Random inspection report
Care homes for older people
Name: Address: Miranda House Nursing Home High Street Wootton Bassett Wiltshire SN4 7AH one star adequate service 25/03/2010 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Susie Stratton Date: 2 8 0 9 2 0 1 0 Information about the care home
Name of care home: Address: Miranda House Nursing Home High Street Wootton Bassett Wiltshire SN4 7AH 01793854458 01793853951 qualitycarewilts@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Gillian Gray Type of registration: Number of places registered: Conditions of registration: Category(ies) : Quality Care (Wiltshire) Ltd care home 68 Number of places (if applicable): Under 65 Over 65 68 68 dementia mental disorder, excluding learning disability or dementia Conditions of registration: 10 10 No more than 2 persons not less than 50 years in receipt of day care at any one time. Persons less than 45 years of age may not be accommodated. Date of last inspection Brief description of the care home Miranda House is able to provide personal care and nursing care for up to 68 adults. These may be people with dementia or other mental health problems. Miranda House is in Wootton Bassett, near Swindon, Wiltshire. It opened in 1996, and was extended in 2005. The purpose built accommodation is on two floors, with passenger lifts between them. Most bedrooms have en-suite toilet facilities. All bedrooms are
Care Homes for Older People Page 2 of 19 2 5 0 3 2 0 1 0 Brief description of the care home currently used as single rooms. Baths and showers are provided throughout the building. There is also a range of communal space, including lounges, dining rooms and a conservatory. There is a garden and several parking spaces at the front of the building. The fees start at six hundred and sixty eight pounds, with higher rates reported to be charged for people with an increaced dependancy. People are able to request copies of the homes Statement of Purpose and Service Users Guide. Care Homes for Older People Page 3 of 19 What we found:
This random inspection took place on Tuesday 28 September 2010 between 9:35am and 3:35pm. Two inspectors performed the inspection. These people are referred to as we throughout this report, as it was performed on behalf of the Care Quality Commission (CQC). We performed this random inspection because we had issued three Statutory Requirement Notices to the persons registered on 10 September 2010. These Notices were issued to ensure that they met our Regulations in relation to meeting residents wound care needs, provision of sterile gloves and sterile scissors and reviews of care plans. We had required the home to meet residents wound care needs and provision of sterile equipment by 17 September 2010 and reviews of care plans by 27 September 2010. The provider responded to us, enclosing an action plan and stated when the different areas would be addressed. The provider informed us during the inspection that the registered manager was currently absent from the home and that they had placed one of their peripatetic managers to manage the home during the registered managers absence. This peripatetic manager was on duty at the time of the inspection. During the inspection, we met with two residents and observed their care, as well as reviewing their records. We also met with the peripatetic manager, two registered nurses, and four care assistants. We toured parts of the home, reviewed some of the facilities in the home and observed a lunch-time meal. We found that the home now had full stocks of sterile gloves and scissors. This would enable residents wound care to be performed aseptically. There were also stocks of sterile gloves available in a range of sizes to suit both male registered nurses and smaller female registered nurses. We found that the peripatetic manager had put much work into accessing suitable training for registered nurses in wound care, so that they were aware of their responsibilities for correct wound management. Records relating to wound management were now clear, completed in detail and reflected directions from external health care professionals, particularly tissue viability nurses. The tissue viability nurse informed us before the inspection that registered nurses were now following their instructions and complying with local guidelines. Records and discussions with registered nurses showed that residents responses to their treatment plans for wounds were regularly reviewed and up-dated. The peripatetic manager, as well as accessing training for registered nurses in wound care had reviewed the homes training programme. By the time of the inspection, they had commenced training for all staff on record-keeping and care planning. Some staff had been trained in prevention of pressure ulceration and more training was planned for October. The peripatetic manager was also able to show us their plans for further training in areas such as manual handling, dementia care and infection control. A member of staff reported to us that they had had lots of training since the last inspection. Care Homes for Older People Page 4 of 19 We found that improvements had been made to the cleanliness of the home. A sluice room which we visited now showed a clean floor and walls. Improvements had also been made in the provision of furniture provided for residents in sitting rooms and all the chairs in these rooms we saw were clean and well maintained. Much work had been put into the garden areas and items from the home which were broken had been removed. On the ground floor a room had been provided where confidential information about residents needs could be passed on between