Care Home: 77 Gloucester Road North

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CARE HOME ADULTS 18-6577 Gloucester Road NorthFilton Bristol BS34 7PLLead InspectorSandra Jones Unannounced Inspection 3rd June 2008 09:30DS0000071364.V364403.R01.S.docVersion 5.2Page 1 DS0000071364.V364403.R01.S.docVersion 5.2Page 2 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 organisationReader InformationDocument 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.ukInternet addressDS0000071364.V364403.R01.S.docVersion 5.2Page 3 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.DS0000071364.V364403.R01.S.docVersion 5.2Page 4 SERVICE INFORMATIONName of service 77 Gloucester Road NorthAddressFilton Bristol BS34 7PLTelephone 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)TBC TBCadmin@aspectsandmilestones.org.uk Aspects and Milestones TrustManager post vacant Care Home 7Category(ies) of Learning disability (7) registration, with number of placesDS0000071364.V364403.R01.S.docVersion 5.2Page 5 SERVICE INFORMATIONConditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 7.Date of last inspectionBrief Description of the Service: Aspects and Milestones Trust operates 77 Gloucester Road North as care home providing personal care to seven people with learning disabilities. The property is within its own grounds close to shops, pubs, Cafes, library and bus routes. There is level access into the home and for individuals with mobility impairments there is a passenger lift to both floors. Communal areas are on the ground floor and bedrooms on both floors. Bedrooms are single, with full en-suites and decorated to reflect the person’s personality.DS0000071364.V364403.R01.S.docVersion 5.2Page 6 SUMMARYThis is an overview of what the inspector found during the inspection.The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key inspection was conducted unannounced in June 2008 over two days and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the Annual Quality Assurance Assessment (AQAA). This information was used to plan the inspection visit. “Have your say” surveys were sent to the relatives of the people living at the home and health care professionals. Surveys were received at the Commission from two relatives. Five individuals were living at the home were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings.What the service does well:Relatives made the following comments about what the service does well, “The care given allows for clients to be involved in decision making as well as giving respect and valuing each individual” and “ My daughter is well looked after”. The property provides a homely environment that meets the needs of the people at the home.What has improved since the last inspection?DS0000071364.V364403.R01.S.doc Version 5.2 Page 7 It is evident that the staff are more cohesive and are working together to provide good outcomes for the people at the home. Members of staff support individuals to use the local facilities, which ensure that they are recognised in the local community.What they could do better:There are two requirements arising from this inspection and are based on including “best interest” decision in the care plans of the people that have communication needs. Members of staff must sign medication administration records immediately after administering the medication.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.DS0000071364.V364403.R01.S.docVersion 5.2Page 8 DETAILS OF INSPECTOR FINDINGSCONTENTSChoice 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 InspectionDS0000071364.V364403.R01.S.docVersion 5.2Page 9 Choice of HomeThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): (2) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There is an effective admissions procedure in place, which enables individuals wishing to live at the home to make an informed choice about moving there. They can be reassured that the home will have the skills and resources to meet their assessed needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide which outlines the services and facilities offered at the home. Included within the Statement of Purpose are the arrangements for admission and states that referrals for admission are generally made by the Local Authority and Trust polices are followed for admission to the home. The Service User Guide is symbolised with pictures and words and informs individuals about extra charges not included in the fees, their responsibilities and the assistance that will be provided. Copies of the home’s Statement of Purpose and Service User Guide are kept in the personal files of the people at the home. The home can offer accommodation to up to seven people with learning disabilities and currently there is one vacancy.DS0000071364.V364403.R01.S.doc Version 5.2 Page 10 DS0000071364.V364403.R01.S.docVersion 5.2Page 11 Individual Needs and ChoicesThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): (6), (7) & (9) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. There are effective care planning systems in place and individuals benefit from receiving an individualised and consistent service. Documentation must show that individuals are involved in making decisions about all aspects of their care.EVIDENCE: Care plans are written in the first person and describe the individual’s routines with additional information about mobility, personal safety and they way they make choices and communicate. While there is a vast improvement in the care plans, further developments are needed about the person, decisions making abilities and risk assessments. The assistant team leader, present