Inspection on 09/10/06 for 8 Stickley Lane

This inspection was carried out on 9th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 Stickley Lane 13/01/06

8 Stickley Lane 24/05/05

8 Stickley Lane 24/01/05

8 Stickley Lane 11/06/04

8 Stickley Lane 09/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 8 Stickley Lane Lower Gornal Dudley West Midlands DY3 2JP Lead Inspector Jayne Fisher Unannounced Inspection 9th October 2006 10:00 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 8 Stickley Lane Address Lower Gornal Dudley West Midlands DY3 2JP 01902 662076 NONE 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) Langstone Society Clive Lingard Care Home 6 Category(ies) of Learning disability (4), Physical disability (2) registration, with number of places 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6 February 2006 Brief Description of the Service: Stickley Lane is a purpose built residential home owned by Black Country Housing and operated by the Langstone Society. The home is registered to provide 24-hour care to a maximum of six people with a learning disability including two with additional physical disabilities. Accommodation is provided over two floors; the main staircase accesses the upper floor. On the ground floor are two bedrooms, bathroom with bath chair and walk in shower, lounge, dining room, kitchen and laundry. A further four bedrooms are on the first floor along with the main office, bathroom with shower and toilet, and a further toilet. There are a few parking spaces at the front of the property and a landscaped garden at the rear. The home is situated in a residential area of Lower Gornal and is in keeping with other properties in the area. Local shops and other amenities are within walking distance and a bus service is easily accessible. Two private mini buses are also available to service users and the ring and ride can be used if needed. A statement of purpose and service user guide are available to inform residents of their entitlements. Information regarding fee levels were provided on 10 August 2006 by the manager which are between £700.00 and £1,000 per week. There are additional charges for toiletries and hairdressing. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days between 10:00 a.m. and 19:00 p.m. hours on the first day, and 09.15 and 13:00 hours on the second day. The home was given no prior notice of the inspection. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: interviews with the manager and five staff. Feedback was received from three relatives and a General Practitioner. Five residents completed questionnaires with the assistance from staff. Where possible, responses were discussed with residents in order to make judgements about the service. All five service users were at home during varying stages of the inspection. Some were happy to speak with the inspector and either gave consent, or showed the inspector their bedrooms. Formal interviews were not always appropriate therefore the inspector relied upon brief chats, observations of body language, eye contact, gestures, responses and other observations of interaction between staff and service users Three residents’ care was case tracked by reading and assessing care documents, observing interactions and by talking to staff and chatting to residents. One meal time was observed. A tour of the premises was undertaken to assess the standard of the environment. Staff personnel files were accessed and a sample of maintenance and service records were examined. Other documentation was reviewed including a pre-inspection questionnaire completed by the manager. What the service does well: Residents’ benefit from a well run home and are supported by a stable and experienced staff team who are aware of their individual likes and dislikes. Residents are fully supported to make choices and staff endeavour to ensure that their wishes are upheld. For example, residents’ meetings are held regularly and these are followed by a staff meeting so that any requests made by residents are then discussed with staff which is an excellent strategy. Where possible residents are encouraged to be independent; they can make their own drinks and help staff prepare meals and can also travel and visit their relatives on their own if they wish. Residents are enabled to lead meaningful lives and enjoy a range of stimulating activities and leisure pursuits. There is a strong emphasis on allowing residents to choose their own activities within the home and in the community. Staff support both residents and families to maintain their important relationships. All relatives were positive in their comments about the home; for example one relative stated, “the staff are wonderful and very 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 6 caring”. Residents are provided with a varied and well balanced diet. There is a complaints procedure so that they can raise their concerns and there are good systems in place to protect residents from abuse. The healthcare needs of residents are monitored by staff and treatment sought for any identified problem. The premises is furnished to a high standard thereby providing residents with a comfortable and homely place to live. Bedrooms are decorated and furnished according to resident’s wishes and tastes. All parts of the home were exceptionally clean and hygienic. There were no offensive odours. The atmosphere through out the inspection was relaxed and friendly with lots of positive interaction observed between staff and residents. One member of staff commented “it’s like one big family here” and this was evident through out the visit. All residents looked happy and relaxed in their surroundings they made no complaints or gave no indication that they were not satisfied. 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. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 The overall outcome for this group of standards is judged to be adequate. Assessment tools need to be developed to aid in the assessment of any new potential residents, and in order for existing residents’ needs to undergo periodic reassessment to assist with the evaluation of existing care plans. EVIDENCE: Residents at Stickley Lane have resided at the home for at least one to three years thereby demonstrating that previous assessments prior to admission have been appropriately conducted and resulted in successful placements. None of the residents either observed or spoken to during the inspection indicated any dissatisfaction about living at the home; they looked relaxed and happy in their surroundings. Due to the recent unfortunate demise of one resident the home now has a vacancy (see further comment in standard 24). The manager acknowledged that an assessment tool needs to be developed which meets the requirements of the National Minimum Standards 2.3 to assist in the evaluation of potential new residents. As service users have resided at the home for a number of years, copies of the original assessments prior to their admission were not seen to be contained within the service users’ care plan files. As the Care Homes Regulations 2001 require that the assessment of service users’ needs are kept under review, a holistic assessment tool needs to be developed to aid in this process and help with the periodic review and measuring the effectiveness of existing care plans. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 10 There is an outstanding requirement to amend contracts/terms of conditions of occupancy in order to comply with the National Minimum Standards 5.2. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The overall outcome for this group of standards is judged to be adequate. All residents have a range of care plans and risk assessments in place, however some of these are more detailed than others and as a result, require review and expansion in order to ensure all aspects of residents’ support and needs are included. EVIDENCE: A sample of residents’ care plans were examined and interviews were held with staff. The high level of support provided to residents by staff and their detailed knowledge regarding residents’ likes and dislikes are not reflected in the current care planning system. Some elements of care planning were found to be very good with particularly detailed information provided to staff to aid them in meeting residents’ needs. For example care plans relating to residents’ personal hygiene were found to be excellent as there were detailed aims, goals and actions required by staff to meet goals identified. No other care plans contained this level of information being in a proforma type format which does not allow for such details. For example, one resident has mobility problems and requires the use of a wheelchair within the home and in the community. Although the risk assessment stated ‘please see care plan’, there 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 12 was no care plan in place other than one sentence within a section entitled ‘assessment of daily living skills’ within the care plan proforma. The key worker demonstrated detailed knowledge regarding this residents’ needs but these were not always contained within the care plans. For example, with regard to likes and dislikes in relation to food types. The behavioural care plan stated ‘see also behavioural management and support, appendix h.), although this could not be located in the care plan file. The care plan stipulated that ‘encouragement’ should be given but does not state how this should be delivered (for example, verbally). The resident is registered blind but there was no care plan in place regarding how this impacts upon the resident’s daily life and the support required from staff. Particular health complications are not always reflected in a specific care plan. For example, one person has cellulitus but there was no care plan in place with regard to how this is managed (including the use of emergency medication), although there was a risk assessment in place. Another resident has a particular blood complication but apart from a statement on a separate page (reminding staff to wear protective clothing) at the beginning of the care plan folder, there was no actual care plan in place. As required at the last inspection behavioural care plans are in place for one specific resident. However, one care plan was dated 1 December 2004 and did not describe all the types of behaviours exhibited (and as recently displayed including physical aggression). Another behaviour ‘care plan’ was also seen but this was only a brief statement and again did not describe types of behaviours or all of the strategies employed by staff to manage the behaviour. There were no detailed care plans in place with regard to epilepsy. It was pleasing to see that all care plans are regularly reviewed along with other professionals and families. Staff are in the process of introducing a person centred planning system; all residents have ‘personal planning books’ which staff are currently helping them to complete. All residents have brief statements within their care plans containing information regarding their communication needs. This is being supplemented by very detailed communication passports which staff are completing with speech and language therapists. Although staff were observed to be thoroughly aware of residents communication methods, these are extremely useful tools particularly for people who do not know the resident including any new staff. There are no advocacy services currently being utilized however as seen in care plans and through discussions with staff and residents, families and other professional staff are available to assist residents in making their wishes known with regard to decision making if necessary. All residents require some form of assistance with regard to management of their finances however there were no care plans in place with regard to the support provided by staff. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 13 As with care plans, some risk assessments were more detailed than others. One resident with mobility problems had a fairly detailed risk assessment in place with regard to showering. However, the separate risk assessment with regard to moving and handling requires more information being of a ‘tick list’ format. For example, there was no level of risk identified, there was no description of the type of hazard, for example the level of mobility problems (the resident can weight bear according to staff) or any potential cognitive behavioural issues, communication or visual (the resident is registered blind), there was no information regarding the environment. Although the tick list identified that two staff are required for most transfers there were no details as to what type of assistance was actually required. There were no detailed risk assessments seen to be in place with regard to challenging behaviour. One resident who can display challenging behaviour had a risk assessment in place but this related to ‘invading’ the personal space of another resident’. There were no details regarding other residents, visitors or staff. The level of risk was not identified, nor were the different types of behaviour, triggers, deescalation techniques, staff training etc. One resident is a wheelchair user there was no specific risk assessment in relation to this equipment including risks identified in previous medical device alert notices (including posture belts and seating accessories). A copy of these notices were given to the manager for information. There were no details as to how the resident accesses the home’s two minibuses both of which have different types of lifting/transfer equipment. Some risk assessments had not been reviewed since 20 June 2005. Some reviews simply consisted of a staff initial and a date; there were no details of the outcome of the review. There was no risk assessment in place with regard to one resident’s particular blood complication or infection control issues. It was however pleasing to see that risk assessments were in place (and up to date), for one resident who travels independently and regarding independent living tasks which are undertaken within the home. Another service user has a kettle in his bedroom to make drinks if he wishes and is supported to make drinks in the kitchen. This was also found to be risk assessed. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 The overall outcome for this group of standards is judged to be good. Staff support service users to achieve fulfilling lifestyles through a variety of stimulating activities and community outings. Staff support residents and their families to maintain their important relationships. The meals provided to residents are well balanced offering both choice and variety. EVIDENCE: Interviews with staff, chats with residents, feedback from relatives and observations made during the inspection visit confirmed that staff support residents to lead meaningful lives and ensure that their individual aspirations are met. Five out of the six residents at Stickley Lane attend formal day care provision during the week. Residents were observed both going to, and returning from their day care; they looked eager to be going and upon their return looked 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 15 happy and chatted about their favourite activities. One resident said that he liked cooking and was going to help cook the evening meal for the other residents. Another resident talked excitedly about a day trip undertaken at the weekend and was happy that he had brought a jigsaw puzzle which is one of his favourite leisure pursuits. In addition to this residents also benefit from a monthly key worker day. This is an excellent idea whereby residents have the opportunity to not attend their day centre but instead choose an activity which they undertake on a one to one basis with their key workers. There is a useful planning and preparation sheet for staff to complete prior to the day out and an activity monitoring form to complete after the event. It was pleasing to see that a forthcoming evening activity for staff to support one resident to go and see a John Lennon tribute band at a local music venue had been planned and prepared by staff using this tool. Staff are to be commended on their approaches to ensuring that residents are enabled to participate in the community and that their individual preferences are met. One resident’s personal activity sheets demonstrated a wide range of community outings. For example, during a one month period the resident had been to his evening social club, local disco, a safari park, Weston Super Mare, Windsor castle, Chester zoo, Warwick castle and on food shopping trips. Minutes from a residents’ meeting in September 2006 demonstrated that residents had enjoyed their outings and were encouraged to make suggestions about what trips and activities they would like to undertake in the forth coming months. In interviews all staff stated that they felt residents were offered sufficient activities and outings and that there were enough staff to accommodate their wishes. There was only one deficiency noted which was in relation to recording. One resident does not attend a day centre and day care is provided by staff. There was no activity programme in place. The manager stated that this was not a preferred system as staff wanted to respect the wishes of the resident who likes spontaneous activities. It was difficult to case track this residents’ activities during the day time as their was little detail recorded on a daily basis and information was disseminated in various recording systems, including the duty rota, personal activity sheets, monitoring sheets, senior workers’ daily reporting system and day book. This is a confusing system. For example, whilst the duty rota indicated that staff had been allocated on shift to take the resident on a particular outing, there was no reference to this in the residents’ daily notes or activity recording sheet. In addition, when the resident was not on an outing there was no evidence in the daily reporting system as to how the resident had spent her day or what activities had been undertaken within the home. There is an activity section within the care plan proforma although this did not contain all of the preferred activities as revealed by the resident’s former key worker and neither did it contain details as to who is responsible for co-ordinating the daily activities and how this are planned etc. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 16 All relatives who completed feedback forms confirmed that they were made welcome when they visited the home and could see their family member in the privacy of their bedroom if they wished. All relatives made positive comments including “A lovely caring home and staff always ready to oblige in any situation. Peace of mind for me as I know ‘X’ is happy”. Staff are to applauded for their efforts to help both residents and families maintain their links. For example, relatives are invited to participate in joint outings or events planned by staff on at least four occasions during the year. Events have included a cheese and wine party, barbeque and various outings; relatives recently accompanied residents to their outing to Warwick castle. It was particularly refreshing to hear that even though one resident was to ill to participate in this outing, her family were encouraged to go with the other family and residents. Another example of the dedication and commitment towards relatives and their families demonstrated by staff is whereby one resident is taken to visit her family who also are collected in the mini-bus and then taken on an outing during the week. Daily routines are flexible as observed during the inspection. For example on arrival on the second morning of the visit at 9.15 a.m. one resident was having a lie in. One resident does not like to eat their evening meal with the rest of the residents and staff made no complaint about having to provide a later meal for this service user. One resident has chosen to hold his own bedroom door key. During interviews other residents when asked, confirmed that they did not wish to have their own bedroom door key. There was lots of examples of positive interaction observed between residents and