Care Home: Fosse House

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What the care home does well Residents and visitors praised the staff and manager of the home and comments from the returned surveys included that "staff are very good and helpful" and that their relative was "very happy" in the home. It is important that visitors feel comfortable voicing any concerns to the manager and in the surveys relatives said that "families are welcomed at any times and feel free to make suggestions to the management". All returned surveys contained positive comments and, apart from issues about laundry, no concerns were raised.The returned staff surveys commented that in the home "communication is good" and that staff are provided with "good induction training". Staff also said the home had "good management" and none of the staff who returned the surveys could think of any improvements which could be made to the home. Some of the residents we spoke with said the food at the home was "excellent" and relatives who were visiting the dementia unit said they were very happy with the dementia care provided at the home. Care staff told us they receive on-going training in dementia care and we saw evidence of very good practice on the dementia unit during our visit. What has improved since the last inspection? An additional evening staff shift has been introduced at the home so that laundry services could improve and the manager said that there have been far fewer concerns expressed about washing and returning residents` clothes since that time. The home has a thorough system for identifying residents` dietary needs end ensuring that kitchen staff are aware of this information and that it is acted on. This ensures that residents` health is not put at risk. We saw all food appropriately covered before it was taken to residents` bedrooms so that the meal was kept hot and uncontaminated. What the care home could do better: Although the dementia care we observed in the home was good, we advised that staff numbers and deployment in this unit, and especially at meal times, should be reviewed to ensure there are always enough staff to meet residents` complex needs. CARE HOMES FOR OLDER PEOPLE Fosse House Ermine Close St. Albans Hertfordshire AL3 4LA Lead Inspector Pat House Unannounced Inspection 3rd November 2008 09:45 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 Fosse House DS0000019349.V372712.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. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fosse House Address Ermine Close St. Albans Hertfordshire AL3 4LA 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) 01727 819 700 01727 819 768 fosse@quantumcare.co.uk www.quantumcare.co.uk Quantum Care Limited Jennifer Barbara Gauthier Care Home 61 Category(ies) of Dementia (61), Old age, not falling within any registration, with number other category (61), Physical disability (61) of places Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical Disability - Code PD 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 61 12th February 2008 Date of last inspection Brief Description of the Service: Fosse House is a purpose built care home for 61 older people, including two rooms for short (or respite) stays. It is a two-storey building, with two units on each floor. Three of the units have 15 rooms and one has 16 rooms. Each person has his or her own bedroom with an en-suite toilet and washbasin. Each unit has it’s own lounge, dining room and kitchen. There is a hairdressing salon and a sensory room on the first floor. There is also a day centre on the ground floor, which is separate from the residential accommodation. There is a large garden with wheel chair accessible, paths, patio areas and summerhouse. The home is close to the parkland leading to St. Albans Abbey. It is in a modern residential area, next to a small shopping parade and a Waitrose supermarket. The current fees range from £420 - £620 per week depending on an assessment of care needs. Copies of the home’s Statement of Purpose, Service User’s Guide and most recent inspection report are displayed in the entrance hall. Information about the service is also available on the Quantum Care web site. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 5 SUMMARY This 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. The information in this report is based on an unannounced inspection of the home, which took place on one day by two regulation inspectors carrying out the work of the Commission. For the purposes of this report the Commission will be referred to as ‘we’. The manager was present during the inspection and we spoke with residents, visitors and staff and checked a selection of records. One inspector spent two hours in the dementia unit where they completed a short observational period of assessment. This is called a Short Observational Framework for Inspection, which allows us to focus on outcomes for the people with dementia by observing the interaction between them and the staff providing their care and support. The results are included in this report. The manager has completed and returned to the Commission an annual selfassessment quality review, the Annual Quality Assurance Assessment, (the AQAA). The AQAA focuses on how well the service meets the outcomes for people using the service and also provides us with some numerical data. Information from this document is also included in this report. We also sent surveys to residents and staff at the home. Comments from the returned surveys have been included in this report. What the service does well: Residents and visitors praised the staff and manager of the home and comments from the returned surveys included that “staff are very good and helpful” and that their relative was “very happy” in the home. It is important that visitors feel comfortable voicing any concerns to the manager and in the surveys relatives said that “families are welcomed at any times and feel free to make suggestions to the management”. All returned surveys contained positive comments and, apart from issues about laundry, no concerns were raised. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 6 The returned staff surveys commented that in the home “communication is good” and that staff are provided with “good induction training”. Staff also said the home had “good management” and none of the staff who returned the surveys could think of any improvements which could be made to the home. Some of the residents we spoke with said the food at the home was “excellent” and relatives who were visiting the dementia unit said they were very happy with the dementia care provided at the home. Care staff told us they receive on-going training in dementia care and we saw evidence of very good practice on the dementia unit during our visit. 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. The summary of this inspection report can Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 8 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 Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 9 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): Standards 1, 3 and 4. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are given written information about the home and its services so that they can decide if the home is the right place for them. Detailed assessments are completed for all new residents to ensure that individual and specialist needs are identified and met by staff at the home. EVIDENCE: The home’s written Statement of Purpose and Service User’s Guide are displayed in the entrance hall. The manager said she is currently updating these documents and that copies of the revised documents would be sent to the Commission when completed. We checked a selection of residents’ records during the inspection and all contained detailed written assessments of need, completed by senior staff from Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 10 the home, as well as care summaries provided by referring agencies. Initial care plans had been drawn up from the recorded information. The home has units providing specialist care for people who have a dementia. We spent two hours observing the action and interaction between residents and care staff on one of these units. We saw evidence of care staff treating people as individuals and providing appropriate support for the people who were quite confused. The manager said that recent staff training had emphasised the importance of the right level of interaction and we saw evidence that care staff knew when to approach a resident and when to let the person remain with their own thoughts. None of the staff passed a resident without acknowledging them and we saw a lot of eye contact maintained. One care worker came to “go for a walk” with a resident, which clearly pleased the person concerned. The communal areas in the unit were also set out with items, which could provide visual stimulation and with items that could be touched and examined. We saw appropriate support provided when the main meal was served and there were snacks and fruit available for residents to eat when they wanted to so that good levels of nutrition could be maintained even if a main meal was not eaten. However we did recommend to the manager that staffing levels be reviewed on the dementia units, especially at meal times. This issue is commented on later in this report. As in other homes in the company, the manager has completed a dementia leadership course and is part of a support group, which provides support and advice on dementia care. Someone is available from this group at all times, on a rota basis. We also saw advice about the condition of dementia, for visitors, displayed in the entrance hall of the home. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good care planning and procedures followed in the home ensure that people who use the service have their health needs met in the way they prefer. The system for administering medication is thorough and helps to protect residents from harm. EVIDENCE: We spoke with and observed residents during the inspection and then tracked a selection of their care plans. In all cases the plans reflected the people we had seen and the recorded information was detailed and appropriate. A range of risk assessments had been completed including those for the risk of falls and those connected to moving and handling. On one care plan we saw a management plan, completed with input from the G.P., outlining a falls prevention programme. Written nutrition assessments had been completed and choices about end of life care were documented. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 12 Staff told us that the home maintained good relations with local doctors and that currently Community Psychiatric Nurses visit four residents. A doctor’s visit had been requested for a resident before we arrived at the home and we heard staff informing relatives about the concerns in question. One resident had decided to remain in bed at the time of our visit and issues around this decision had been documented and assessed. A district nurse was visiting the home daily to deal with insulin injections and to provide catheter care for a resident. The residents we asked confirmed that all visits from Health professionals took place in private and said that all care staff provided personal care in a way the resident preferred and always treated them with dignity. We checked the system for administering medication in the home. We spotchecked some medication totals and no errors were found. Recording was also thorough. Staff confirmed that only those who had been trained were involved in administering drugs and the manager confirmed that staff competencies were regularly checked. Currently no one in the home is able to administer their own medication. The manager said that letters had been sent to all G.Ps asking for medication review dates. This is so that people can be assured that every resident is currently prescribed appropriate medication. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home for providing activities and welcoming visitors help to ensure that people who use the service remain as independent as possible, receive adequate stimulation and remain part of the community. Residents enjoy the food provided and the range offered helps to promote their good health. EVIDENCE: We saw details of the week’s activities displayed on notice boards in the home and events included quizzes, ball games and gentle physical exercise sessions. One male care worker organises a “boys club” for the male residents and those we spoke with said they enjoyed these male-targeted events. One member of staff also holds a weekly “tea party” where the staff dressed in waitress outfits serve the residents. One resident we spoke with was knitting squares for charity and they told us there had been a Halloween party held in the home with music and dancing. Staff also told us that the home holds “multi-cultural days” and one had been held in July with a barbeque and steel band entertaining the residents and visitors. The manager acknowledged that she Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 14 would like more daily events planned for the home and that she had advertised for a second activity co-ordinator so that a wider range of activities could take place. However, one member of staff is currently allocated on each unit, each day, to arrange appropriate events for the residents concerned. The residents we spoke with said that visitors were welcomed in the home at all times and that they were supported by staff to make their own decisions about how they spend their days. Residents also said they enjoyed the food provided in the home. We saw the day’s menu displayed on the wall in the dining room so that residents could be aware of the main meals due to be served. We saw snacks provided in areas around the home and saw finger food being taken around and offered to people in their bedrooms. This practice is recommended in current guidelines for promoting good nutrition in the elderly. Residents confirmed they could ask for additional food or drink whenever they wanted. We saw water and juice left available in communal areas around the home and in residents’ bedrooms and the staff we spoke with were aware of the need to promote hydration for residents. We saw the main meal served during the inspection and this looked nutritious and well balanced. We saw care staff taking meals to residents who were remaining in their bedrooms and all meals had been appropriately covered. We visited the kitchen and the chef explained the system in operation so that the kitchen staff are kept aware of all the residents’ dietary needs. Currently one resident has their food liquidised and is provided with thickened drinks to ensure their nutritional needs are met. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that any concerns they might have will be listened to and acted on and that procedures followed in the home help to protect residents from abuse. EVIDENCE: The home has written policies covering making a complaint, Safeguarding Adults and Whistle Blowing. The staff we spoke with said they were aware of these policies and of their implications. Care staff also said they had received training in Safeguarding. The manager demonstrated an up to date understanding of Adult Safeguarding and the procedures to be followed if any concerns should be raised. There had been one safeguarding issue dealt with at the home and we were aware that appropriate procedures had been followed. The residents we asked said that if they had a concern they would not hesitate to tell the staff or the manager about this. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 16 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): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from living in a home, which is well maintained and kept clean and hygienic. EVIDENCE: We visited all parts of the home briefly and all areas were well maintained and well decorated. The home was very clean and there were no unpleasant odours in any areas. The reception area has CCTV coverage for the residents’ safety. In the AQAA the manager states that a new handrail has been provided in the garden for residents’ safety and there is a new summerhouse with wheel chair access for residents to enjoy in the summer. All communal bathrooms and toilets contained liquid soap and soft paper towels, as recommended in current guidelines for good infection control. We Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 17 visited the laundry and the member of staff working there confirmed that an evening staff shift had been introduced in the home so that laundry could be dealt with more efficiently. This was as a result of relatives’ comments that clothing was not being appropriately washed and returned, as they would wish. However there was still a very large amount of clothing in the laundry, which could not be returned to residents, as it had not been labelled. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported by staff who are well trained and able to meet their needs although the staff numbers need to be reviewed to ensure that dementia care remains good at all times. The home’s recruitment procedures are thorough and help to protect residents from the risk of abuse. EVIDENCE: The residents we spoke with felt that there were usually enough staff on duty to meet their needs. People confirmed that call alarms were answered promptly when they were activated. However, we observed the mid-day meal being served on the dementia unit and, although assistance with eating was appropriately provided, we felt that staff numbers here were only just adequate. There is a medication round which takes place at this meal time and to ensure both the safety of the residents and the member of staff involved with administering this medication there should be no interruptions to this task. We also saw some of the more confused residents become restless during the time they were seated at the table until the meal was served and some decided to leave the dining room. Additional staff could have provided diversions or occupation for these residents so that they had more chance to enjoy the meal when it arrived. The current residents on this unit may also need more assistance as time goes on, and we recommended that the Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 19 manager reviews the staff numbers, especially at meal times, to ensure the safety of residents and so that staff are able to provided all the support needed. The care staff we spoke with said they received good levels of training and that they were encouraged to undertake NVQ training. Currently 13 care staff have completed NVQ 2 training and 7 more are doing this course. The home has its own assessors on the staff team so that there is a culture of providing a professional approach to providing care in the home. Training courses are provided on an on-going basis and all care staff have individual training profiles and we saw certificates of courses on the records we checked. We looked at a selection of staff recruitment files and saw evidence that all appropriate checks had been in place before staff had been employed. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home which is well run and where their views are listened to and acted on. Procedures followed by staff at the home ensure that people who use the service are protected from financial abuse and have their welfare and safety promoted. EVIDENCE: The residents and staff we spoke with praised the manager and said she was always available and approachable and always provided good support. The manager confirmed that she completes unannounced night checks in the home to ensure the care provided at night is appropriate. Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 21 The manager said that a Health and Safety audit for the home had recently been completed. The manager also completes monthly audit reports from the monitoring of accidents, incidents and other statistics such as falls and any pressure area care. These reports are sent to the company head office for inspection. Care staff confirmed that there was a new system in place in the home and that care staff have been trained to complete accident forms and to monitor individuals after a fall. Staff now monitor anyone who has fallen to ensure that there are no on-going health problems and so that any special risks are noted and eliminated as much as possible. A company manager had audited residents’ personal finances the week of the inspection and all records and amounts of money were in order. The home has a written policy of Quality Assurance and surveys are sent to residents, relatives and other stakeholders and returned to the company head office for scrutiny. Comments from recent relatives’ surveys had resulted in an extra evening staff shift being provided to improve the functioning of the laundry, as already described. We saw no hazardous substances left accessible to residents during the visit and storage rooms were being kept locked. Fosse House DS0000019349.V372712.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 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 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP27 Regulation 18(1)(a) Requirement Staff numbers and deployment on the dementia units in the home must be reviewed to ensure there are enough care staff on duty at all times to meet residents’ needs. Timescale for action 01/03/09 RECOMMENDATIONS 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 Recommendations Fosse House DS0000019349.V372712.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Fosse House DS0000019349.V372712.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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