staff. The home had purchased equipment to meet residents needs, this included new safety rail protectors, refuse bins and hoist slings. The peripatetic manager was able to provide evidence that more slings for use with standing aid hoists were on order. A review of meals provision had taken place and residents were now given a choice of meal. Staff we spoke with were pleased with this development, stating how much residents liked having choice at meal times. A carer described to us how for one resident who was not able to communicate verbally, they took both choice of meals to the person for them to look at, and the person would then indicate to them which meal they would prefer. A relative said to us about the meals provision its much better, much nicer. Improvements had been made in areas relating to residents dignity. We observed in two residents rooms that all underclothing was in a good condition and attractively presented both in their drawers and wardrobes. Such clothes also had the residents own name written on them and we made no observations of clothing being provided in either residents room which was not named for them. The peripatetic manager was able to report on the improvements they were making in medicines administration, including regular audits of practice. We did not review medicines management in any detail at this inspection. However we did observe for one resident that their medicines administration record had not been completed on nine separate occasions during September and that one prescription for a dietary supplement which was prescribed to be given twice a day was only documented as being given twice on six occasions during September. Similar matters were identified by our pharmacist inspector during the key inspection of 25 March 2010. This indicates that full action had not been taken to meet this requirement. When we looked at reviews of care plans for two residents, we found that improvements had been made in some areas. One resident who had a complex skin condition had a clear care plan relating to their skin treatments and how these were to be performed. Another person had a clear description of their preferred consistency for food and that they liked cold drinks. However this was not reflected across all parts of their care plans (for detail on this, see the section on What they could do better below). Both the residents we considered in detail experienced complex nursing and care needs, including dementia and both had very limited communication abilities. This means that reviewing care plans was particularly important to ensure that care could be provided by staff in a consistent manner and in the way that the resident needed. We were concerned that while some actions had been taken to meet our Statutory Requirement Notice, that the Notice had not been met in full. This was despite the action plan sent to us by the provider where they stated that the home would meet our Statutory Requirement Notices by the end of September 2010. Additionally the provider had also declared that they were compliant with this outcome area in their submission for registration under the Care
Care Homes for Older People Page 5 of 19 Standards Act 2010, when it came into force on 1 October 2010. We have therefore decided to issue the home with a Compliance Condition as part of their registration under the new Act. This will be in relation to ensuring that people are protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them. The home will need to maintain an accurate record in respect of each person, which shall include appropriate information and documents in relation to their care and treatment. We will perform an early compliance review, to ensure that residents are protected by the homes systems, particularly their completion of records relating to residents care. What the care home does well: What they could do better:
The home needs to continue to ensure that it reviews residents care plans when needed. As both of the residents we met with were not able to verbalise their needs, this was a particularly important area in service provision. Both of the residents we met with had tissue damage. Both residents were reported by staff to have experienced pain from their tissue damage. Both residents were prescribed pain killers. A registered nurse was able to describe to us how they assessed if the residents were in pain, including observations of facial expression and body language. A carer also told us about how they observed a resident for restless behaviours if they thought the person was in pain. The registered nurse was aware of actions the home had
Care Homes for Older People Page 6 of 19 taken, including consultation with the residents GPs, to try to prevent the residents from being in pain. One resident had one limited reference to their experience of pain in their care plan, which was not up-dated when their care plan was reviewed. This reference made no mention of signs shown by the resident if they were in pain or the effectiveness of any prescribed pain relief. The other resident did not have any details relating to their experience of pain in their care plan. One resident had been seen by the tissue viability nurse on a regular basis. On 1 September 2010 the tissue viability nurse had given clear instructions in writing about prevention of pressure ulceration for the person to different pressure points. The persons care plan had not been up-dated to reflect what the tissue viability nurse had documented. The persons night care plan directed that the person was to turned four hourly. However the homes policy and procedure stated that people assessed