staff through out the inspection visit. It was pleasing to see that residents and staff were eating their evening meal together and according to staff this is the normal practice. The atmosphere was relaxed with residents and staff contributing to conservation topics. The home does not operate a structured menu plan instead residents are able to choose on a daily basis what they would like to eat. This is an excellent initiative as it promotes choice and independence. Residents also participate in food shopping so they are able to pick their favourite foods. During interviews residents confirmed that they could choose what they want to eat and talked about their preferred meals. On the first day of the inspection, one resident helped staff to prefer the evening meal of egg and bacon sandwiches. One resident had chosen to have a different meal of a cheese sandwich and pork pie. Staff were seen to assist one resident to eat and drink in an appropriate manner which respected the resident’s dignity and promoted their health and safety. On examination cupboards, fridges and freezers were well stocked with good quality brand food products and a range of fresh fruit and salad produce. There are only a couple of issues which need action. One is related to ensuring that residents’ food choices are more consistently recorded including their refusals. As already stated, one resident likes to have a later evening meal as they have a cooked meal at the home during the day. However on a couple of 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 17 occasions there was no record as to whether this resident had an evening meal or supper. The second item relates to nutritional assessment and screening. There is no professionally recognised nutritional screening tool (for example from the community dietician). However there is a risk assessment in place with regard to diet and nutrition. This tool however does not identify whether risks associated with obesity, low weight or eating and drinking problems have been considered, nor does it state whether or not the resident is the ideal weight for their height/frame etc. One risk assessment had not been reviewed since 20 June 2005. The risk assessments state ‘to weigh X at regular intervals’ however this is not being carried out (see standard 19). There is a ‘nutritional needs and preferences’ section in the care plan proforma however these need expanding to actually include residents’ preferences, how they are supported in maintaining healthy eating, choosing their own meals etc. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The overall outcome for this group of standards is judged to be good. The personal care and health needs of service users are well met with evidence of good multi-disciplinary working taking place on a regular basis. There are safe systems for the residents in the control and administration of medication, only a few improvements are required to enhance current practice. EVIDENCE: All relatives who completed feedback forms stated that there satisfied with the overall care provided. One relative commented “X always has the best care and attention since he has lived there. I praise the staff for all their hard work and support”. Care plans contained details regarding residents’ preferences regarding opposite or same gender care. Residents preferred times for getting up and going to bed are not recorded but staff reported that this was because residents were able to choose themselves when they wished to rise or go to bed, which was confirmed during interviews with residents. When asked about what one resident liked about living at the home he replied “I like everything”. Residents were seen to wearing clothing and have hairstyles which reflected their individual personalities and tastes. One resident was wearing a football shirt which he said he had chosen himself. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 19 Interviews with staff and examination of records demonstrate that residents are facilitated to receive specialist support as and when required. One resident is currently receiving support from a psychiatrist, psychology and speech and language therapists in order to provide behavioural management guidelines and a communication diary has been established. Feedback was received from a General Practitioner (G.P.) who stated that there is always a senior member of staff to confer with, staff demonstrate a clear understanding of residents’ needs and that they communicate clearly and work in partnership with the primary care team. On examination there are good records relating to appointments and outcomes with medical practitioners. From the case files sampled residents were seen to have regular ophthalmology and dental checks. There was only one exception where the resident had not received an ophthalmology check since November 2004, annual tests had taken place prior to this as the resident wears glasses. The senior support worker on duty could offer no explanation but thought that staff may have forgotten to record the appointment. This needs to be clarified. There are only a couple of minor issues identified which need attention and as detailed in the Requirements section of this report. Residents are not weighed on a regular basis. One resident has not been weighed according to records since 2003. The manager stated that he feels that this is not necessary as the resident in question is visually checked and there are no concerns. The section in the care plan proforma is entitled ‘Nutritional needs and preferences (including weight management), however there was no reference to how weight is monitored or managed or the current system in place. Another residents’ care plan and risk assessment stated that his weight is monitored ‘regularly’. However, the resident had only been weighed in January and June 2006. Care plans and risk assessments need to give guidance to staff as to the frequency of weighing residents (and if this is not taking place, then the type of monitoring in place such as visual checks). Residents do not receive annual health checks (or attend well person clinics). Although it is clear from records that they see the G.P. whenever there is an issue this does not constitute a full health check (or include a medication review) as required by the National Minimum Standards 19.4.