Care Home: Elms House

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What the care home does well Residents said they liked living in the home. One said, "I am very happy here." Others talked about how well they got on with the staff, especially their key workers. Staff and residents talked together in a friendly and respectful way. Staff made sure that residents were This meant that residents were able what goals they wanted to achieve. good directions about what help the involved in meetings about their care. to say what was important to them and The Person Centred Plans gave staff very residents needed.Staff encouraged residents to be as independent as possible. If they were safe to do so residents went out on their own, otherwise staff went with them. Residents had at least one holiday a year. They had just returned from Blackpool, which they said was, "a great holiday." Residents said that staff looked after them very well if they were poorly. The manager made sure that residents had a health check every year and they saw specialists if they needed to. Almost all of the care staff had a nationally recognised qualification in care. They also attended courses that would help them to understand the special needs of some of the residents. Staff had up to date health and safety training. Fire safety equipment and electric and gas systems were serviced regularly. This helped to make the home safe for the people who lived and worked there. All the residents who could comment said they were happy with the home, their lifestyle and the food. They all said they would speak to their key worker or the manager if anything went wrong and all were confident that it would be put right. What has improved since the last inspection? The manager carried out thorough background checks on new staff to make sure they were suitable to work with residents. The manager continued to make improvements to the environment to make the home more comfortable for residents. A new bathroom suite had been put in since the last inspection. What the care home could do better: The home generally managed medication safely but the way medicines are stored and recorded needed improvement to reduce the risk of drug errors and make sure that residents stay safe. When asked if there was anything that could be improved, one resident said, "I don`t think anything could be any better." CARE HOME ADULTS 18-65 Elms House 24/26 Woone Lane Clitheroe Lancashire BB7 1BG Lead Inspector Jane Craig Key Unannounced Inspection 17th October 2006 09:30 Elms House DS0000009450.V305479.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 Elms House DS0000009450.V305479.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. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elms House Address 24/26 Woone Lane Clitheroe Lancashire BB7 1BG 01200 424263 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) Mrs Joanne Brown Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: Elms House provides care for up to six adults with a learning disability. The home is privately owned by Mrs Joanne Brown, who has responsibility for managing the service on a day to day basis. Elms House is a terraced property in a residential area close to Clitheroe town centre. A bus stop is located near to the home and there are small shops, a church and swimming baths within walking distance. The house has a small front garden with a bench seat, shrubs and flowers. The garden leads directly on to the street at the front of the house, where there is roadside parking. There are two small yards at the rear, with some garden furniture. Access for people using wheelchairs is at the rear of the house. There are four single bedrooms and one shared room. None of the rooms have en-suite facilities but there is a bathroom and WC on both floors. There is a steep staircase to the upper floor. Communal areas on the ground floor include two lounges, a dining room and domestic sized kitchen. Information about the home is sent out to prospective residents when they have a trial visit. Copies of the Commission for Social Care Inspection reports are available on request. At 17th October 2006 the weekly fees ranged from £403 to £780. There were no extra charges. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Elms House on the 17th of October 2006. At the time of the visit there were 6 residents accommodated. The inspector met with all the residents and wherever possible talked about their experiences of living in the home. Some of their comments are included in this report. Four residents and two visitors/relatives returned comment cards before the inspection. Their views about various aspects of the home were all positive. Discussions were also held with the registered provider/manager and three members of staff. A tour of the premises took place and a number of documents and records were viewed. This report also includes information submitted by the home prior to the inspection visit. What the service does well: Residents said they liked living in the home. One said, “I am very happy here.” Others talked about how well they got on with the staff, especially their key workers. Staff and residents talked together in a friendly and respectful way. Staff made sure that residents were This meant that residents were able what goals they wanted to achieve. good directions about what help the involved in meetings about their care. to say what was important to them and The Person Centred Plans gave staff very residents needed. Staff encouraged residents to be as independent as possible. If they were safe to do so residents went out on their own, otherwise staff went with them. Residents had at least one holiday a year. They had just returned from Blackpool, which they said was, “a great holiday.” Residents said that staff looked after them very well if they were poorly. The manager made sure that residents had a health check every year and they saw specialists if they needed to. Almost all of the care staff had a nationally recognised qualification in care. They also attended courses that would help them to understand the special needs of some of the residents. Staff had up to date health and safety training. Fire safety equipment and electric and gas systems were serviced regularly. This helped to make the home safe for the people who lived and worked there. All the residents who could comment said they were happy with the home, their lifestyle and the food. They all said they would speak to their key worker Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 6 or the manager if anything went wrong and all were confident that it would be put right. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elms House DS0000009450.V305479.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 Elms House DS0000009450.V305479.