Care Home: Highermead

What the care home does well Highermead provides a good standard of accommodation. The bedrooms are spacious and there is a choice of lounges and dining areas. One relative of a person living at Highermead commented that "I do think the layout of the home helps my mother who likes to wander around as she walks around the walkways until she returns to her original place". The food is well cooked and enjoyed by people. There is a relaxed atmosphere in the dining room and people have enough time to eat their food without being hurried. What has improved since the last inspection? People who are thinking about moving to Highermead are now being assessed to decide if the home can meet their needs. The Manager has a good understanding of the sort of needs they can meet, and those they can`t. Care Plans are now more detailed and have been updated as people`s needs change. Staff are aware of these documents and are able to talk about what individuals needs are and how to manage difficult situations. Staff feel confident enough not to force people into situations, but understand that given time and gentle persuasion more can be achieved. One relative commented about the staff "They are very caring to my mother who is a very gentle and kind person. They are careful to take the time to listen and try and understand what my mother says. The staff are lovely towards my mother and whenever I attend (once a week at least) they are always present helping the patients". Where people have particular health care needs such as diabetes, there is now a good record of how these needs should be met. There are now good systems in place for dealing with any concerns about the well being of people at Highermead. The Manager keeps Social Services and the Commission informed of any issues that we need to know about. The home is cleaner and all unpleasant odours have been eliminated. A new system has been set up in the laundry and this will help lower the risk of any infections spreading. The recruitment system has improved and all the necessary checks are now being done on prospective staff. This will help ensure that unsuitable people do not work at Highermead. The home is well managed and the Commission has now registered the new Manager. Staff now feel well supported and there is a sense that there is someone in charge, something that was missing in the autumn of 2007. One of the relatives of a person living at Highermead commented "Since the appointment of the new management the whole place has a far better outlook. Staff appear happier which is reflected to the residents", another person said " I feel that Highermead provides... the care that my mother needs, especially since the new manager took over". What the care home could do better: The Fire Risk Assessment and the record of checks made on the fire system could not be found at this inspection. We were also told that environmental risk assessments were still waiting to be completed. Whilst we had no concerns about the safety in the building these records are important as they confirm that risks are being managed. The Statement of Purpose has been amended, however it still contains information that could be very confusing concerning admission for assessment under the Mental Health Act. CARE HOMES FOR OLDER PEOPLE Highermead College Road Camelford Cornwall PL32 9TL Lead Inspector Helen Tworkowski Unannounced Inspection 11th June 2008 10:00 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 Highermead DS0000009188.V364400.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. Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highermead Address College Road Camelford Cornwall PL32 9TL 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) 01840 212528 01840 211024 info@arkcare.co.uk Ark Care Services Ltd Julie Ogden Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (22) Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 22 adults aged over 65 years with a mental illness (MD(E)) Service users to include up to 22 adults aged over 65 years with dementia (DE(E)) Total number of service users not to exceed a maximum of 22 Date of last inspection 13th February 2008 Brief Description of the Service: Highermead is a privately run home, which provides twenty-four hour personal care and accommodation for up to twenty-two older people who suffer with a mental disorder or dementia. Arc Care Services Ltd who operates Highermead have a second home in the North of England. Highermead is a large detached house on the outskirts of Camelford. Accommodation is provided on two floors. All of the bedrooms are single with the exception of one double room. There are two lounges, which provides a choice of where to sit. Stair gates restrict access between floors. A passenger lift is available. In good weather there is a courtyard garden area available for use. There is good car parking by the home. Information about the home in the form of a Statement of Purpose is available in the office. There is a copy of the Service User’s Guide in each bedroom. The fees charge are £400 to £488 per week and according to the Service User Guide are inclusive of colour TV and licence, transport to all local appointments, entertainment throughout the year, NHS optician and dentistry, pedicure and creams, food, accommodation, church service, laundry, individual diets, private telephone calls by arrangement. Highermead DS0000009188.V364400.