(and in line with strategies outlined in the Valuing People – White Paper). It was pleasing to see that the home has introduced the Priority for Health Screening Tool (although the section to be completed by the Primary Care Team has yet to be filled in). Care plans need to be established with regard to health screening for particular complications such as testicular, breast and cervical cancer. Screening should include annual attendance at well person clinics, where possible a programme of education with regard to self examination should be considered or guidance for staff with regard to observing any physical abnormalities and action to take. All residents receive chiropody treatment at their day centres or health clinic. There is one resident who is the exception and staff undertake this 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 20 responsibility. As discussed with the senior support worker, approval and guidance must be obtained from a chiropodist to ensure correct techniques are employed and that safe practice is adhered to. This must be recorded in the relevant care plan. An evaluation was undertaken of medication practice. Generally this was found to be very good. For example, the drugs cupboard (which are two lockers) were found to be clean and tidy, extraneous items being removed by the senior support worker on the day of the visit. There are good records relating to the receipt and checking of medication. There were no gaps or unauthorized letter codes on the medication administration record (MAR) sheets. Care plan folders were seen to contain residents’ consent to medication being administered by staff. There were comprehensive and individualized homely remedies polices contained within each service users’ care plan. One resident had recently been administered Paracetamol as a household remedy according to their daily notes and this had been recorded on the MAR sheet. The local pharmacist undertakes an audit on a regular basis. Some practice and recording issues were identified and are detailed in the Requirements section of this report (none of which represent a serious concern). For example, one resident had run out of Dovonex cream on 20 September 2006, the senior support worker on duty was unsure as to why this had happened but had ordered a new supply (to be delivered on 13 October 2006). In the interim staff had substituted Aqueous cream. Staff had failed to seek approval from the G.P. or pharmacist. The service user had not been prescribed Aqueous cream since 19 May 2005. However it seems some old stock had been retained and was used (but was within the expiry date). Other tubs were found which were found to be past the expiry date and were removed by the senior support worker. During interviews with staff it was found that on occasions two staff are involved in the administration of medication (there was no policy regarding this procedure). Senior support workers check and pop the medication from the monitored dosage system (MDS) into medication tots. Support workers are then given the medication tots to administer to the service user and sign the MAR sheet. As the support workers do not check the medication and MAR sheets themselves prior to administration, they should not be signing to confirm administration of medication unless they have carried out the required checks to ensure that the correct medication has been dispensed from the MDS. In addition support workers have not received training. During interview the senior staff member reported that they had received training. However there was no training certificate to confirm that this had taken place and to what standard. Training certificates were found for three members of staff however there was no evidence that this training was accredited or meets the requirements of the Skills for Care. There was evidence however, that some senor staff are currently undergoing this training. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The overall outcome for this group of standards is judged to be good. There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. There are procedures in place to safeguard service users from abuse. EVIDENCE: Since the last inspection the manager states that the complaints procedure has been made more visual thereby enabling residents to more readily access the procedure as previously required. There have been no complaints received by the Commission for Social Care Inspection (CSCI) regarding the service and no complaints have been received or investigated internally during the last twelve months. There is a complaints log together with an explanation for staff with regard to record keeping. During interviews staff gave good examples as to how they would deal with complaints from residents. Residents’ case files contained confirmation that the complaints procedure had been explained to them. All relatives who completed feedback forms stated that they were aware as to how to make a complaint if they wished. The home has robust procedures in place to protect residents from abuse. Copies of the Local Authority vulnerable adult abuse procedures were held on the premises as well as Department of Health guidance – No Secrets. According to training certificates eleven out of thirteen staff have received training in vulnerable adult abuse. During interviews staff gave good examples as to how they would deal with a potential incident of abuse and understood the principles of Whistle Blowing. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 22 On inspection there continues to be good systems in place to manage residents’ finances. There are up to date personal expenditure sheets in place for each resident. One resident’s records balanced accurately with the money held on the premises. Another resident’s records was slightly inaccurate (£0.02p) when checked with monies held. It was pleasing to see that residents are reimbursed for replacement meals when on outings in the community; residents are allocated £3.00 per meal (this should be included in their care plan and contract). There were receipts obtained for the majority of purchases however one receipt for a meal on 7 October 2006 enjoyed by residents during an outing could not be located. There are two staff signatures for transactions made on behalf of residents as is good practice and senior support workers check and balance residents’ monies and records at least twice daily upon handover. All residents have their own bank accounts. Staff reported that two residents are able to withdraw their own monies from these accounts. Two staff withdraw monies from bank accounts for four residents (this procedure needs to be included in a care plan). The provider is appointee for all residents. It is recommended as per guidance from CSCI that an independent audit of residents finances and records is undertaken at least on an annual basis. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The overall outcome for this group of standards is judged to be good. The standard of the environment within this home is good providing service users with an attractive and homely place to live. All parts of the premises are clean and hygienic. EVIDENCE: A tour of the building was undertaken and a sample of residents’ bedrooms were visited with their consent in order to determine compliance with these standards. The communal areas are pleasantly decorated and comfortably furnished, they were airy and brightly lit. Bedrooms are decorated and furnished to a good standard and individualised with personal possessions, photographs and stereo equipment. It is pleasing to see that colour schemes, décor and furnishings reflect service users’ individual tastes. During interviews one resident stated that he liked his bedroom. There is evidence of an ongoing rolling programme of redecoration; the dining room was said to have been recently refurbished. There is a small garden to the rear which consists of a patio area and a small established garden made attractive with flowers and shrubs. A range of 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 24 garden furniture was available for residents. locked gate. The area was secure with a The home is currently registered for up to two persons with a physical disability. One of the bedrooms occupied previously by a resident with a physical disability is now vacant. This room does not meet the National Minimum Standards with regard to floor space and as previously agreed with CSCI, the condition of registration will now be reduced to one person with a physical disability. The manager states that discussions are being held with the provider as to whether a planned extension is now to go ahead. All areas of the home were exceptionally clean and tidy including the kitchen and laundry area. There is a small laundry containing a washing machine with a sluice cycle, wash hand basin, protective clothing for staff and plastic sealed containers for dirty laundry. Laundry procedures were displayed. Staff were seen to wear protective clothing when carrying out domestic and catering tasks. Only a small number of minor issues were identified with regard to infection control practice as identified in the Requirements section of this report (see comments in standard 42 with regard to infection control training). 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 The overall outcome for this group of standards is judged to be good. Residents are supported by a stable, experienced and competent staff team who know their preferred likes and dislikes and routines. Recruitment and selection procedures are good and offer protection to residents only slight improvement is needed. EVIDENCE: There are currently thirteen staff employed not including the registered manager. Information provided by the manager prior to the inspection states that eleven staff are qualified to NVQ II or above (which exceeds the National Minimum Standards). However, only a small number of training certificates were held on the premises to confirm that this training had been undertaken (for a total of four staff). During interviews staff confirmed that they had undertaken the training. The duty rota was examined which demonstrated that a total of three staff are on duty at peak times. There is one waking and one sleeping in member of night staff. The manager confirms that he has supernumerary hours and also works on shift (including night duties). There is an extremely stable staff group as demonstrated at previous inspections. The manager reported that during the last twelve months only one member of staff has left employment and has been replaced. During interviews staff demonstrated excellent 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 26 knowledge of residents’ needs and expressed a dedicated and conscientious approach to their responsibilities. One member of staff stated “ I like everything about working here, I love the residents and the staff are a good team; we all help each other out”. There are regular staff meetings. Minutes examined confirmed that a good range of topics are discussed and there is a focus upon residents’ wellbeing. Examination of a staff personnel file confirms that good procedures are followed when recruiting new staff and appropriate pre-employment checks are undertaken. For example the person commenced employment only after a POVAFirst (Protection of Vulnerable Adults) check had been received (a criminal record bureau disclosure check has now been received). Providers are allowed to commence staff on POVAFirst checks in extenuating circumstances however a written risk assessment must be carried out and a copy forwarded to CSCI. There was one shortfall identified in the recruitment process. The Care Homes Regulations 2001, Regulation 19 require that a full employment history is obtained and there is a written explanation for any gaps. The dates of former employment completed by the member of staff on their application form did not correlate with the dates given by the former employer on their reference. There was no written explanation on the file or confirmation that this had been investigated or explored and the manager was unaware of the discrepancy. Systems must be in place to ensure that any inconsistencies are explored and verified. Evaluation of training was difficult due to disorganised training records and certificates. There was no central training programme or matrix. A handwritten training plan for 2006 was found but this only focused upon statutory training. There were individual training profiles for each member of staff as required by the National Minimum Standards however these did not include all training which staff stated that they had undertaken. For example, some staff stated that they had undertaken training in understanding and managing challenging behaviour and epilepsy awareness although these were not included in the individual profiles. There was a central file containing a range of training certificates however these did not correlate with the training profiles and training which staff stated that they had undertaken. For example, one member of staff’s training profile stated that she had undertaken training in moving and handling in 2003 for which there was no certificate, neither was there a certificate to corroborate food hygiene training undertaken in January 2006. As already stated there were only NVQ certificates for four staff yet eleven staff are said to have completed this training. Another member of staff stated that they had undertaken training in challenging behaviour and medication for which there were no training certificates. (See further comment in standard 42). It is pleasing to see that progress has been made in providing staff with induction and foundation training which had been provided by an accredited learning disability awards framework (LDAF) trainer. However, staff are not 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 27 completing this training within the timescales required. No staff have undertaken training in equal opportunities or disability equality as required by the National Minimum Standards 35.4. Training certificates must be obtained for all training which is said to have been carried out by staff. (See further comment in standard 42). 