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents would only be admitted to the home following an assessment to ensure their needs could be met. EVIDENCE: No new residents had been admitted to the home since 2004. The manager stated that a new resident would not be admitted to the home unless their assessed needs could be met. A policy and procedure was in place to that effect and pre-admission assessments were seen on the files of residents who were case tracked. Two residents said they had visited the home before moving in. One said that the manager had been to his house for a chat and brought him to Elms House a few times for tea before he moved in properly. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The person centred plans ensured that issues of importance to residents were addressed. Residents were supported to maximise their independence by taking responsible risks and making decisions about their own lives. EVIDENCE: Each resident had a person centred plan and a set of care plans to address long term goals and day-to-day health and personal care needs. Plans were drawn up and reviewed with the involvement of the resident wherever possible. They were written from the resident’s perspective and included strategies for communication, issues of importance to the resident, and their prioritised needs and goals. Action plans stated clearly who took responsibility for assisting the resident to meet their needs. All residents had a set of risk assessments to support their activities, ensure their personal safety and protect others from risk of harm. Most assessments generated detailed strategies to instruct staff as to what actions to take to minimise risk. However, the strategy to manage one resident’s occasional Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 10 aggressive outbursts was not clear enough to ensure staff knew exactly what to do to ensure their own and other residents’ safety. Residents were consulted on a one to one basis about any issues that affected them specifically, for example, health care, activities or meals. Group meetings were in place to discuss and decide issues affecting all residents such as house matters, holidays and trips out. Staff assisted less able residents to make choices by using non verbal communication and cues. One resident had a communication passport and, using photos of familiar places and activities, staff helped him to pick out where he wanted to go. Staff had also involved the advocacy service and for a resident to help them to make choices about their future placement. One resident was involved in a local advocacy strategy group. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Residents were supported by staff to engage in a lifestyle of their choosing. EVIDENCE: Residents worked out a weekly programme during the review of their person centred plan. Some residents were very active; they went out most days and participated in community groups and events. Others said they preferred to stay in and read, watch TV or play games. Staff supported residents to go out independently if they were able. Residents valued this. One said, “You can go out on your own, I like to go errands” another said that being able to come and go as they pleased was the best thing about the home. Those who were not able to go out alone were supported by staff to access community facilities. Two residents had one to one support from staff to enable them go out nearly every day. Residents had just returned from a holiday in Blackpool, which they had all chosen. They said it was, “a good holiday” and they had enjoyed it. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 12 Residents were encouraged to attend a weekly men’s group. Minutes of the meetings showed that residents discussed health and social care issues and things of importance to people living in a care home. Those who attended community groups such as the preferred provider scheme monitoring group and the advocacy strategy group reported back to the rest of the residents. There was open visiting at the home. Relatives who completed comment cards said they felt welcome and staff kept them informed about important issues. Residents were supported to keep in contact and, if possible, visit their families. One resident talked about going on the bus to see his sister and said, “we have a meal and a chat; I can’t wait” Daily routines were flexible. Residents could go to their rooms whenever they wanted. Their rights to privacy and independence were understood and upheld by staff and reflected in their care plans. Residents had locks on their doors and said that staff always asked permission before going into their rooms. Mealtimes were flexible to fit in with residents’ activities. Records showed that residents were offered a varied and nutritionally balanced diet. Residents said they could help with the cooking if they wanted but didn’t have to. There was written guidance for staff on the preparation of a Halal diet for one resident and very specific directions on appropriate foods for another resident for medical reasons. Meals at the time of the inspection looked appetising and all residents said they were happy with the food, saying it was “good all the time” and “I like the meals here.” Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 the service. Residents’ personal and healthcare needs were met in accordance with their wishes. Some practices for managing medication were not completely safe. EVIDENCE: Health and personal care needs were addressed through person centred plans and care plans. Records showed that ongoing health care issues were monitored. There was evidence that new healthcare needs were identified quickly and referrals were made to the appropriate professionals. Staff acted upon advice from other professionals. For example advice from a speech and language therapist was recorded in detail on the resident’s plan and staff were able to say precisely how care should be given. Personal care plans showed evidence that residents were encouraged to maintain their independence. Residents who were not able to tell staff how they preferred to be helped had a “summary of preferred routines” on file. This gave very specific instructions should a new or temporary carer be involved. Residents said they were well looked after or thought they would be if necessary. One resident said, “I don’t need any help but I would ask if I wanted anything.” Another resident said he had, “not been very well and they have looked after me.” Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 14 All the residents had consent forms to allow staff to manage their medication. There were complete records of medicines received and disposal of unwanted medication. Medication Administration Record (MAR) charts were generally complete and up to date. However, handwritten amendments were not always double signed and there was no written explanation as to why some medication for two residents had been omitted. Storage of medication was not completely safe. For example, medication was being stored out of its original packaging and storage temperatures were not being monitored. The manager took steps to address these issues before the end of the site visit. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were protected by the home’s complaints and abuse policies and staffs’ knowledge of adult protection issues meant that any allegations would be dealt with appropriately. EVIDENCE: There was a complaints policy and procedure on display in hall. There had been no complaints either to the home or to the Commission for Social Care Inspection. Residents said they did not have any complaints. They said they knew how to make a complaint and that they would speak to their key worker or to the registered person if they were not happy. One resident said, “If there was anything wrong I would go to Joanne but I’m alright,” and another said, “Joanne would try to sort things out for you.” The two relatives who returned comment cards indicated that they knew how to make a complaint but had not needed to. All staff had received in-house training “abuse in the care home,” which comprised a video teaching session and an assessment. Written guidance on adult protection was available. There was a copy of “No Secrets in Lancashire” and the Elms House policy, which instructed staff on how to respond to any allegations. Staff said they would document any allegation of abuse and refer it straight away to the manager. They were aware of how to report outside the home if necessary. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents benefited from a safe, clean and comfortable environment. EVIDENCE: An environmental audit, which highlighted areas needing attention, was carried out in March. There was a plan of redecoration and renewal and dates when actioned but no timescales for further planned improvements. A new bathroom had been fitted since the last inspection. The home looked to be in a good state of repair. The two lounges were comfortable and homely with a good standard of furnishings. Residents were satisfied with their bedrooms, some of which were very personalised. One resident said he liked his room and he had helped to choose the decoration and carpets. All bedrooms had locks and there was privacy screening in the shared room. Laundry facilities were adequate for the size of the home. The home was clean and tidy at the time of the inspection. Residents who filled in surveys said it was always clean and fresh smelling. Some residents said they sometimes helped with the cleaning but the staff usually did it. There was an infection control policy and staff had access to protective clothing if Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 17 necessary. There were no recommendations following an Environmental Health department inspection last November. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Recruitment practices safeguarded residents. Residents were supported by a competent and qualified staff team. EVIDENCE: Duty rosters showed flexible staffing levels to meet residents’ needs and 1:1 commitments. Staff were available to escort residents to healthcare appointments or to go out more or less whenever they wanted. Visitors who completed surveys indicated they thought there were always enough staff on duty. Residents said they got on very well with staff. One resident said he liked his key worker and got on very well with her. One person had been employed since the last inspection. Pre-employment checks were carried out and the required documents were retained on file. The new staff member had an initial induction. It took place over two days and covered key policies, including fire and emergency procedures, infection control and control of substances hazardous to health (COSHH). The Skills For Care induction training was not appropriate in this case but the manager was aware of the common induction standards. The manager submitted a training matrix that showed all staff had received refresher training in the safe working practice topics. Staff said opportunities Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 19 for other training were good. All staff had attended a session on person centred planning. Two members of staff said they had attended a mental health awareness course and another had been on a diabetes awareness course. Seven of the eight care staff held an NVQ level 2 or above. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents benefitted from a safe and well managed home. There was a good level of consultation which enabled residents to contribute to service development. EVIDENCE: The registered person managed the home on a day to day basis. She held the registered managers award and it was evident that she kept up to date with any new legislation and best practice guidance and ensured that this was put into place. Residents and staff spoke highly of the registered person. Staff said the home was well managed and the manager was approachable and supportive. There were a number of systems in place to monitor the quality of the service. Elms House was on the preferred provider list for Lancashire County Council. The home also held the Investors in People award. In-house monitoring systems included annual resident surveys, regular resident meetings and staff Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 21 meetings. Residents were invited to comment on all areas of the home and make suggestions for changes but none had. At the time of the inspection a resident told the inspector “I wouldn’t change anything, I don’t think anything could be better.” Servicing and testing of the fire system, equipment and alarms was up to date. All staff and residents had received one to one fire safety training and been involved in practice drills. Residents were familiar with the fire procedure and told the inspector that the assembly point had changed. Certificates were available to evidence maintenance of installations and equipment in the home. There were environmental risk assessments and potentially hazardous items were stored safely. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Medication must be stored in its original packaging to ensure that the name of the recipient and directions for administration are clear. Medication must be given as prescribed and clear reasons given when it is omitted. Timescale for action 20/10/06 2 YA20 13(2) 20/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA20 Good Practice Recommendations Strategies to minimise risks to safety caused by aggressive behaviour should be clear enough to ensure consistency. Handwritten amendments to MAR charts should be signed and witnessed. The temperature of storage areas should be monitored to ensure that medicines are stored in accordance with the manufacturer’s instructions. Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Elms House DS0000009450.V305479.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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