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 in 2 star. This means the people who use this service experience good quality outcomes. This was a key unannounced inspection and looked at all aspects of the service provided at Highermead. This inspection included a visit to the home on 11/6/08 between 8.20am and 4pm. As part of this inspection we looked at the care of three of the people who live at Highermead. We looked at the medication system, at the care records, and spent time in the care home talking with some of the people who live at Highermead. We also looked at records relating to staff recruitment and training, and talked with four of the staff and the Manager, Julie Ogden. In addition to the site visit we sent surveys to the people who live at Highermead who would be able to complete a form, none were returned. We also sent surveys to the relatives of those who were unable to complete a survey form , seven were returned, and to the care staff, seven were returned. We also received a questionnaire, completed by the Registered Provider, which gave us information about the home. What the service does well: What has improved since the last inspection? People who are thinking about moving to Highermead are now being assessed to decide if the home can meet their needs. The Manager has a good understanding of the sort of needs they can meet, and those they can’t. Care Plans are now more detailed and have been updated as people’s needs change. Staff are aware of these documents and are able to talk about what Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 6 individuals needs are and how to manage difficult situations. Staff feel confident enough not to force people into situations, but understand that given time and gentle persuasion more can be achieved. One relative commented about the staff “They are very caring to my mother who is a very gentle and kind person. They are careful to take the time to listen and try and understand what my mother says. The staff are lovely towards my mother and whenever I attend (once a week at least) they are always present helping the patients”. Where people have particular health care needs such as diabetes, there is now a good record of how these needs should be met. There are now good systems in place for dealing with any concerns about the well being of people at Highermead. The Manager keeps Social Services and the Commission informed of any issues that we need to know about. The home is cleaner and all unpleasant odours have been eliminated. A new system has been set up in the laundry and this will help lower the risk of any infections spreading. The recruitment system has improved and all the necessary checks are now being done on prospective staff. This will help ensure that unsuitable people do not work at Highermead. The home is well managed and the Commission has now registered the new Manager. Staff now feel well supported and there is a sense that there is someone in charge, something that was missing in the autumn of 2007. One of the relatives of a person living at Highermead commented “Since the appointment of the new management the whole place has a far better outlook. Staff appear happier which is reflected to the residents”, another person said “ I feel that Highermead provides… the care that my mother needs, especially since the new manager took over”. What they could do better: The Fire Risk Assessment and the record of checks made on the fire system could not be found at this inspection. We were also told that environmental risk assessments were still waiting to be completed. Whilst we had no concerns about the safety in the building these records are important as they confirm that risks are being managed. The Statement of Purpose has been amended, however it still contains information that could be very confusing concerning admission for assessment under the Mental Health Act. Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 7 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. Highermead DS0000009188.V364400.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 Highermead DS0000009188.V364400.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): 1 and 3, (6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering a move to Highermead can be confident that staff, prior to a move, will know their needs. EVIDENCE: No one new has moved to Highermead since the last inspection. The Manager, Julie Ogden, said that she was in the process of assessing a number of people who were considering a move to Highermead. As part of this process she has visited people and had sought information from relevant professionals. The Manager was aware of the importance of ensuring that Highermead was the right home, and was able to show that where she felt a person’s needs could not be met, then they were not admitted to Highermead. At the last inspection it was noted that the Statement of Purpose, a document that give information about a care home, contained information that suggested that people could be admitted to the home for assessment under the mental health act. This is not the case. The information was still in the document at Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 10 this inspection. This document should be amended. Information about what any individual can expect from a stay at Highermead is available in a Service User Guide, the Manager said that copies of this document are available in each person’s bedroom, and the owners have said that this contains a sample of the contract, inspection reports, quality assurance surveys and information on advocacy. Highermead DS0000009188.V364400.