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 28 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 The overall outcome for this group of standards is judged to be good. The manager is supported well by his senior staff in providing clear leadership through out the home. Quality assurance systems require development so that residents and other users can be confident their views underpin the development of the service. The manager ensures so far as is reasonably practicable the health, safety and welfare of residents and staff only slight improvement is necessary. EVIDENCE: Mr. Lingard has been registered manager of Stickley Lane for a number of years. The findings of this inspection confirm that he is an experienced manager whose priorities are clearly those dedicated to provide a high quality service to enrich residents’ lives. Good rapport was observed between the manager and residents. All staff who were interviewed were positive in their comments about Mr. Lingard’s management style. Comments included: “he is 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 29 fair” and “I can approach him about anything”. Staff stated that they felt valued and listened to and were praised when they made progress. Mr. Lingard shares his knowledge and experience with staff and delegates duties to senior staff. All staff confidently participated in the inspection process. Whilst Mr. Lingard has a NVQ IV in care and keeps himself up to date with changes in legislation undertaking other training, he does not have a NVQ IV in management. There is new guidance from the CSCI with regard to experienced and competent managers who may be nearing retirement and who are not qualified to the required standard. Providing that the home continues to be competently managed and well run, no recommendation has been made for Mr. Lingard to complete a management qualification. Quality assurance systems need developing further. An annual development plan needs to be established based upon a systematic cycle of planning, action and review. It was pleasing to see that last year service users’ questionnaires were completed, however although these were not pictorial and varying formats may need to be explored. In addition it would be beneficial if residents require assistance to complete these forms, that people other than staff working at the home provide support. There was no evidence of consultation with stakeholders or families. The organisation has also recently engaged in a professional quality award system – ‘PACE’ (practical award in community excellence) which the home will be completing. Staff personnel files continue to be held at the provider’s head office and as a result information required by the Care Homes Regulations 2001 are not held on the premises. New guidance was issued by CSCI earlier this year. The provider needs to decide whether this is applicable to the organisation and make applications for a formal agreement to CSCI to retain documents at their head office. A sample of maintenance and service records were examined. These were found to be largely up to date. For example, there is annual servicing of the fire alarm and emergency lighting system. Fire extinguishers have received an annual inspection and service. There is an up to date fixed electrical wiring installation check and gas safety inspection. Staff undertake regular fire evacuation drills and there is annual training by a qualified fire safety trainer. Water systems were chlorinated and tested in 2005. There are a couple of minor shortfalls as indicated in the Requirements section of this report. For example more consistent weekly checking of the fire alarm system is needed: during August 2006 there was only one recorded test and only three checks in July and September 2006. As already stated it was difficult to verify training due to the lack of training certificates. The majority of statutory training seems to have been undertaken (apart from infection control), an audit is required in order to complete a central training plan and to ensure that all training certificates are in place, and arrange for any training which is necessary. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 30 On examination food hygiene practice is good with regular testing of fridge and freezer temperatures. All high risk foods were seen to be stored and labelled correctly. Cleaning schedules are regularly completed. Only a couple of items were identified as requiring action. Any other items discussed during this inspection are contained within the requirements section of this report. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 4 14 X 15 4 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X 2 2 X 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 32 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(2) Timescale for action To develop an assessment tool 01/03/07 which meets the requirements of standard 2.3 of the National Minimum Standards for Younger Adults - in order to assist in the assessment of new service users, and to assist in the periodic reassessment of existing service users. Develop a contract covering all 01/03/07 the requirements under this standard and 16.11 in a suitable format. (Previous timescale of 1/4/06 is not met). To review and expand existing 01/03/07 care plans to ensure that all aspects of personal and social support and health care needs are included in for example: mobility, challenging behaviour, epilepsy, cellulitus and nutrition. To ensure that care plans 01/03/07 contain goals and objectives with regard to service users who require assistance/supervision with managing their own finances. To review and expand risk 01/03/07 assessments. For example with DS0000025016.V314688.R01.S.doc Version 5.2 Page 33 Requirement 2. YA5 5 3. YA6 15 4. YA7 15 5. YA9 13(4)(c) 8 Stickley Lane 6. YA17 16(2)(i) 7. YA19 12(1)(a) regard to challenging behaviour, use of a wheelchair, access to and travel on the minibus. All risk assessments must be reviewed at least annually (or sooner depending upon level of risk). To ensure more consistent 01/12/06 recording of residents’ chosen meal options/food intake. All refusals must also be recorded. To make the following 01/01/07 improvements to health care management: To establish care plans with regard to specific health care screening in respect of breast, testicular and cervical cancer. All refusals and consent issues must be discussed within a multi-disciplinary forum preferably including the General Practitioner. To ensure that all service users receive an annual health care check including a medication review. To ensure that the service user identified on the second day of the inspection, receives an annual ophthalmology check (or to record on the care plan why this is not necessary). To make arrangements for the service user who does not receive professional chiropody treatment, to do so, or to gain approval and guidance from a chiropodist in order for staff to continue to carry out this procedure. This must be fully recorded in the resident’s care plan. 