during the inspection, explained that care plans are to be reviewed and keyworkers are in the process of gathering information to compile personal care plans and there are set timescales.DS0000071364.V364403.R01.S.doc Version 5.2 Page 12 The senior member of staff giving feedback said that support workers act as keyworkers and as part of their role, they are reviewing the care plans. As there is more of a team spirit, suggestions are being made about the best methods of managing and supporting the people at the home. These suggestions will then be discussed and where appropriate included in the individuals care action plan. Members of staff maintain daily records of occurrences, observations of the person, tasks undertaken and outcomes of visits. The records also show that people at the home are supported to make decisions about their daily lives. The team leader stated that at a recent team day, staff were informed about the Mental Capacity Act and “best interest” decisions. Staff will be attending Mental Capacity Act training, this will empower people living at the home to make choices over all aspect of their lives. Feedback about the way individuals are empowered to make decisions was sought from the senior member of staff. It was stated that new care plans would include offering choice and describe the way choice is to be offered to the person. Two relatives gave feedback through surveys about the home and their comments indicated that the home always meets the needs of their relative living at the home. Each person has a Personal Safety Summary that states the individual’s ability to leave the home without staff support, the individual’s ability to summons help and where appropriate health care needs. Risk assessments are being reviewed by keyworkers along with care plans and risk assessments must also be developed for activities that may involve an element of risk. For example removing clothing in public.DS0000071364.V364403.R01.S.docVersion 5.2Page 13 LifestyleThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): (12), (13), (15), (16) & (17) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There are good support systems in place for residents to lead active and interesting lifestyles and to be valued members of the community EVIDENCE:Day services are currently provided by an external organisation for all but one person currently accommodated. A rota of the day services provided by external day services including 1:1 are maintained and daily routines include information about the things individuals enjoy doing. Staff organise in-house and community activities and these include trips to the local shops, church services, leisure centres, library and aromatherapy visits to the home. Through the surveys relatives said that the home supports their relative at the home to live the life they choose.DS0000071364.V364403.R01.S.docVersion 5.2Page 14 Staff say that people at the home are recognised in the community because individuals are supported by the staff to use local shops, visit the library, churches and leisure centres. It was further stated that people at the home are invited to local Coffee mornings, go to Bingo and agencies in the community are working with the staff to develop links that support the people at the home. The Visitor’s policy recognises the importance of maintaining contact with friends and family. It endorses open visiting. The staff at the home said that two people have regular contact with relatives and individuals are supported to visit family. The two relatives that responded through the surveys said that the care home always helps their relative at the home to keep in touch. The Statement of Purpose confirms that the Trust policies about rights, sets the approach for respecting individuals privacy and dignity. The team leader said that job descriptions, staff training and documentation ensure that people at the home are respected as individuals. The team leader stated that people at the home are encouraged to be involved in the day-to-day tasks but there is no expectation that they undertake household chores. It was also stated that there are no rules for smoking or alcohol because people at the home are nonsmokers. All rooms are single with full en-suite and while bedroom are lockable the people at the home are not able to use the keys or understand the purpose of locking their door. Individuals were observed independently using all parts of the home, with the exception of the kitchen, which is kept, locked when staff are not present. The team leader said that mail is opened with the person and staff will usually read it for the person. Menus are devised by the staff and generally people have a continental style breakfast, a light lunch and cooked evening meal. There is a good range of fresh, frozen and tinned foods and staff record the individual’s menu choices in the daily report. At a recent Environmental Health inspection the home was awarded 5Star for the hygiene in the kitchen.DS0000071364.V364403.R01.S.docVersion 5.2Page 15 Personal and Healthcare SupportThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): (18), (19) & (20) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. While medication systems are safe, staff must ensure that medications are signed immediately after administrationEVIDENCE: Personal care plans include daily routines that specify the individual’s personal care needs and the way the staff must meet the needs. Health care action plan also form a component of the personal care plans and to monitor individuals health, members of staff complete the Trusts “OK” health checks annually. Its