugs. The manager audits medication regularly and had also been involved in ordering and checking prescriptions in the absence of the assistant manager. This has provided an opportunity to observe and coach staff, and check their understanding of the process of administering medication correctly. Staff demonstrated that individual service users, rights of privacy and dignity were respected, and this was observed when undertaking a tour of the building. Staff knocking on service users doors, and calling out before entering bedrooms. On the day of inspection service users appeared appropriately dressed, clothing did not look creased, their hair looked nicely groomed and they did appear clean. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. There is a limited range of activities available in the home, therefore residents do not receive appropriate stimulation according to their level of need. Residents are offered a good choice of wholesome food. EVIDENCE: The provision of activities has declined since the last inspection. The last inspection report stated “the elements contained within the above standards form the main strength of the home.” The manager advised that service users had repeatedly said that there were too many activities. Activities used to be in the morning after morning prayers, but the service users committee had asked that this be moved to the afternoon, as it was too much. There was a notice on display stating that activities had been reduced due to the staffing levels at the moment. The manager said that this was no longer the case, and that the notice had not been removed in error. However staff interviewed said that activities were almost non-existent, which was a problem for the people with higher needs. From speaking to service users the less dependent still managed to go out and therefore activities were not seen as a Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 13 priority. But for the more dependent the service now offered very little stimulation. One member of staff was observed reading the newspaper, and it was encouraging to see that she talked to the two service users sitting next to her. It was noticeable that only the more able participated in this activity. Several service users said ‘the residents committee is a waste of time’, they also said that no changes were made that were requested. Several relatives stated that relatives/carers meetings had not been held this year, and that there was little opportunity to express their views. Minutes of the meeting with any agreed outcomes had not been recorded. It has been recommended that the use of advocacy services are invited to meetings to ensure that people with high dependency are represented. The home is managed and run on Christian beliefs and values and this underpins much of what happens in the home on a day-to-day basis, therefore, this attracts residents of like mind and a mutual interest. The range and choice of food remains very good. There was no criticism of the food served from either service users or relatives. The dining area was very pleasant and welcoming. Tables at breakfast, lunch and for tea were attractively laid and presented. Many of the bedrooms seen were above average in size and some service users had made a small separate area where they chose to eat. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust complaints procedure was in place and people using the service and their relatives can be confident that their complaints will be listened to and acted upon. EVIDENCE: Several residents and family members were asked for their views and all said if they had a complaint, they would have no hesitation in speaking to the manager and felt that he would listen to them and try to resolve things. The manager knew all the service users to talk to and appeared to understand their individual needs. He said he tried to intervene when a service user expressed a concern, as he did not want them to feel worried. He usually investigated complaints himself, and responded personally. Several service users said that any issues of discontent are dealt with very quickly and therefore formal complaints are not common practice. There has been one formal complaint recorded since the last inspection. The service should consider recording service users concerns/ grumbles as several people said that they did not feel they always had a response, and as few complaints are made, it was difficult to establish if the concern had been dealt with and resolved. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for people to live. The home is well maintained and appeared to be clean and homely. EVIDENCE: The communal areas in the home have a comfortable and homely atmosphere and all are individually decorated. Each bedroom is different in both size and decor. Individual service users said they were encouraged to bring personnel belongings and make their bedrooms their own personalised space. The home was odour-free and very clean. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has adequate recruitment procedures therefore service users are protected from abuse. Staffing levels vary and service users cannot be assured that staff will always have much time to spend with them EVIDENCE: The home is fortunate in being able to retain a small number of regular staff, who have worked at the home for many years. This provides service users with a number of people that they are familiar with and know well. At the last inspection concerns were raised about the consistency and quality of care. This has improved, but further work is required to ensure, that all service users receive the appropriate level of support that they need. Service users spoken to during the inspection were on the whole positive about the care they received, but most did say that mornings were ‘exceptionally busy’. One service user said ‘the carers are very busy, they don’t always have time to come and chat with me’. Another said, ‘Staff are very kind here, but I try to do as much as I can because staff are so busy.’ It must be acknowledged that the people interviewed were the more able group of service users, and the majority of concerns related to the less able people who required greater assistance. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 17 On the first day of the inspection, there were two carers, and the manager who was acting as the shift leader. Service users seen were clean, tidy and dressed in a presentable manner. Staff on duty appeared busy, but not overwhelmed. Staff interviewed over the two days were generally appreciative of the manager who they described as ‘supportive’ and ‘helpful’, but every staff member interviewed clearly stated that the needs of service users now living at the home had increased and that staff felt that the workload had increased and was heavier. One care worker said, “it’s really hard work, but it’s a lot better then other places I have worked, and I am very happy here”. A further person said, ‘morale has been effected by staff shortages, but sickness is a problem, some staff just don’t turn up and this has caused problems in the team”. Service users and their relatives comments were variable, some felt the standard of care was good, whilst others felt that although there had been improvement from earlier in the year, the care was dependent on which staff were working i.e. inconsistency in the quality of provision. The rota was looked as part of the inspection and showed that there usually was two carers and a senior leading the shift in both the morning and afternoon, but often only two staff, one senior, and one carer had been available in the afternoon. When seniors are managing the shift they are not necessary expected to provide hands on care, which places extra pressure on care staff. One service user said that sometimes carers forgot what she had asked for. This had partially been overcome by writing her requests down, but this should not be necessary. Two further service users were very clear that the needs of people now being admitted to the home had increased. But overall staffing ratio’s had not changed. The Manager confirmed that this was the case, but that he personally completed the initial assessment prior to admission, and was careful that new admissions “did not stretch resources”. The recruitment records for a recently appointed member of staff evidenced that the correct procedures and checks had been carried out and that the new staff member had not commenced duties until a clear CRB check had been received. This area of work has improved since the last inspection, along with the development of training relating to safeguarding. This provides confidence and reassurance to people living in the home that unsuitable people will not be employed to care for them, and that staff know, and understand how to protect them by using appropriate polices and procedures. The manager advised that 48 of staff is now N.V.Q qualified. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is approachable but shortfalls have been identified in the management processes, which impact on the quality care EVIDENCE: The manager explained that over the past year there had been difficulty in ‘recruiting good quality carers’. The deputy had left earlier in the year, and the assistant manager experienced a period of ill health. Staff spoken to acknowledged that it had been a difficult period, but that ‘the managers door was always open’. He was ready to listen, and made every effort to sort things out. Despite this, supervision had not been offered on a regular basis, and Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 19 team meetings had been held on an infrequent basis. Communication with regard to the care of service users has continued through regular handovers. Whilst the manager has experience of both working in, and managing the service he had not set out his priorities to move the service forward. Most of his time appears to have been spent working with staff to try to maintain the quality of the service. On several occasions he acknowledged he had worked in the kitchen as the cook. The records evidenced that staff are not appropriately supervised and that a programme of annual staff appraisal is not in place. Team meetings are infrequent, and not all staff feels a commitment to taking part. Some staff spoke of a divide within the staff team. There is a need for this to change to develop a sense of team spirit and improve overall service delivery. The arrangements for quality assurance were reviewed. The manager was able to evidence that various satisfaction questionnaires had been sent to stakeholders and had been returned with comments. At the time of the inspection there had been no analysis of the information collected and therefore the information was not yet able to drive change and improvement. It is important that an objective system is operated to demonstrate that the service has a continuous self-monitoring qualitative approach using a systematic cycle of ‘planning, action and review’ as described within National Minimum Standards. There will need to be at least an annual internal review of the service quality with the outcome results published and made available to service users and other stakeholders. Relatives, service users and staff all said they had not had an opportunity to see the outcomes of the quality review and this should be displayed with the statement of purpose, service user guide and registration certificate. The manager has not completed his N.V.Q 4, manager’s award qualification as he had planned to at the last inspection and he outlined the difficulties he had experienced with the local college. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 X 3 Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement Service users must be able to access an up to date, accurate service user guide and brochure, prior to moving into the home, which meets the requirements of the Care Homes Regulations 2001 (revised). Care plans must contain accurate, detailed information on the person’s care needs, and ways to provide their care, particularly for those with higher dependency. This is to ensure that residents receive the care they need and risks are minimised or eliminated. Assistance must be provided to residents personal care needs at all times. All service users must be offered the opportunity to engage, and participate in a range of appropriate activities. This will ensure that service users live in a stimulating environment. The registered person must ensure that there are suitable numbers of staff employed and DS0000015484.V351493.R01.S.doc Timescale for action 01/03/08 2. OP7 15 (1) 2 (b) 01/02/08 3. 4. OP8 OP12 12 (1)(b) 16 01/01/08 01/02/08 5. OP27 18 01/02/08 Westerley Version 5.2 Page 22 deployed within the home to meet the needs of all service users. (This refers to the concerns expressed by staff and relatives in relation to service users with ‘high needs’.) 6. OP33 24 There must be an effective system for monitoring and improving the quality of care. A report must be submitted to CSCI in respect of an annual quality review. Staff must receive regular recorded supervision to ensure that staff are supported to provide appropriate care to service users. The manager must undertake training to ensure that he has the skills to manage the home in the best interests of the service users 30/04/08 7. OP36 18 01/04/08 8. OP31 9 01/12/08 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 OP16 Good Practice Recommendations The procedure for the definition and recording of complaints should be reviewed to ensure that, any concerns/complaints raised by service users or stakeholders are recorded and responded to. Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westerley DS0000015484.V351493.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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