Inspection on 16/03/06 for Breadstone House Care Centre

This inspection was carried out on 16th March 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 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

Breadstone House Care Centre 28/01/09

Breadstone House Care Centre 29/09/08

Breadstone House Care Centre 25/06/08

Breadstone House Care Centre 22/10/07

Breadstone House Care Centre 30/11/06

Breadstone House Care Centre 22/09/05

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

CARE HOMES FOR OLDER PEOPLE Breadstone House Care Centre Breadstone Nr Berkeley Glos GL13 9HG Lead Inspector Ms Jacqui Burvill Unannounced Inspection 16th March 2006 10:55 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 Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 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. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Breadstone House Care Centre Address Breadstone Nr Berkeley Glos GL13 9HG 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) 08453 455782 Blanchworth Care Homes Ltd Mrs Denise Rose MacKereth Care Home 43 Category(ies) of Dementia - over 65 years of age (43) registration, with number of places Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named service user under 65 years of age with a DE Category. Date of last inspection Brief Description of the Service: Breadstone House Care Centre is a registered Care Home with Nursing. It is registered to accommodate older people with dementia. The home is situated off the Gloucester to Bristol road and is approximately 20 miles from Gloucester. It is a detached house situated in attractive grounds. The communal areas are situated on the ground floor and include 3 lounges and a dining room. There are 25 single bedrooms (7 with ensuite) and 9 double bedrooms. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 16th March from 10.55 am until 5.45pm. During this time, at least 4 hours was spent with service users, staff and visitors, observing meal times, an activity, a part of a medication round and the interactions between staff and service users. Five service users, two visitors, three care staff, the cook and both the registered and clinical managers were spoken with during the inspection. The following records were looked at: admission assessments, care plans and risk assessments, daily record sheets, medication, menus, staff training and recruitment records, quality assurance documents and fire safety records. There was a partial tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: Care plans should be reviewed at least once a month consistently. To look at the way meals are being provided and the effect this may have on service users. This includes specialist warming equipment, recording drinks Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 6 and meals on charts and staff offering alternatives to meals that are refused or left. Guidance and information on ways to develop practice can be found on the CSCI website, where there is a document called ‘Highlight of the Day?’ There needs to be a quality assurance audit as this has not been taking place annually. 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. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 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 Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 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, 6 Standard 6 does not apply to this home. Service users benefit from having their needs assessed prior to admission. EVIDENCE: The assessment and admission documents were requested for two newly admitted service users as well as one service user who was due to receive respite care. These included an initial enquiry sheet, which contained basic details of the service users’ needs and details of the next of kin and an assessment summary sheet, detailing the range of needs service users may have. The manager completes the assessment and circles the need identified on the checklist, which is comprehensive. It includes details of memory, interaction, co-operation, speech, place and time and any other issue that may affect their personal safety. These records were all signed and dated by the manager. This record is then transferred into the main care plan, which is in the form of a booklet. The inspector asked visitors how they had chosen the home and in both cases, it was the relative who had chosen the home, rather than the service user. Each of the new service users had a care plan, although it was not clear from the document whether there was a trial period in place. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 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): 9 Standards 7, 8, 9 and 10 were assessed at the last inspection. Standards 7 and 10 were met and 8 was exceeded. A practice element observed for two service users with recording medication given, does not fit with the protection afforded by the policy and procedure. Other elements of practice and record keeping benefit service users. EVIDENCE: It was not clear if the previous recommendation has been met regarding service users that may be taking hypnotic or anxiolytic medication having guidance on this described in their care plan. There is a medication policy and procedure and the manager explained that all staff have a copy of all policies and procedures, which they receive during induction. Only staff who have been trained in administration of medication can do this. There are two sites were medication is held in the building and both of these are safe and secure. There are additional safeguards for insulin and controlled medication. Both records relating to these medications were in order, although one CD Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 10 medication does need to be returned and this was identified with the clinical manager. There are safe arrangements for the disposal of medication, although the pharmacy does allow some medications to be returned. Medication Record sheets were found to be in order. Part of a medication round was observed. This was carried out in a calm and unhurried manner, with full concentration on the task in hand. The inspector queried the practice when the person administering medication was seen to sign the MAR sheet prior to giving medication to the service user. The person administrating acknowledged her error in this. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 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, 15 There is insufficient evidence to suggest the activities on offer match service users’ expectations. When the activities take place, service users clearly benefit from this. Not all service users can benefit, as the range of activities on offer does not meet all their abilities or needs. Service users benefit from visitors and other outside activity providers. Service users may be unable to exercise full control over all aspects of their lives. Not all service users benefit from the approach to mealtimes, and they may not receive a wholesome appealing balanced diet. EVIDENCE: The care records were looked to see what level of activity had been included in the care plan. Service users were observed taking part in ‘Pat a Dog’ during the afternoon, when the activities usually take place. Service users clearly enjoyed this activity very much. One service user said ‘it’s good isn’t it?’ The effect on their state of animation was marked during the activity and half an hour later in the same room, when all of the service users were either asleep or not engaged. The activities co -ordinator was spoken with and she explained the variety of activities in the home, which she leads. This includes fortnightly visits from other people who provide activities, such as ‘sing-a-long’ and ‘music and movement’. These activities are usually aimed at the more able service Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 12 users in the home. There are other one to one activities which are lead by the activities coordinator, who also explained the need to be adaptable as sometimes, activities that are planned have to be changed due to the person’s emotional state that day. There are three sitting rooms and a dining room and service users are present in varying numbers in all of these rooms as well as service users who are taking bed rest, or prefer to spend time in their room. Service users asking for help could not be responded to, as staff were busy in other areas of the home. At one point, the inspector had to get help for a service user who had been calling out for help on and off for about 10 minutes. Interactions between staff and service users are limited in the main to task related activities. However, when staff spoke to service users, either at the service users’ instigation or because the service user needed help, the way in which staff spoke was supporting, encouraging and reassuring. Staff spoken with, were clear that they would like to spend more time talking to service users, but felt that there was really no time to do this on a shift. The inspector spoke to two visitors who had varying views on the care provided in the home. One relative explained how often they visit and commented that it ‘felt like home’ to them. Staff were said to caring and wonderful. While the other visitor agreed that staff were caring, minimum staffing levels were noticed and there was some concern that insufficient time was being given to service users who were on bed rest or unable to maintain any interaction and needed help in all aspects of their care. Service users are able to bring small items to decorate their room. The majority of furniture is supplied by Blanchworth Care. Lunchtime was observed in one of the sitting rooms and the way the meal is served in sections, left some service users without receiving a meal for some time, or other service users having to wait for the second course for a period of 20 minutes. Meals for the second serving of the first course are kept warm, and then taken out to service users who need to be supported with eating. This meal may take some time and the food is not kept warm during the time service users are fed. This was raised with the manager, who said that there was no equipment available through the resources that she could use. There were very few conversations during the mealtime, especially with service users who needed to be fed. Two service users were spoken with during this time as they had not eaten their meal and pushed it away. One service user said that he didn’t like it. He was clear about what food he would like and talked about food he used to eat. The other service user did not want to eat and said it was ‘good enough’ and no attempt was made to persuade or encourage them to eat. Staff were asked by the inspector what would happen in such circumstances and the staff said alternatives were available and at when it was pointed out that two service users had not eaten the meal, the staff offered a Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 13 range of sandwiches, which were turned down by the service users. When dessert arrived one service user said it ‘looks quite attractive to me.’ Service users who have to be fed have charts in their rooms to record this. On some occasions there are considerable gaps between one day and the next, when it appears as though no food or drink has been offered. The daily check list record, which has a section for meals and drinks, had not been filled in to show whether the service user had refused food, as staff suggested this is what sometimes happened. ‘Ensure’ drinks are prescribed and given once a day. Staff described how they knew which flavour service users who were unable to say, liked. There is a four week menu devised by the organisation. The cook was asked about the alternatives on offer, which are referred to on the menu. She explained that she could make an omelette when staff ask her to, but that this does not happen much more than once a week. The cook also described her approach to special diets in the home. She has a list of foods that one service user cannot eat. The cook blends foods for some service users and this depends on their need. Some have all dishes (such as meat and vegetables) blended together; others have each dish blended separately. There are plate guards and other utensils in use. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 14 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): 18 Standard 16 was assessed as met at the last inspection. Service users are protected from abuse by the policies and procedures, but staff may not be fully aware of them, or how to be an alerter. EVIDENCE: The organisation has an adult protection and Whistle blowing policy and procedure. Pinned to the notice board in the dining room is the local ‘No Secrets’ guidance for Gloucester. Two staff were asked to describe their understanding of the procedure and after some discussion, were able to describe some elements of the thinking behind the procedure. Staff have received training in this, although it is not clear if this includes information about the ‘No Secrets’ procedure and how to be an ‘alerter’. As previously mentioned, staff have their own copies of policies and procedures as part of their induction. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 15 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 Standards 19 was assessed as met and 26 was assessed as a minor shortfall at the last inspection. Some parts of the home need to be better maintained, in order that service users live in a safe well maintained environment. EVIDENCE: The previous requirement had been met regarding the odour identified at the last inspection. During the partial tour, the following was observed; Parts of the carpet in the corridors had stains, including outside the sitting room in phase II and stairs and landing. There was a small pane of broken glass in the kitchen, through which some insects had come through and died. Parts of the kitchen need to be cleaned thoroughly, especially the area by the freezers and fridges, which had fridge shelves and cardboard between them. This was pointed out to the cook at the time, who was asked to report the broken pane of glass. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 16 There were a number of bins throughout the home in toilets and other areas that did not have lids. There are some items of equipment not in use in the garden that need to be removed. The corridor between Phase 1 and 11 was being replaced with laminate flooring during the inspection. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 17 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, 30 Service users’ needs may be better met by more staff on duty at peak times. Service users would benefit from more staff with an NVQ. Service users are protected by the recruitment policy and practice. Staff receive training to meet service users’ needs. EVIDENCE: There were five staff on duty at the time of the inspection, with the registered manager on an ‘admin’ day and the clinical manager also on duty. A cleaner, cook and kitchen assistant were also on duty. Peripatetic staff also work in the home as and when required. They are part of the Blanchworth staff. Breadstone Care Centre is an accredited NVQ centre. The manager is due to complete the A1 assessor’s award next week and other staff have undertaken training to become ‘expert witnesses’. The rota states the number of staff who have NVQ level 2 or 3. This is currently under 50 . The manager, clinical manager and one other staff member have a First Aid certificate. This means that there is not a person who can administer first aid on every shift. Further training is planned in May. The number of staff on the list will still not provide sufficiently competent staff on duty. The recruitment process was discussed with the registered manager in the morning and in the afternoon, the records for staff recruitment and training were looked at with the clinical manager. For the period between April 2005 and the present date, no new staff have been recruited. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 18 There is a computer based system, which holds all of the relevant details for staff employment. Two staff were selected at random from the day’s duty rota and these records were all in order. Staff are responsible for their own individual training needs. The manager provided the inspector with a training programme, a training diary and a list with an overview of who had completed training in mandatory areas. One day dementia training takes place at least once every two years. 11 staff have completed this and 14 have not. In the first three months of the year the following training has taken place; Heath and safety, abuse and challenging behaviour, care planning, medication and communication. There are a small number of staff who have few entries of completed or anticipated training against their name. This was discussed with the clinical manager. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 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 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, 38 Service users benefit from the way in which the manager discharges her responsibilities. The quality assurance system is not up to date so it is not possible to say if it currently benefits service users. Fire safety practices in the home ensure service users’ safety. EVIDENCE: The registered manager has been in post at Breadstone Care Centre for 3 years and has many years’ experience as a registered manager. She is due to complete her NVQ assessors’ award in the near future. She is supported in her role by the clinical manager. The organisation has a quality assurance policy and procedure. The quality assurance file showed a completed audit dated 2003 for all Blanchworth homes. There is an audit questionnaire in place, which asks for service users’ Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 20 views on the accommodation, care, domestic, laundry, food, hair care, chiropody, activities and admission. Part of the audit process includes the care managers auditing care plans on a monthly basis and the directors of care auditing the home on a six monthly basis. The care plans had not been audited by the care manager on a monthly basis, consistently. The last audit relating to the home was dated 2002. Regulation 26 visits take place each month. The fire safety records were looked at. There are two files and one contains the most up to date information, showing whether staff have received a drill, lecture or training. Three night staff have completed fire drills in January 2006 and there have been two other drills on 15th and 8th March this year. The fire safety records for the alarm, means of escape, fire fighting equipment and emergency lighting were all in order. The fire alarm went off during the inspection, due to renovation work taking place. All staff responded to the alarm in an appropriate manner. The home stores some oxygen. It is important to log the site of the cylinders on the fire plan, so that in an emergency, the fire officers are aware of it and can take the appropriate action. Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 3 Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 22 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. 2. Standard OP9 OP15 Regulation 13 (2) Reg 17 Sch 4.13 Reg17 Sch4.13 23 (2) (b) Requirement Staff must record medication having been given after it has been administered. Service users must be offered an alternative when their meal has been refused or left and a record made of this. Drink and food charts must clearly show when food has been refused if offered. The carpet must be cleaned in the corridors, stairway and first floor landing. Timescale for action 16/03/06 16/03/06 3. 4. OP15 OP19 16/03/06 30/05/06 5. 6. 7. 8. 9. OP19 OP19 OP19 OP30 OP33 Unused items of furniture must be removed from parts of the garden. 16(2)(k) All bins in the home must have 23(2)(b) lids in place. 23 (2) (b) The broken pane of glass in the kitchen must be replaced. 13(4)(1)( There must be at least one staff c)18(1)(a) member on duty at all times with a current first aid certificate. 24(1)(a)( There must be an up to date b)(2)(3) review of the quality of the service and a copy of the report sent to the local CSCI office. 23 (2) (b) 30/05/06 30/04/06 30/04/06 30/06/06 30/07/06 Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 23 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 Care plans should be drafted to guide staff in the administration of hypnotic and anxiolytic medication prescribed for service users on an ‘as required’ basis (Carried forward from the last inspection) Activities to meet the needs of less able service users should be developed. The approach to mealtimes and the way they are served should be reviewed and improved. The adult protection training should include information for staff on how to be an ‘alerter’ for abuse within the local ‘No Secrets’ guidance. There should be a review of staffing levels in the home at peak times, such as meals. Care staff should receive six formal supervision sessions per year. (Carried forward from the last inspection) 2. 3. 4. 5. 6. OP12 OP15 OP18 OP27 OP36 Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Breadstone House Care Centre DS0000063838.V285676.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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