Inspection on 16/01/06 for Broadoaks

This inspection was carried out on 16th January 2006.

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

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

Other inspections for this house

Broadoaks 12/08/08

Broadoaks 17/09/07

Broadoaks 31/10/06

Broadoaks 03/08/05

Broadoaks 20/01/05

Broadoaks 20/09/04

Broadoaks 24/03/04

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

CARE HOMES FOR OLDER PEOPLE Broadoaks 2 Southend Road Rochford Essex SS4 1HA Lead Inspector Ms Vicky Dutton Unannounced Inspection 08:00 16 January 2006 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 Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broadoaks Address 2 Southend Road Rochford Essex SS4 1HA 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) 01702 545888 01702 546442 Eastwood Hall Limited Mrs Agnes Stubbings Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2005 Brief Description of the Service: Broadoaks is a large detached 19th century Manor House situated close to Rochford town centre. Care and accommodation is provided for twenty residents. The home is not registered to admit service users who are diagnosed as suffering from dementia. Accommodation is provided on two floors with a shaft lift to enable access. Bedrooms are all single rooms with en suite facilities. The Home has two lounges, a pleasant dining room and a visitor’s room. There is parking to the front of the building and a secure garden with seating available to the side of the building. The Home shares a minibus with two sister homes, and this is available to provide transport and outings for service users. The registered providers have a website that can be accessed on www.crollgroup.co.uk Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of six hours. On the day of inspection eighteen residents were being accommodated at Broadoaks. The registered manager was available on the day of inspection, and assisted throughout. The area manager also attended for part of the inspection. A partial tour of the premises was undertaken. Care, medication, staffing and other records were randomly selected and examined. Many residents were spoken with. The inspector also spoke with staff. A notice was displayed beside the homes signing in book advising any visitors that an inspection was taking place, with an open invitation to speak with the inspector. What the service does well: What has improved since the last inspection? The home continues to provide residents with a good level of care. Although further work is needed, the home has developed a better system of monitoring what residents eat to ensure that they keep well. The registered manager felt that since the previous inspection residents have had a better level of activity provided, and have been out on trips more frequently. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 6 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. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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 Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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, 4. Prospective resident’s have their needs assessed before moving into the home. Staff at the home have received appropriate training to help them to meet residents needs. EVIDENCE: Files of recently admitted resident’s showed that their needs had been assessed before they moved into the home. During the inspection an enquiry was made about possible placement for a relative. The caller was given appropriate information, such as the need for the home to carry out an assessment and their category of registration. The visitor was shown around the home. Staff records sampled showed that they had received appropriate induction and general training to meet the needs of residents. Where specific conditions were identified, information was available. Residents spoken with felt that staff cared for them well and attended to their needs. Although the home is not registered to admit residents who suffer from dementia the home has a significant number of residents who show signs of dementia and confusion. Staff at the home have completed training in dementia awareness. Intermediate care is not provided at Broadoaks. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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. Resident’s health and care needs are identified and planed for, but some development is needed to ensure that care plans are comprehensive, current and used by staff. Medication practices at the home are generally well managed and ensure that residents are kept safe. EVIDENCE: A care plan was in place for each service user. Those viewed identified resident’s needs and gave information to staff to assist them in meeting these needs. Care plans are reviewed on a monthly basis and any changes noted. However, the care plans themselves had not been updated to show the changes and give staff accurate information as to individual care needs. For example the monthly reviews for one resident identified a number of changes in condition, care and behavioural needs that had not been transferred to the care plan. Some information was not dated so it was difficult to know what was current information. The care plan of a respite resident had not been fully completed. As residents needs become more complex the registered person(s) will also need to monitor the format of the care plan. Currently there is limited space available to record complex or multiple needs, and the actions required to meet these needs. Residents current daily records are still kept in a separate folder from their individual care plans. This is not best practice and will not encourage care staff to refer to and use care plans on a regular basis. