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Inspection on 18/01/07 for Alderwood Nursing Home

Also see our care home review for Alderwood Nursing Home for more information

This inspection was carried out on 18th January 2007.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

One of the deputy managers has worked with the service users, their representatives and the service user board to design a way of recording restrictions and limitations that are imposed on residents. Staff can now show for example why units may be locked and why people may need to be closely observed. This record has started to be introduced. The home has been completely redecorated and everybody was extremely positive about the changes these had made to the environment. The downstairs has been extended and a bigger kitchenette has been fitted. This means residents can now make meals on the unit and this will help them relearn skills they would need to use when living more independently.

What the care home could do better:

A few staff on the dementia care unit need to start to use person-centred care approaches more effectively. These staff also need to work as a team members when providing care to residents. The failure of some staff to work together and the lack of a hot lock led to the meals on the upper unit being cooler than expected.

CARE HOMES FOR OLDER PEOPLE Alderwood Nursing Home Rectory Place Bensham Gateshead Tyne & Wear NE8 1XD Lead Inspector Mrs Katie Tucker Key Unannounced Inspection 9:30 18 and 22nd January 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alderwood Nursing Home Address Rectory Place Bensham Gateshead Tyne & Wear NE8 1XD 0191 477 7833 0191 478 3212 samgreenrmn@aol.com 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) Mental Health Concern Mr Philip Samuel Green Care Home 32 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (23), Mental disorder, excluding learning of places disability or dementia (9), Mental Disorder, excluding learning disability or dementia - over 65 years of age (9) Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26th January 2006 Brief Description of the Service: The local authority first built Alderwood nursing home in the late 1960s. In the 1990s it was leased by Mental Health Concern and registered to provide nursing and personal care for people with mental health needs and dementiatype illnesses. The fees at the home are £634 but several grants and funding bodies pay these monies. Last year Mental Health Concern purchased the property and the staff who remained on NHS contracts transferred under TUPE arrangements to the organisation payroll. The home is divided into three units. The downstairs unit provides nursing care for people who require long term care because of the nature of their mental health needs. The upstairs contains a unit for the long term nursing care of older people with dementia type illness. The other unit on this floor provides short break nursing care for older people with dementia type illnesses. Alderwood nursing home is in the Bensham area just off the main road leading to Gateshead. There are local shops and bus stops on this main road. The home stands on an elevated site and is surrounded by a mix of houses. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. During this unannounced visit time was spent talking with people using the service, staff and visiting relatives. Several residents were identified. The care they received was tracked through discussions with all concerned and by looking at their records. Some of the people have difficulty with speech and stating their views verbally. Therefore staff practice, attitude and approach were watched and judgements made on how well staff worked with people. During this inspection all of the key standards were checked. What the service does well: The manager and deputy managers have a passion for delivering good quality care for people with dementia care needs as well as for those with mental health needs. The manager and nurses keep abreast of new developments around looking after the people who live at the Alderwood. The expert by experience said ‘the welcome I received from Sam and his staff was second to none and I soon realised I was in a special place despite the locked doors. Katie asked me to stay downstairs and speak to the residents and staff while she went upstairs. Everything that was being done was ‘patient-led’. Nothing was too much trouble for the carers. All residents did exactly what they wanted to do when they wanted to do it. There were plenty of games in the corner if anyone wanted to use them and the staff were happy to sit and help. The kitchen was ‘open all hours’ with constant tea, coffee or whatever available whenever it was wanted. I was treated to a lovely hot lunch – chicken pie followed by bread and butter pudding. There was plenty of staff to help/encourage people to eat and everybody had what they wanted. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 6 I was shown round the rooms. These were a good size, decorated recently and residents had chosen the bedding and curtains. There were plenty of personal things on show, which I liked. Overall I felt privileged to be in this peaceful, happy lace with such caring, efficient staff who were happy at their work’. Mental Health Concern’s staff training department is extremely active and all of the staff have access to a wide range of training, including degrees and secondments onto nurse training. One of the deputy managers has taken on the responsibility for making sure staff receive all of the training they need. Mental Health Concern is not only the owner of Alderwood but also a charity. Headquarters and Alderwood staff actively promote the recognition of people with mental health needs as full citizens. They run service user boards and provide opportunities for people with mental health needs to access employment. Some people who use other Mental Health Concern services now work at Alderwood and this has both benefited the home and employees. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. Wide ranges of records are available and these provide detailed information about residents needs. EVIDENCE: The home uses an assessment document specifically designed to give information about the needs of people who have dementia and younger adults with mental health needs. They are very comprehensive tools, which provides tell staff a lot about all aspects of people’s lives and needs. Staff see the development of the assessment tools as an ongoing process and are in the process of redesigning the younger adults assessment. Case tracking showed that although staff know that residents’ life histories are vital in helping them work more effectively with people and reduce people’s anxieties. The information gathered is often related to the era people are talking about but not all of the staff use it when working with the residents. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. Although the staff in practice help service users to make decisions about their lives, are aware of associated risks and plan people’s care, this is not always reflected within the care plan or risk assessments. EVIDENCE: The staff have a very in depth knowledge of the people using the service and their needs. From case tracking it was found that the majority of staff are writing in a style, which clearly details all aspects of the care provided. One residents does not have English as a first language and although very religious is not Christian. Staff had found out where Mecca was and organised the bedroom to suit the person’s prayer rituals. They had established that the language being used was neither English nor Arabic. They had closely liaised with the person’s spouse to find out how to support this person in all aspects of their life but none of this good practice was written down. But care plans were not in place to detail how staff would support this person meet their spiritual Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 10 and cultural needs. Other residents care plans did detail this sort of information. Case tracking showed that staff impose limitations on some residents because of their dementia or physical health needs such as locking doors to the units or needing residents to be accompanied when outside the home. When any restriction are in place to be recorded and the resident or relative need agree that it is acceptable. The manager is aware of the effects of the introduction of the Mental Capacity Act 2005 in April, and how those people who were found to have capacity must be allowed to take any risk they see as fit and those who lack capacity must be cared for in ways that are the least restrictive. Therefore the deputy manager has developed a tool to record all of the reasons that restrictions would be imposed and these are being introduced. Case tracking also showed that residents, were able, or their relatives work with staff to write the service user plan. Risk assessments are in place but these tend to refer physical needs and not other risks such aggression, social and emotional vulnerability. Also risktaking actions are not recorded. These would identify the strengths people have and the common day risk that would be acceptable for someone to take. The deputy manager is in the process of designing a suitable risk-taking assessment form. From case tracking the medication it was found that staff maintain the medication of residents who live permanently live at the home well and therefore an auditable trail could be established. The rapid turnaround on the short break unit and new staff starting who were unfamiliar with the system led to occasional discrepancies in the booking in of medication. The nurse overseeing this unit was aware of these issues and has put measures in place to make sure all medication is booked in and recorded as leaving the building appropriately. Whilst staff were completing a medication round it was noted that they crushed one person’s medication and covertly administered it. Staff discussed all of the actions they had taken prior to administering medication in this form. Therefore staff confirmed that the doctor, pharmacist and relative had been involved. And, established that the two professionals responsible for prescribing and issuing medication had agreed that chemical formula could be changed by crushing. However, neither of these parties had written to confirm they are in agreement with this method of administration and need to as should ill-effects be caused the staff need to show why this decision was taken. Staff have formed very good links with the local hospitals. Many of the residents continue to see consultants. Also staff have repeatedly shown that they can seek out medical support when it is needed. On the whole staff worked well with people. They were very respectful and valued people. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. Some staff are directing care at people and allowing there relationships with other staff interfere with the service being offered to residents. Thus at times residents are not treated as the priority. EVIDENCE: The expert by experience found that the residents on the younger adults unit had a wide range of opportunities to take part in activities. Also the way this unit has been set up has changed recently so people are encouraged to relearn skills such as cooking, budgeting and time management. People on the short break unit said ‘it is good here – I like to join in the different games they have’ and ‘ they are good people here’. Residents on this unit were encouraged to join in a wide range of activities from dominoes and Jenco to discussing local news or events in people’s lives. During the visit staff on the other dementia care unit provided very limited access to activities and most of the time staff were observed to guard people and ask them to remain seated. Staff said that people on the unit did not join Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 12 in anything so they found it hard to put things on. One staff member did talk about the hand massages people enjoyed. The operational manager recently completed a dementia mapping exercise at the home and had a similar experience. The manager and deputy manager are putting measures in place to help staff use the person-centred approaches they have been taught. Residents’ were making some chooses about how they spent their time. One person discussed the work they were doing and staff fitted into this person lived history. However, some staff used out dated practices of making people aware of the things they had forgotten and this can be very distressing for residents with memory problems. Alderwood operates a cook/chill method for providing meals. Thus meals are sent to home prepared and staff then heat them. The home does not have kitchen staff and care staff complete this as part of their daily routine. Kitchen facilities have been provided in the younger adults unit and people have started to make some of their own meals. The expert by experience found the meal and service downstairs to be very good. Staff supported people to enjoy their meals. Upstairs there was some dispute between care staff on the two units and this delayed the delivery of meals for some 40 minutes. The home does not have hot locks and the meals were cool when finally served. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The management have shown that they will check that the service is working for residents, help people to raise concern, work in partnership and take all actions necessary to resolve issues. Thus, residents can expect that poor practice will not be tolerated. EVIDENCE: The complaints procedure is made available to residents and relatives through the service user guide. Relatives said ‘the staff and manager are interested in what you have to say’. Case tracking showed that when people had raised concerns, even minor irritations staff treated these seriously and took action to resolve the issue. Alderwood has an appropriate protection of vulnerable adults policy and follow Gateshead Social Services Department guidance. This guidance does, however, require Mental Health Concern to put in a section about what they would do if an allegation of abuse were made. Staff do not have experience of using the procedures, as allegations of abuse have never been made but staff receive regular training and up dates. Senior managers are aware that if residents behave abusively towards one another that this must be looked at with reference to the POVA guidance and CSCI need to be alerted. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The home is provides a clean, comfortable and well-maintained environment, which on the whole meets the needs of the residents. EVIDENCE: The local authority originally built Alderwood and the building is accessible for those with a wheelchair plus it is close to local amenities. However the road leading to Alderwood is on a slope as is the main road leading to the turning for Alderwood. Thus accessing shops for those using wheelchairs will at times be difficult. Alderwood has been completely refurbished and this has been done to a high standard. The lounge downstairs and kitchenette have been extended so more space can be provided. The lounges have been opened up so more natural Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 15 light filters into the corridors. The bedrooms throughout the home have been changed to create more space provided. Various decking areas have been created outside and these have been enclosed so people can come and go safely and with little supervision. Environmental adaptations on the dementia care units were discussed, as the use of colour and signage can really help people find their way around. The manager said that consideration was being given to using colour on doors, as well as other minor alterations such as using contrast colour in the toilets. The option of providing similar domestic facilities upstairs has been discussed as research completed by the University of Stirling advocates maintaining everyday activities, such as completing domestic task because it follows peoples lived experiences and reduces anxiety plus provides meaningful activities for people. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgment has been made from evidence gathered both during and before the visit to this service. Good staffing levels are provided and a wide range of staffing. The manager is always makes sure this is used in practice and meet residents needs. EVIDENCE: The organisation has set their staffing level at a minimum of 2 first level nurse (RMN) and 8 care staff during the day. During the night 1 first level nurse (RMN) and 4 care staff are provided. Domestic staff are employed to complete tasks around the home. These levels are high and mean residents personal care needs are fully met. Mental Health Concern has a dedicated training department. This department provides staff with opportunities to go on a wide range of training. Care staff have completed NVQ training. The nurses and care staff are able to go on various courses including degrees. Plus secondment opportunities are provided for staff that wish to complete nursing qualifications. Staff records are kept centrally but these can be seen via an intranet link. These are well maintained. The manager told about new legislation related to age, diversity and protection of staff from harassment that will need to be incorporated into the recruitment practices and management policies. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. Overall management systems are effective and make sure the home meets the residents’ needs. EVIDENCE: The manager is very competent and holds appropriate management qualifications as well as being a registered nurse. His management team are skilled and provide strong overall management of the home. Mental Health Concern has a comprehensive quality assurance system, which has recently brought to light inconsistent practices on the dementia care unit. Thus senior managers and the management team at the home have Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 18 highlighted that some staff use out of date practices and action has been taken to resolve these problems. A team of finance staff at the head quarters look after the personal allowance records. Relatives and resident’s when they need information can get this from the manager via the intranet system. Only small amounts of money are held on behalf of residents. Receipts are kept. When money collects in the accounts held at head quarters this is sent to the appointee or relative to put in people’s savings accounts. No health and safety issues were noted at the time of the inspection. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 20 YES 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 OP3 Regulation 12 (1) (a) Requirement Social profiles for the service users with dementia-type illnesses must be used in practice. Staff must use information related to people’s cultural and spiritual needs when developing the care plans. Risk assessments must include information about risk-taking. (Required at previous inspection - timescale 26/06/06) 3. OP12 16 (2) (n) Staff must ensure personcentred approaches are used so culturally and individually appropriate are used when working with residents. 21/06/07 Timescale for action 19/07/07 2. OP7 12(2) Sch 3(3) (q) 19/07/07 4. OP19 23 (2) (a) The decoration within the 17/08/07 dementia care units must meet the requirements of the Disability Discrimination Act 1995 and be user friendly for people with a dementia. (Required at the last inspection – timescale 27/07/06) DS0000018167.V313485.R02.S.doc Version 5.2 Page 21 Alderwood Nursing Home 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 OP9 Good Practice Recommendations Staff should ensure their administration practice complies fully with guidance such as that related to covert administration and crushing tablets. Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection South of Tyne Area Office St Nicholas Building St Nicholas Street Newcastle NE1 1NB 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 Alderwood Nursing Home DS0000018167.V313485.R02.S.doc Version 5.2 Page 23 - 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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