purpose is to assess whether further investigation is needed for example, specific health care needs Visits to the GP and hospital appointments are recorded separately from the care plan and reports include the reasons for the visit and outcome of the visit. For specific health care needs, such as epilepsy, care plans are devised and instruct the staff on the actions to be taken.DS0000071364.V364403.R01.S.doc Version 5.2 Page 16 Documentation held within files show that people at the home access specialist input through the Community Learning Disability Team (CLDT), which include input from psychiatrist and physiotherapists. People also access NHS facilities and, members of staff organise visits to the Chiropodist, dentist and optician. The member of staff was asked to explain the systems that ensure medical advice is consistently followed by the staff. It was stated that health care visits are recorded in daily reports, discussions during handovers and where appropriate included in the care plan ensure that medical advice is followed. Both relatives that responded through the survey said that they are always kept informed about important issues that affect their relative living at the home. Manual handling risk assessments are completed for individuals that have mobility needs and other activities that may involve an element of risk. These include bathing and using transport. Risk assessments are being reviewed with care plans to ensure that correct manual handling techniques are being used. Overall, risk assessments are detailed and will include photographs to support correct moving and handling techniques. Medication statements about the persons ability to self medicate are held in personal files and included the person’s preferred method of taking medication. For example, individuals will eat yogurt in conjunction with their medications. For individuals that lack capacity, the home has sought consent to conceal medication from the psychiatrist through the CLDT and “best interest” decisions were made on their behalf. Feedback about pre-procedure medication was sought from the senior member of staff, who said that two individuals are prescribed sedatives by their consultant, which is administered before a procedure. It was further explained that to reduce distress to the person, specialist NHS facilities are used, for example, the dentist from the CLDT was contacted to visit the home. For individuals that have “when required” medications prescribed, there are protocols that guide the staff on administering the medication. A stock of homely remedies is not currently kept at the home for administration when needed by the person. A record of medications no longer required is maintained and the signature of the pharmacist indicates receipt of the medication for disposal. Medications administration records sheets were checked against the medications held within the secure cabinet. Gaps in the recording of medications administered were found which suggests incorrect use of codes or the staff are not signing the records immediately after administration.DS0000071364.V364403.R01.S.docVersion 5.2Page 17 Concerns, Complaints and ProtectionThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): (22) & (23) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals can expect to be supported to raise concerns and to be protected from abuse.EVIDENCE: The Complaints procedure is symbolised with pictures and words, with copies held in the person’s case file. Two relatives responded to the questionnaires sent to the home and one person said that they knew how to make a complaint and the service always responded appropriately to their complaints. The other relative stated that they could not remember how to make a complaint and the home always responded appropriately to their complaints. Since the last inspection one complaint was received from the neighbour about the fencing and a new higher fence was installed, resolving the complaint. The senior member of staff on duty was consulted about the way individuals are empowered to complain. It was stated that depending on the perceived complaint either the home would resolve the complaint or a complaint would be made on behalf of the person. For example, making an appeal about benefits.DS0000071364.V364403.R01.S.doc Version 5.2 Page 18 The manager said Data Protection, Whistleblowing and Safeguarding Adults are the Trust policies that show a commitment towards safeguarding individuals from abuse. It was also stated that during the induction programme, staff attend safeguarding adults training to instruct them on the factors of abuse and the action that must be taken. It was reported that there are no outstanding Safeguarding Adults referrals.DS0000071364.V364403.R01.S.docVersion 5.2Page 19 EnvironmentThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): (24) & (30) 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 maintained so that individuals can benefit from living in a comfortable and clean environment.EVIDENCE:77 Gloucester Road North was recently purchased by the Trust and converted to offer accommodation to seven individuals with learning disabilities. The property is detached and ahs the appearance of a domestic dwelling, which blends, well with its local environment, close to shops, pubs, library and bus routes. Arranged over two floors with communal space on the ground floor and bedrooms on both floors. Communal space consists of a large lounge and conservatory currently used as a dining room there is also a passenger lift for individuals with mobility impairments to access the first