as being at high risk of pressure ulceration needed to be turned two hourly. The persons night care plan did not reflect this advice or state in its review why the resident needed to have their position moved at a lower frequency than stated in the homes policy and procedure. One of the residents had been cared for in bed since July 2010 and staff reported that they were concerned that the person might become socially isolated. When we visited them, they had safety rails with protectors on their bed, so they would not be able to see much apart from upper walls and the ceiling of their room. The section of the persons care plan relating to social and emotional well-being was un-dated, unsigned, did not have all the sections in the homes care plan proforma completed and did direct how staff were to support the person from social isolation, now that they were cared for in bed. We observed that the other resident was sitting in a lounge during the morning and staff reported that the person was returned to bed during after lunch. This persons care plan did not document how they were to spend their day and how they were to be supported by staff in not becoming isolated when they were on their own in their room or on preferences for activities when they were in the sitting room. Both residents had records relating to their bowel movements, these indicated periods when the person did not open their bowels for an extended period. Both of these records were included in the residents records but did not have the residents name on the record. When we spoke to staff, they informed us of different matters relating to the individuals bowel care needs. Both residents care plans did not reflect what their other records documented or what staff told us about. One of the residents was prescribed a bowel opening prescription on a regular basis; this was not referred to in their care plan, so the effect of this prescription could not be assessed. As constipation can make a person with dementia become more confused and may be very uncomfortable for a person who has limited communication, care plans relating to bowel care need to be reviewed to ensure that they reflect the current supports needed for the resident. We observed that the resident who was cared for in bed all the time had an assessment for the use of bed rails which had not been completed in full and was un-dated. The section on their care plan relating to maintaining a safe environment documented that the person was immobile and not at risk of falls, but on 30 August 2010 the review of this section of their care plan stated that the person continued to need safety rails to prevent them from falling out of bed. The Health and Safety Executive (HSE) and Medicines and Health Care Regulatory Authority (MHRA) report that the use of bed rails presents a risk to people and therefore they should only be used if there are no other suitable
Care Homes for Older People Page 7 of 19 alternatives. This resident was in a profiling bed, which could have been lowered close to the floor and a crash mat used, as recommended by the HSE. The persons bed rail assessment and care plan should have been reviewed to reflect the current situation for the resident and ensure that equipment was used in the best interests of the resident. One of the residents had a hand-written note in their room, which stated that soap or bubble bath were not to be used on the person. This note was un-dated and un-signed. This was not documented in the personal hygiene section of the persons care plan. While parts of residents care plans had been reviewed and up-dated, as many previous reviews of care plans had not been archived, finding relevant information was complex. Some care plans were duplicated. For example one resident had a section in their care plan relating to their continence needs, followed by a section relating to their incontinence needs. Some information was difficult to find in a care plan. For example one of the residents care plan had two different sections relating to personal hygiene, both of which were current and two different sections in their care plan relating to their skin lesions, both of which were also current. These had differing information relating to care to be provided in these different sections of their care plan. Across all these different sections of the persons care plan, all the information needed was available. This included reference to prescribed topical applications observed in the persons room. As these directions were documented in different parts of the persons care plan, it would have made accessing all relevant information, for example by an agency person or a member of staff who did not work full time, complex to find. This persons record of dressing changes did not document that their dressings were being changed at the frequently directed in their care plan. When we visited a persons room, we noted that a slide sheet to assist the person in changing their position had been left on the floor. This is ill-advised practice and the sling should have been hung up, to prevent contamination of it by, or from, the floor. The sling had also not been named and in order to eliminate risk of cross-infection and ensure residents dignity, all slide sheets should be named and used only for the named resident. When we visited the sluice room, we observed that two new refuse bins had been provided, however the bin used for clinical waste was not foot-pedal operated, which it needed to be, to prevent risk of hand contamination for staff when placing items in the bin. The Health and Social Care Act 2010 came into force on 1 October 2010 and this inspection took place under our previous legislation, so we will not be setting requirements or making regulations relating to the issues identified as part of this report. The provider needs to review issues identified during this inspection, to ensure that it complies with the new Act. We plan to perform a compliance review early on in our review programme, to ensure that our essential standards for quality and safety are met. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 8 of 19 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 2 5A The home must provide people with the information required in relation to the breakdown of fees. Not reviewed at this random inspection. This will help to make sure that people and their representatives have access to information about the fees charged by the home. 05/01/2009 2 3 14 Pre-admission assessments must include a full assessment of all of a persons nursing and care needs. Not reviewed at this random inspection. This will ensure that the home can meet the persons individual needs. 28/05/2010 3 7 12 A care plan must be put in 28/05/2010 place whenever a person has a nursing or care need. The care plan must be fully updated when a persons condition changes. The care plan must use precise, measurable language. Care Homes for Older People Page 9 of 19 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Not addressed by the timescale for action. Care plans are needed to direct staff on actions to take to meet individual need, this ensures that care is delivered in a planned and consistent manner. 4 9 13 When any medicine is 01/05/2010 administered to people who live in the home this must always be accurately, clearly and completely recorded. (This particularly relates to recording the actual dose of medicine administered where a variable dose is prescribed and other shortfalls in the records identified in the report). Not addressed by the timescale for action. This is to help to make sure people receive their prescribed medicines correctly and to help reduce risks of mistakes because of poor medicine records. 5 9 13 Put in place safe 01/05/2010 arrangements, in accordance with best practice guidance, for the handling, storage and recording of any medicines that are applied to the skin. Not reviewed at this random inspection. Care Homes for Older People Page 10 of 19 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action This is to help make sure that people receive these treatments correctly and are not put at risk because of inadequate practices and incomplete records. 6 16 22 The home must provide written evidence that they have fully investigated all complaints. Not reviewed at this random inspection. If records are not made of investigations into complaints, the home cannot show that it has fully and impartially investigated any complaint. 7 26 13 Practice and equipment in 28/05/2010 relation to prevention of spread of infection must be improved to ensure that all relevant equipment is provided, that it is intact and fully wipable with all dust and debris regularly removed, particularly in laundry and sluice rooms. The parts of this requirement reviewed at this inspection had been addressed. This is to prevent risk of cross infection. 8 29 19 The home must perform a 28/05/2010 full audit of all its staff files, to ensure that they include all required pre-employment
Page 11 of 19 28/05/2010 Care Homes for Older People Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action information for the individual. Not reviewed at this random inspection. This is to ensure that the home can provide evidence that they are following safe recruitment practice. 9 29 19 The home must provide evidence of a persons past employment history. Not reviewed at this random inspection. This is to ensure that the home can provide evidence of the prospective member of staffs suitablity for their role. 10 37 12 Records of care given must be accurate and completed when nursing and care is provided. All documents must be dated. Not addressed by the timescale for action. If records are not accurately completed and dated, the home cannot evidence that care has been given as needed by the resident. 11 38 23 The home must make sure 28/05/2010 that the most up to date fire risk assessment is made available for inspection. 14/05/2010 30/04/2010 Care Homes for Older People Page 12 of 19 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Not reviewed at this random inspection. This is to ensure that people will be safe in the event of a fire. 12 38 13 The homes risk assessment 10/05/2010 in relation to bathing/showering of residents must be fully revised, to reflect directives from bodies such as the Health and Safety Executive. Not reviewed at this random inspection. This is to ensure that risks of scalds to residents is prevented. 13 38 13 The homes infection control procedure must be revised and be specific to the home. Not reviewed at this random inspection. This is to prevent risk of cross infection. 30/06/2010 Care Homes for Older People Page 13 of 19 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 1 The statement of purpose should have information about how the home cares for people with dementia and those with mental health needs, which should also describe how their privacy and dignity is addressed. The information relating to how to contact us should be up-dated. Parts of this recommendation was identified at the inspections of 6/4/09 and 25/3/10. It had not been addressed by the inspection of 2/8/10. It was not reviewed at this inspection. 2 3 Assessments of need or risk should take place in a timely manner, in accordance with research-based guidelines. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 3 3 All subsequent assessments after admission should contain sufficient attention to detail to help ensure that peoples dignity is respected. This recommendation was identified at the inspection of 6/4/09. It had not been addressed by the inspection of Care Homes for Older People Page 14 of 19 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 2/8/10. It was not reviewed at this inspection. 4 7 Where a persons first language is not English, care staff should be advised of key words for that person, so that they can explain care being provided and actions taken. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 5 9 Review and update the medicine policy and procedures to include up to date information about all aspects for the management and handling of medicines in this home so that staff have access to good information about the way in which they are expected to handle medicines. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 6 9 Write the date on containers of medicines when they are first opened to use to help with good stock rotation in accordance with the manufacturers good practice directions and to help with audit checks that the right amount of medicines are in stock. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 7 9 Make arrangements to include an appropriate entry in the allergy section on all medicine administration records as an additional action that can reduce the risk of people being supplied with a medicine to which they are known to be allergic. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 8 9 Review medicine records and care plans to make sure that any medicines prescribed with a direction when required or with a variable dose have clear, up to date written guidance available to staff that clearly describe how to reach a decision to administer the medicine at a particular dose, taking into account the provisions of the Mental Capacity Act 2005. This will help to make sure all people living in the home receive the correct amounts their medicines in a consistent way in line with planned actions. Care Homes for Older People Page 15 of 19 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 9 9 Review the storage arrangements for insulin injections once these have been first used to make sure these are in accordance with the manufacturers directions. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 10 9 Obtain and check the guidance published by the National Patient Safety Agency about Safer lithium therapy and actions that can make anticoagulant therapy safer. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 11 10 Staff should use the residents own name when addressing them and not use generic terms of endearment, without also using the residents name. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 12 10 The persons preference for sex of carer to provide personal care should be documented. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 13 15 The people who cook meals should be provided with training on how to meet the dietary needs of people who are frail, have dementia and conditions such as diabetes. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 14 15 Clothes protectors should be provided individually to residents and only provided when assessed as being needed by a resident. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 15 16 All verbal concerns and the actions taken to resolve them should be recorded. A written reply to relatives about the outcomes of any concerns should be completed.
Page 16 of 19 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations This recommendation was made at the inspections of 6/4/09 and 23/3/10. It was not reviewed at this inspection. 16 24 Staff should check bath/shower water temperatures and maintain a record, prior to bathing/showering a person. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 17 26 Used laundry should be separated at source, not in the laundry. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 18 28 The home should consider how it supports and encourages more care staff to undertake National Vocational Qualifications. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 19 32 The results of any quality assurance surveys are given to the people completing the surveys, for example relatives, which could take the form of a newsletter about the home where improvements are highlighted. This recommendation was identified at the inspections of 6/4/09 and 23/3/10. It was not reviewed at this inspection. 20 33 Reports on visits to the home by a senior manager should review care plans in more depth and more care staff should be met with on each visit. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 21 33 An observational tool could be used for quality assurance purposes as many people are unable to comment about the home. This recommendation was identified at the inspections of 6/4/09 and 23/3/10. It was not reviewed at this inspection. 22 35 The homes safe should be secured to a load-bearing wall. Care Homes for Older People Page 17 of 19 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 23 37 The home should consult the Fire and Rescue Authority about the use of locks on residents room doors. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. 24 38 Individual fire evacuation plans should be developed for residents. This recommendation was identified at the inspection of 23/3/10. It was not reviewed at this inspection. Care Homes for Older People Page 18 of 19 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 19 of 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