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): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Highermead are treated with respect and staff know their needs. Medication is well managed and is administered as prescribed. EVIDENCE: The relatives of people who live at Highermead, who responded to the survey all said that the home always or usually met their relatives’ needs. One relative commented “They are very careful to take the time to listen and try and understand what my mother says”, another person said about their relative “… is always clean and tidy and is very happy there, as all the other patients are”. We looked at the Care Plans, documents that should tell staff about the needs of people and how they are to be met. We found that the improvements made at the last inspection had continued. Care Plans were in general up to date, where needs have changed there was a record of this. Where there were specific needs, for example in relation to diabetes there was information about how this condition was to be managed. Five out of the seven staff responding to the survey said that they always had up to date information about the needs Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 12 of people. One person commented, “I believe our service users are usually very much at home with us- we try to be sensitive to their needs- we are usually very friendly and produce a caring environment…”. We also found that where individuals were not able to contribute to the review of their care plans, the family were involved. We observed how staff and the people who live in the home interacted; people were always treated with respect and given time to answer. When we spoke with staff about what they knew about people’s care needs they had a good understanding of the approach that they should be taking. We looked at the medication system. The home now uses a monitored dose system, this is where the medication is prepared in blister packs by the pharmacist. This system seems to be working well, the correct medication was in stock and medication was signed for. We checked to see if staff were administering creams, and found that this was the case. Highermead DS0000009188.V364400.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): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at Highermead are offered a range of activities to participate in at the home. Meals are well cooked and to the taste of the residents. EVIDENCE: We spent time with the people who live at Highermead in the dining room whilst meals were being eaten. The meals were relaxed and people were not hurried to eat. We were told that breakfast is between 7.30am and 9.30am, and can be eaten in the dining room or on a tray in a bedroom. The main meal of the day is at around 12.30, with tea now being eaten after 5pm. People are given a choice of food, on the day we visited the home people could have had a roast dinner or an egg salad. There is no fixed menu yet, though this is planned to be introduced, along with printed menu cards. We observed that people enjoyed their food and were not afraid to ask for something different. One of the visitors we spoke with about the home, said that she had noticed that the standard of food had improved, and that there were now home made cakes in the afternoon. Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 14 The Manager told us that they were planning more activities, and had recently introduced regular visits from an entertainer. We observed a poetry reading session on the day of the visit. A member of staff read out loud some wellknown poems. Everyone seemed to enjoy this and people sat quietly listening. We looked at one of the Care Plans that said an individual should be offered the opportunity to go out four times a week. The records did not show that this was happening. However when we spoke with staff they confirmed that the individual was given the opportunity to go for a walk or to spend time in the garden. We discussed with the manager the need for better recording. Highermead DS0000009188.V364400.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Highermead can be confident that their complaints will be looked into and that they will be protected from abuse. EVIDENCE: We looked at the record of complaints with the Manager. Complaints are now being recorded, and any issues dealt with. A number of concern have been reported promptly to Social Services and to the Commission, as is required. This has meant concerns could be dealt with in a prompt manner and the situation resolved. The complaints procedure is displayed in the hallway, and this is also in the information provided to Service Users in their rooms. Five of the seven relatives returning surveys said that they knew who to complain to if it were needed, and six of the seven staff returning surveys said that knew what to do with a complaint or concern. Staff have received training in relation to protecting people from abuse and importantly have an understanding of the standards that the people in care homes can rightfully expect. Highermead DS0000009188.V364400.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Highermead are provided with comfortable and clean accommodation suited to their needs. EVIDENCE: We looked around much of this building during this inspection and found that there had been significant improvements in the standard of cleanliness in the home. There were no unpleasant odours anywhere in the home; the Manager said a cleaner is now employed. The rooms were all clean and the people who live in the house seemed comfortable. New flooring had been fitted in some areas of the ground floor, and this meant that the house was easier to keep clean. We also noted that hand rails fitted in corridors had been fitted at a better height, so that people could more easily use them. At the last inspection we were told that hot water was not readily available in all wash hand basins. The manager confirmed that this problem had now been resolved. Door locks have now been fitted to bathrooms, although not all bedrooms have suitable locks. The Manager showed us a new system that has been set up for Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 17 dealing with laundry; this system ensures that there is a separation of clean and soiled linen. The information that has been provided to the Commission by the home also shows that the home has used a recent report by the Department of Health on how to stop infections spreading. This should mean that people are better protected from infections. Highermead DS0000009188.V364400.