floor.DS0000071364.V364403.R01.S.doc Version 5.2 Page 20 Bedrooms are single occupancy with full en-suites and decorated to reflect the person’s personalities. Two of the upstairs en-suites are not in use because of leaks, the manager has given assurances that action is being taken to rectify the leak. The laundry is away from the kitchen, it has tiled and painted walls and vinyl flooring for easy cleaning. There is a domestic washing machine that can reach 90 and tumble dryer.DS0000071364.V364403.R01.S.docVersion 5.2Page 21 StaffingThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): (34) & (35) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals at the home are supported by a competent, qualified and skilled staff team who are well supervised.EVIDENCE: Two members of staff were recruited since the last inspection and the manager said that completed application forms and written references are retained at the Trust office until the probationary periods is complete. Personal details and notifications of a clear Criminal Records Bureau (CRB) are held at the home for new staff. The Induction programme is detailed and covers statutory training, Trust Values and work base training. Wok base inductions focuses on local procedures, employment information, the role of the worker and the people at the home. Regarding access to training, the manager said that the main aim was for all staff to attend mandatory training. This includes, First Aid, Fire, Food Hygiene,DS0000071364.V364403.R01.S.doc Version 5.2 Page 22 Food Safety and Safeguarding Adults. Members of staff also attended epilepsy and Manual handling training to ensure that they have the skills to meet the changing needs of the people at the home. Medication training was also provided for staff that administer medication. At a recent team day the agenda covered risk assessments, care plans, roles and responsibilities and intimate care for new staff. The senior member of staff giving feedback about the standards of care said that training is accessible and staff have equal opportunities to all training provided by the Trust. It was also said that with the exception of new recruits, all staff are either undertaking or have completed NVQ level3. The two relatives that responded through the surveys said the staff always have the right skills to look after the people living at the home. One person stated “They have training days and also NVQ training.” Individuals supervision occurs 4-6 weekly and copies of the supervision sessions indicate that personal development, duties and responsibilities form part of the sessions. Action plans are then developed from the session.DS0000071364.V364403.R01.S.docVersion 5.2Page 23 Conduct and Management of the HomeThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): (37), (39),& (42) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals can expect to live in a safe environment and can be re-assured that standards will be the subject of ongoing monitoring.EVIDENCE:The manager was consulted on the management style used at the home and said that while the style depends on the situation, mainly it’s a team approach to making decisions. Staff meetings, communication book, individual supervision and handovers when shift changes ensure that the standards of care are maintained.DS0000071364.V364403.R01.S.doc Version 5.2 Page 24 The senior member of staff on duty said that there is a more settled atmosphere and support workers are more aware of their roles. It was also stated that there is a lot more positives about working at the home and individually staff are more constructive. The Trust operates its own Quality Assurance system and generally peers complete the audit, which is based on 4 NMS Standards. These include Choice of Home, Care Planning, Concerns and Environment. Audits are based on reviewing the records, looking around the property and feedback from staff and people living at the home and, from the finding four recommendations were made. The rota examined shows that three staff is rostered throughout the day with one person awake at night. Existing and bank staff cover vacant shifts and agency staff are only used as a last resort. Facilities for the safekeeping on cash and valuables exist at the home and a sample check of the records against balances held was conducted. Records are accurate, up to date and receipts held further evidence purchases made on behalf of the person. There are fire risk assessments for the property and focus on fire hazards and evaluation of the risk. Individual fire risk assessments relate to the person’s reaction to the sounding of the fire bells.DS0000071364.V364403.R01.S.docVersion 5.2Page 25 SCORING OF OUTCOMESThis 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 applicableCHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score2 2 x 3 xLIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 173PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score3 3 2 x3 x 3 x x 3 xDS0000071364.V364403.R01.S.docVersion 5.2Page 26 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 Standard YA7 Regulation 17(1)(a). Sch.3.l 13(2) Requirement Care plans must be further developed to guide staff on the way individuals communicate and make decisions. Staff must sign records of administration immediately after administering the medication Timescale for action 30/08/082YA2030/07/08RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice RecommendationsDS0000071364.V364403.R01.S.docVersion 5.2Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 CSCIDS0000071364.V364403.R01.S.docVersion 5.2Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!