Inspection on 26/04/05 for Alston View Nursing & Residential Home

This inspection was carried out on 26th April 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alston View Nursing &... 09/08/06

Alston View Nursing &... 08/11/05

Alston View Nursing &... 12/10/04

Alston View Nursing &... 06/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Alston View Nursing & Residential Home Fell Brow Longridge Preston, Lancashire PR3 3NT Lead Inspector Janet Proctor Unannounced 26 April 2005 10.00 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 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. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Alston View Nursing & Residential Home Address Fell Brow Longridge Preston Lancashire PR3 3NT 01772 782010 01772 785649 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MPS (Investments) Limited, Green & Co Mrs Pat Dixon (Registration pending) Care Home with nursing 44 Category(ies) of Physical disability (PD) 44 registration, with number Old age, not falling within any other category of places (OP) 44 Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 A max of 44 service users requiring nursing care who fall in either the category of OP or PD. 2 A max of 15 service users requiring personal care of the category OP 3 Staffing for service users requiring nursing care will be in accordance with the Notice issued dated 12 May 2000. Date of last inspection 12 October 2004 Brief Description of the Service: Alston View provides long and short stay care for a maximum of 44 service users who are elderly and need personal care, or who are elderly and have physical needs for which they need nursing care. The home can also accommodate adults’ aged 18-64 for nursing care. The registered persons are MPS (Investments) Limited, Green & Co. There has been a change in the person who takes repsonibility for the day-today running of the home and an application for registered manager has been submitted in respect of this person. The home is located within the village of Longridge in a residential area. Acccess to shops, a Church and other facilities is within walking distance. The building is a modern purpose built home, which overlooks landscaped grounds to the side and rear of the home. All bedrooms, except for one, are single rooms. All of the rooms are en-suite, with the exception of two single rooms. There are separate lounge areas and dining areas located on each floor of the home. Service users have access to garden and patio areas to the side and rear of the home and a small car parking area is located to the front of the home. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over seven and a half hours on the 26th April 2005. The previous inspection was done on 12th & 13th October 2004. One additional visit had been made to the home in-between these times and that was in response to a complaint about the care of a service user. The report of this visit can be obtained from the CSCI office on request. On the day of the inspection there were 38 residents at the home. Information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to 10 service users, the Manager, 3 staff members and 3 visitors. Wherever possible the views of residents were obtained about their life at the home. Views have been reported collectively where the answers obtained were similar. Any specific or differing comments have been included. Detailed notes were taken, which have been retained as evidence of the inspection findings. What the service does well: Residents were cared for in a friendly and professional manner. Wherever possible their choices in how they lived their lives were respected. Residents spoken to said “ The Staff are brilliant”, “I can’t complain how they treat me”, “They are very good they can’t do enough for you”. Visitors were encouraged and welcomed and there were no restrictions on visiting times. There was a very friendly and welcoming atmosphere throughout the home. Social activities were seen to be important and there was a designated person employed to do these with the residents. The residents were provided with bedrooms that were clean and nicely decorated and had a choice of sitting and dining areas. Varied and well-presented meals were served. All the residents spoken to, with the exception of one, said that the meals were good. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: In order to demonstrate that appropriate admission procedures have been followed the manager should ensure that all relevant documentation in respect of a resident’s admission are kept on file. In order to ensure that all health care needs are met the plans of care should include all information to enable staff to reduce identified risks of pressure sore development. Residents need to be assured that issues affecting their life at the home are taken seriously. Staff should be able to recognise when residents are making a complaint and ensure that their concerns are dealt with appropriately. The number of Registered Nurses on duty must be sufficient for the number of residents requiring nursing care. The safeguarding of residents is paramount and the recruitment procedures must be strengthened immediately to ensure that all employees are checked against the protection of vulnerable adults register before they start work. In order to ensure continued protection of residents all staff should receive regular training in the protection of vulnerable adults and be aware of whom to contact should such an incident occur. Induction training and Foundation training should be given to all staff on commencement of employment to ensure that the home has a competent and well-trained team of staff. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 6 Residents had their needs assessed prior to moving into Alston View with the result that their needs were known and met. Each resident was issued with a contract, which meant that they had written details of their terms and conditions of residency. EVIDENCE: The Manager said that a pre-admission assessment was always done before a resident was admitted. Only one of the files examined had evidence that an assessment had been done prior to the person coming to live at Alston View. The assessment covered a full range of personal and health care needs and gave sufficient information for the manager to make a decision about whether the proposed resident’s needs could be met at the home. The Manager stated that a pre-admission assessment had been done but the documentation had not been retained in the files. Following the assessment a letter was then sent to the resident telling them whether their needs could be met at Alston View. A copy of this had not been kept in the files, as there were no photocopying facilities at the home. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 10 Following admission each resident was given a contract that stated their terms and conditions of residency. There was a copy of this in each file examined. Those residents who were receiving nursing care also had a copy of the letter from the Primary Care Trust explaining what level of funding they were receiving for this. Standard 6 was not applicable, as Alston View did not provide Intermediate Care. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, and 10 Resident’s healthcare needs were identified and met. Their personal care was delivered in a way that promoted their privacy and dignity. EVIDENCE: The plans of care were well set out and all followed the same format with the sections clearly marked. The individual plans of care identified the full range of residents’ care needs. They included good directions to staff on how to meet these needs and were reviewed monthly. Staff members spoken to said that they read the plans of care and found them easy to understand. A visitor spoken to confirmed that the manager had explained his wife’s plan of care to him. The Manager said that she was in the process of inviting all relatives to a review meeting so that they had the opportunity to be fully involved in the care planning process. A risk assessment was done for moving and handling needs. A statement was made as to whether falls had occurred in the past but a full fall risk assessment was not done. Two of the residents whose records were examined had bed-side rails on their bed and had had an assessment done for the use of these. One of these assessments was not dated and it was difficult to determine when the bed-side rails had been in use from. Any accident that Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 12 occurred was recorded with a note made as to whether the GP and the relatives had been informed. A risk assessment was done for nutritional needs. There were details in the plan of care of how to meet these needs but the details did not specify the type and amount of supplements that were to be given. A risk assessment was done for the development of pressure sores. The plan of care for one resident showed that the risk of developing pressure sores had increased but there were no additional directions to staff on how to reduce this risk. Equipment to reduce the development of these was seen on the beds of residents. Any wound that occurred was detailed in the plan of care with the type of dressing to be used and a ‘map’ of it’s progress. The residents who were spoken to said that the staff were kind and looked after them well. They said that staff gave them their care in private. At the time of the visit staff were seen to knock on bedroom doors before entering and to ensure toilet and bathroom doors were closed when attending to residents. The staff members spoken to could give details of the care of individual residents. They gave examples of how they ensured that residents’ privacy and dignity was respected. The control of medications at the home was not fully assessed on this inspection. The requirements and recommendations made at the previous inspection were monitored and most had been addressed. A risk assessment on self-administration of medication for each resident had not yet been implemented. The control of medications will be fully assessed at the next inspection. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Residents were able to make choices about their life at the home so that their lifestyle met their preferences. Resident’s social, cultural and recreational needs were met through links with their family and friends being maintained and opportunities to undertake activities within the home. The meals offered at the home were good and ensured that the individual dietary needs of residents were met. EVIDENCE: Three visitors were spoken to and all said that they were made to feel welcome when they visited Alston View. Residents said they could see their visitors in either the lounge or their own bedroom. One service user said that her daughter came for the day once a week and had her lunch with her in her bedroom. The plans of care examined stated that the resident should be consulted about whether they wished to see their visitor or not. Residents spoken to said that they could make decisions and choices about aspects of their daily life. This included: what time to get up, what time they went to bed; and where and how they spent their time. The staff who were spoken to said that they asked residents what their choices were. Details of preferred routines were written in the plan of care and where residents were unable to make their wishes known these were followed. A programme of activities was displayed on the notice board and a programme of events that Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 14 included relatives and friends was displayed on the front door. There were details of resident’s interests in the plan of care. Resident’s spoken to said that they had the opportunity to join in activities if they wished to do so. A new Social Therapist had commenced employment the day before the inspection was done. She had spend the day introducing herself to residents and finding out what they had liked to do in the past and what they would like to do in the future so that she could arrange a new programme. With the exception of one person, residents spoken to were happy with the meals at the home. They were offered a choice of food at mealtimes and could have alternatives to this if they wished. They were issued with two menus each week. One to make their choices on and return to the kitchen and one to keep to remind themselves of what was to be served. This system worked well with the exception of one resident who had limited food choices due to a medical condition and personal likes and dislikes. This meant that in effect she did not have two food choices at each meal. Her food choices were being accommodated for at the home but the Cook was given very short notice of these on some instances. Records were kept of the food served. The kitchen was clean and tidy and there were systems to ensure safe storage of food and good hygiene. Not all the food in the freezer was dated. This meant it was unknown how long it had been there. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Not all residents were confident that their complaints would be taken seriously and acted upon. Residents felt safe at the home. EVIDENCE: There was a complaints procedure displayed on the notice-board. This gave clear directions on who to make a complaint to and that a response would be made within 28 days. The procedure also had the address and telephone number of the Commission. A record of complaints made was kept at Alston View. Staff spoken to said that if a complaint was made to them they would try to resolve it there and then. If this could not be done they would tell the Nurse in charge or the Manager about it so that they could deal with it. Visitors spoken to said that they had “never had to make a complaint” and that “everything was satisfactory”. This was also the feeling of some residents who were spoken to. One resident said that they would not make a complaint to the staff at the home, as they would be worried about confidentiality. Two residents said that they had complained about things to staff “but they don’t do anything” and “they don’t take any notice when you complain”. There were policies and procedures for the Protection of Vulnerable Adults and residents spoken to said that they felt safe at Alston View. Two staff spoken to were aware of the correct procedure should they have a suspicion about, or witness abuse, but one member of staff was not. The staff members spoken to said that they had not received formal training in Protection of Vulnerable Adults. This meant that the Manager could not be assured that they would be aware of and implement the correct procedure should a situation occur. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25 and 26 Residents were happy with their accommodation at the home and lived in a safe, clean, well-maintained environment. EVIDENCE: A small number of bedrooms were viewed. Locks were not fitted to these. There was evidence in the admission documents of new residents that they had been offered the opportunity to have a lock provided to their bedroom door if they wished. Residents said that they were happy with their bedrooms and that they were kept clean. They could bring in items of their own to personalise their bedroom. One resident said that she had brought a lot of things from her previous home, which had helped her settle at Alston View. The temperature of the hot water of a bath on each floor was tested. This was found to be around 43 degrees Centigrade. The home was clean and odour free at the time of the inspection. The systems for maintaining hygiene included procedures for infection control. There was a separate laundry room, which had sufficient equipment to meet the laundry needs of the number of residents accommodated. Residents said that their Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 17 laundry was returned on time and in a good condition. Although there was no sluice disinfector available at the home there was no indication that this was compromising infection control. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The number of Registered Nurses sometimes fell below that required. This had the potential to affect the level of healthcare given to residents needing nursing care. The recruitment procedures were not thorough and did not ensure the protection of residents at the home. EVIDENCE: There was a duty rota showing which staff were on duty and at what times. At some times during the day there was sometimes only one Registered Nurse on duty instead of the two required under the agreed staffing levels. This meant that at some times of the day one Registered Nurse was having to monitor and tend to the health needs of twenty seven nursing residents over three floors of the building. The number of Carers on duty was correct. Cleaning and ancillary staff were also provided. The files for three recently employed members of staff were examined. These showed that two people had started work without the employer being assured that they did not have a history of abusing vulnerable adults. The references for one of these people had been received after they started work at Alston View. One of these people did not have a valid Work Permit for their employment at Alston View. All staff received in-house Induction training and there was evidence of this in their file. The Manager had not yet finalised a system that ensured that all staff received Induction and Foundation training to TOPSS specification. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed on this inspection. A judgement will be made on the outcomes for these standards on the next inspection. EVIDENCE: Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x 3 3 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x x x Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 21 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 OP9 Regulation 13(2) Requirement Service users must have a risk assessment to determine whether they are able to selfadminister their medication. This must be reviewed regularly. Where agreed, medication must be kept in secure storage facilities in the residents room. (Previous timescale of 31/12/04 not met). All staff must receive initial training and an annual update on protection of vulnerable adults. The number of Regsitered Nurses on duty must comply with that specified by the previous regulating authority. Satisfactory and safe recruitment procedures must be implemented at the home. (Previous timescale of 13/10/04 not met) Timescale for action 30 June 2005 2. 3. OP18 OP27 13(6) 18(1) 31 July 2005 2 May 2005 From 26 April 2005 4. OP29 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 22 Alston View Nursing & Residential Home 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Standard OP3 OP3 OP8 OP8 OP8 OP8 OP15 OP15 OP16 OP30 The pre-admisison assessment form should be kept in the file of the resident A copy of the letter sent to residents confriming that their needs can be met at the home should be kept in their file. The manager should ensure that a full falls risk assessment is completed for every resident. The date on which the use of bed-side rails was commenced should be clearly identified in the plan of care The type and amount of food supplements to be given over 24 hours should be specified in the plan of care The plan of care should be reviewed when it is identified that the risk of developing pressure sores has increased That the Manager works out a personalised menu with a specific resident so that she has two definite food choices each meal. Food stored in the freezer should the date it was frozen displayed on it. Staff should receive training on how to recognise, respond to and document, complaints made by residents. All staff should receive Induction and Foundation training to TOPSS specification. Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 1st Floor, Unit 1 Petre Road Clayton-Le-Moors, Accrington Lancashire. BB5 5JB 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 Alston View Nursing & Residential Home F57 F07 S22500 Alston View V223408 260405 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!