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): 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. The people who live at Highermead supported by staff who are well-trained and insufficient numbers. EVIDENCE: We looked at the recruitment records for two people who had recently started work in the home. We found that people had been properly recruited, with checks being made to see if they were suited to work with vulnerable people. We asked to see the induction records for these two people and was told that the individuals had them, and they were in the process of completing these records. We received information about staff training in the questionnaire completed by the Registered Provider for the Commission; this shows that just over half of the staff have a National Vocational Qualification in Care, which is a mark of competence. The Manager told us that she was in the process of applying for a further nine staff to complete this qualification in care. She also told us that the Cook had started a similar qualification at level 3 in relation to food hygiene. Staff had also received recent training in relation to the protection of vulnerable adults and in relation to medication administration. The surveys from staff showed that whilst the majority of staff felt that they had sufficient training relevant to carry out their role, a couple of staff felt that this was not Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 19 the case. The surveys from all the relatives showed that they felt that staff had the right skills and experience to look after people at Highermead. We observed that there were sufficient staff on duty to provide care for the people accommodated at the home on the day of inspection, staff were not hurried, and spent time with residents. During the visit to the home we asked staff if there were sufficient staff and they confirmed that this was the case. Highermead DS0000009188.V364400.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): 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. Highermead is well managed, and staff and relatives of people who live in the home are satisfied with the standards of care. The house is well maintained and appears free from unnecessary risks though not all of the documentation that should confirm this was available for inspection. EVIDENCE: The Manager, Julie Ogden, has recently been registered by the Commission as fit to manage Highermead. Ms Ogden has been working at the home since November 07, and we have noted significant improvements in the care provided during this period. Comments from relatives about the home include: “I feel that Highermead provides,…, the care that my mother needs, especially since the new manager took over”. We spoke with one visitor to the home Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 21 during this inspection and she commented how happy she was with the way things were going. Comments from staff about the management of the home included “Our new management has everything running smoothly”, and “ Our present manager seems to be very knowledgeable and very caring, so I have a lot of confidence in her”. When we spoke with staff during this inspection they all commented that thing had improved significantly, and staff felt well supported by the manager. We asked the Manager whether there was regular contact with representatives from Ark Care Services Ltd, she confirmed that Mrs Ajisebutu visited the home once a month to check if the home was being run properly. She also confirmed that there was regular contact with in between times with head office. We asked about the Quality Assurance system, and was told that questionnaires had recently been sent out to people who have contact with the home, however these had not been returned yet. The home looked well maintained and no safety issues were noted during this visit. We asked about environmental risk assessments, these are assessments to make sure that the home is safe for people to live in and for people to work in. The manager told us that these were yet to be done. We also asked to see the fire risk assessment and checks that the fire system is working properly. These records could not be found during this inspection. It is important that these records are available at all times for inspection. Highermead DS0000009188.V364400.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 2 X 3 X 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 3 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 2 Highermead DS0000009188.V364400.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 OP38 Regulation 13 (c) Requirement There must be a record of how unnecessary risks, including that of fire, are managed and eliminated as far as possible. These records must be available for inspection. Timescale for action 01/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP10 Good Practice Recommendations The Statement of Purpose should be updated so that it clear that the home does not admit people for assessment under the Mental Health Act. All bedrooms should have suitable door locks for the people the home accommodates. Highermead DS0000009188.V364400.R01.S.doc Version 5.2 Page 24 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 CSCI Highermead DS0000009188.V364400.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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