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 34 8. YA20 13(2) To make the following improvements to the control and administration of medication: 1) To review current procedure for administration of medication – the person responsible for dispensing of the medication from the monitored dosage system should be responsible for the administration to service users and the signing of the MAR sheet. 2) To pursue plans to ensure that all staff responsible for administration of medication receive accredited training in administration and the safe handling of medication (or to the standard required by Skills for Care). 3) To ensure that all service users have an up to date medication profile. 4) To introduce a key holding procedure and handover sheet (the keys to the drugs cupboard must held at all times by the sole person in charge of the shift). 5) To ensure that the drugs cupboards (lockers) are secured to the wall. 6) To clarify any ‘as directed’ dosages with the prescriber and enter correct instructions onto the MAR sheet. 7) To ensure that when any changes of medication are made on the MAR sheets by staff, such as the addition of new medication, two staff initials are obtained to confirm accurate 01/12/06 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 35 instructions have been recorded. 8) To ensure all medicines with a short life (for example creams and ointments) are labelled with the date of opening. 9) To ensure that only medicines which are currently prescribed for service users (or those which are included on the Household Remedy list), are administered to service users. 10) To ensure that detailed guidelines are established for all ‘as and when required’ (PRN) medications (such as Coamoxixclav) – for example: when precisely the medication can be administered, what the initial dose to be administered is, what the maximum daily dosage is, how long the treatment should be continued for before further medical advice is sought. 9. YA30 13(3) To ensure that there is a supply of disposable paper towels in the ‘staff’ bathroom and liquid soap in the laundry. To ensure that the laundry walls are made impermeable. To remove all extraneous items (such as cooling fans, incontinence pads) from the ground floor bathroom. 01/12/06 All staff must have a recent photograph. (Previous timescale of 1/5/05 is not met). To ensure that a written explanation is obtained for any discrepancies in dates of former employment histories given by 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 36 01/12/06 10. YA34 19 11. YA35 18 new staff, (on their application form), which do not correlate with dates provided by their referees. (A full and accurate employment history must be obtained prior to commencement of duties). To ensure that all new staff are 01/04/07 registered on a Learning Disability Awards Framework (LDAF) induction (to be completed within the first six weeks of employment) and foundation training (to be completed within the first six months of employment) course which is provided by an accredited LDAF trainer. To ensure that all staff receive training in equal opportunities and disability equality training. To establish a central training and development programme for staff which includes specialist as well as mandatory training. To carry out an audit of training which has been undertaken and to obtain copies of training certificates to evidence that this has been carried out and update training records. 12. YA39 24 13. YA41 17(2) The home must maintain an 01/03/07 effective quality assurance and monitoring system – including an annual development plan and evidence of consultation with stakeholders, families and friends. (Previous timescale of 1/5/05 is not met). To obtain and hold information 01/03/07 and documents on the premises in respect of persons carrying on, managing or working at a care home as listed in Schedule DS0000025016.V314688.R01.S.doc Version 5.2 Page 37 8 Stickley Lane 14. YA42 13(4) 4 of the Care homes Regulations 2001 (or to make a formal request to CSCI to retain documents at head office and obtain approval). The Registered Manager is required to ensure the health, safety and welfare of service users and staff in relation to safe working practices by: 1) To ensure that there is more consistent weekly checking (and recording) of the fire alarm system. 2) To ensure that there is up to date annual testing of portable electrical appliances. 3) To ensure that there is more consistent checking (and recording) of monthly water temperatures. 4) To ensure that there is more consistent checking (and recording) and cooked food temperatures. To ensure all staff receive training in infection control. 01/12/06 15. YA42 18(1)(c) 01/03/07 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. Refer to Standard YA17 Good Practice Recommendations To consider introducing a recognised nutritional screening tool for assessment and reviewing of nutritional needs, it is recommended that residents’ ideal body weight is assessed using the body mass index calculator. To consider reviewing the level of night time monitoring for one service user who is receiving 1.5 hourly checks. DS0000025016.V314688.R01.S.doc Version 5.2 Page 38 2. YA19 8 Stickley Lane 3. 4 YA20 YA23 To monitor and record temperature of the room containing the drugs cupboards which should not exceed 25 C. To ensure that an independent audit of residents’ finances is undertaken on behalf of the provider on an annual basis. To consider introducing a monitoring system for checking that receipts are obtained (where necessary) for purchases/meals bought on behalf of residents. It is recommended that the home is enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance. Appropriate facilities for communication by facsimile transmission must also be provided. To undertake regular calibrating of the food probe (with boiling and ice water) to ensure that it is working efficiently and to maintain records of these checks. 5 YA37 6. YA42 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 8 Stickley Lane DS0000025016.V314688.R01.S.doc Version 5.2 Page 40 - 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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