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 10 The registered manager is aware of the need to monitor and educate staff in the language that they use. Terms such as ‘tantrum’ are not appropriate. Records, observations and discussions with residents showed that the home monitor and address their health care needs. One letter of compliment praised the home for their actions in caring for the health needs of their relative. A chiropodist visits the home on a regular basis. Opportunities are provided for optical and dental checks. How well residents have eaten was noted to be recorded in daily records. Since the previous inspection an improved nutrition record has been put in place. However this does not provide a full record and, for example, breakfast and supper is not recorded on the format. Although residents are weighed as part of completing a moving and handling assessment, records viewed showed no systematic approach to monitoring resident’s weight. At this inspection one sheet was available that showed that all residents had been weighed in October. The area manager said that nutritional monitoring is an area that the company are currently working to address, and that improvements are to be made across all the group’s homes. Pressure relieving equipment was noted to be available to help residents in maintaining healthy pressure areas, or assist healing. Advice was given to the registered manager regarding the care needs of one resident and the limitations on staff assistance with personal/medical issues. The home uses a monitored dosage system of medication administration. (Blister packs.) Medication systems and records were sampled and showed that residents are kept safe by good practices being maintained. Best practice does however need to be ensured in relation to the storage of items in the homes refrigerator, and in the double signing of items handwritten on to medication administration records. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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, 14, 15. Some activities are provided at the home to provide stimulation and occupation for residents. The food provided by the home is plentiful and residents are offered choice. EVIDENCE: The home employs two part time staff who provide activities with residents on four afternoons each week. Each resident has a ‘Social Care Record’ completed. This records their preferred activities. The registered manager reported that as well as group activities the home have been trying to provide more in the way of one to one outings that reflect individual preferences. Shopping, and trips to the park were examples given. Social events are held at the home that relatives are invited to. Residents spoken with said that they had enjoyed the recent Christmas festivities. Broadoaks is able to access a minibus that is shared between three homes run by the company. Residents spoken with were generally happy with the level of activity provided. Routines are flexible. Residents spoken with felt that they could choose their own routines such as getting up and going to bed. Information on advocacy services was available in the ‘Residents Information’ book in the entrance hall of the home. Bedrooms at the home were very personalised showing that residents are encouraged to bring in their own possessions. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 12 The dining room at Broadoaks is comfortable and airy. The tables were nicely laid and presented. The home has a three weekly menu plan, with a choice being offered at lunch and teatime. Residents spoken with had no complaints about the menus or quality of food offered. Residents are served in their rooms if they do not wish to go to the dining room. When this occurred, trays used were nicely done and reflected resident’s preferences, such as hot milk and lemon tea. The daily menu is written up on a whiteboard in the dining room. Lunch of the day of inspection looked appetising and was well presented. Staff offered residents assistance in a sensitive manner. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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): 17, 18. The home has a complaints procedure in place. Staff have received training in adult protection. EVIDENCE: The home has a complaints procedure in place. The homes complaints record showed that no complaints have been received by the home. For best practice the homes complaints procedure should be on display for residents and visitors. Previous inspections have shown that the home has suitable policies and procedures in place to protect residents from abuse. Staff records showed that established staff received training in adult protection last year. Further training is planned. Staff knowledge and understanding of POVA issues was not tested at this inspection. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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, 20, 21, 22, 23, 24, 25, 26. Residents at Broadoaks live in a comfortable and homely environment. The home is kept clean and well maintained. Sufficient bathing facilities are provided to meet residents needs. All residents have their own rooms, which are personalised to their own taste. EVIDENCE: Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 15 Broadoaks provides a comfortable and well maintained home for residents. The homes grounds are secure and provide a safe environment for residents. Residents spoken with felt that the home was very nice. One said that the home was ‘always kept spotlessly clean’. The home has sufficient communal space available. This includes two lounges, a visitor’s room and a dining room. All areas are pleasantly furnished and decorated. Lighting is domestic in character. There is ramped access to the garden area to assist residents with mobility difficulties to access this area. The Home has a level access shower, standard shower, 2 assisted baths and standard baths. It therefore provides a range of options to meet residents’ needs. In addition all rooms have an en-suite facility, five of which include a bath. Toilets are available close to living areas so that residents do not have far to go when using communal areas. Dependency levels in the home are currently assessed by the registered manager as being low to medium. The home has a hoist available, but this is not currently used. Grab rails and other equipment, such as raised toilet seats, are available in toilets and bathrooms. However there are no grab rails in corridors or communal areas. The Home has adequate storage areas. There are call points available in each room to enable residents to call for assistance. All single rooms with en suite are provided. Bedrooms were all furnished to a good standard. All were carpeted. Most rooms had a lockable storage space. Not all bedroom doors are yet fitted with locks as standard. A previous inspection however noted that this choice is offered in the information provided in the Service Users Guide. Due to the shape and space in some rooms it was not possible to have a bedside table or other surface next to the bed. This may make it difficult if Service users wish to have a clock, drink or books etc. to hand when they are in bed. However many rooms contained over-bed style tables that could be positioned for this purpose. All residents spoken with during the inspection were happy with their rooms and accommodation provided by the home. Many had clearly brought in some of their own furniture and most rooms were very personalised. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 16 All areas of the Home had plenty of natural light. There is emergency lighting throughout the Home. Most resident’s rooms had table lamps. Radiators were guarded and could be individually controlled. Water tested randomly during the inspection was at an acceptable temperature. At the previous two inspections it was advised that a risk assessment in relation to the control of legionella should be in place. This to demonstrate that this area of resident/staff safety had been considered and relevant strategies put in place. The registered manager could not evidence that this risk assessment had yet been undertaken. The home employs housekeeping staff. On the day of inspection all areas of the Home were found to be cleaned to a high standard and were odour free. The laundry area was clean and tidy. This area has no natural ventilation and was very hot and steamy in spite of an extractor fan. The washing machine has a sluicing facility, and there is a large sink available for hand washing. No sluice is provided at the home. Housekeeping staff confirmed that they had received training in infection control and were observed to use protective clothing when carrying out different tasks. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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. Staff are offered induction and training opportunities to enhance their knowledge and enable them to care well for residents. Safe recruitment practices are followed but development is needed to ensure that staffs’ employment history is fully explored. EVIDENCE: Broadoaks minimum staffing levels are currently maintained at: • One in charge plus two care staff during the morning afternoon and evening. • One in charge plus one care staff at night. The registered manager and staff spoken with felt that these levels were sufficient to meet the current needs of residents. The registered manager is aware that this needs to be monitored to ensure that all their needs can be safely met. The home does have a high turnover of staff. The home currently has vacancies for 186 hours a week for day care staff and 36 hours a week for night care staff. Agency staff are therefore used at the home to fill shortfalls in the rota. The registered manager reported that the home tries to use the same agency staff to provide consistency for residents. Housekeeping, kitchen and activity staff are employed. A general hand works at the home on one day each week. All residents spoken with during the inspection spoke very highly of the staff team at Broadoaks. Eight care staff are currently employed by the home. None are yet undertaking an NVQ qualification at level two or above. A senior member of staff is undertaking NVQ level three. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 18 Recruitment is mainly managed centrally and checks for the protection of resident’s are carried out by the organisation. The files of four staff (two recently appointed) were sampled at this inspection. They showed that most appropriate checks and processes had been carried out to ensure that resident’s are cared for by suitable staff. However the application form used by the company does not allow for a full exploration of an applicants employment history or any gaps. On three files the section ‘please give employment history in relation to care’ (should show all employment) did not record any dates. (The fourth included a CV). The files of two recently appointed staff showed that an induction programme was being undertaken. This programme is compliant with Skills for Care standards. The inspector was shown evidence of training planned for the coming year. Currently training certificates are in staff files mixed in with all other information. The area manager said that actions are planned to make staffs training information clearer and more accessible. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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): 35, 33, 38 Where the home holds monies for residents, this is managed safely. The home is generally managed to ensure the safety of residents, but practice in relation to moving and handling needs to be monitored. EVIDENCE: Not all aspects of these standards were assessed. The registered provider arranges for regular visits to be carried out as required under Regulation 26 of the Care Homes Regulations. These visits check that the home is being run effectively and should seek resident and staff views. Copies of reports of these visits were seen to be maintained in the home. However, as requested on previous occasions, copies of these reports should be sent into CSCI on a regular basis. None had yet been received, but were received following the inspection. The format used should show that residents and their representatives have been spoken with and their views on the service sought. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 20 Residents’ finances are mostly managed by their families, or solicitors. One has their affairs administered via the Court of Protection. Records monies held for safekeeping and transactions were sampled. They were well maintained and accurate. Evidence of moving and handling, and other core training areas were seen on some staff files sampled. One member of staff, working as a carer did not have any moving and handling training recorded, but verbally confirmed that this had been undertaken within the previous year. The registered manager confirmed that appropriate moving and handling aids were available to staff. However during the inspection two incidents of poor practice were observed. These were relayed to the registered manager. This must be monitored to ensure that residents are cared for safely. In order for the recommendations of the fire department to be fully complied with, a door guard needs to be fitted to the laundry door. This is outstanding from the previous two inspections. An accident book is maintained. A resident told the inspector that they had had a fall that morning. This had been recorded. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 Requirement Residents care plans must be kept up to date and reflect their current needs. Previous requirement date of 01/10/05 not met. The registered person must make proper provision for the health and welfare of service users. This refers to the need for service users nutritional needs to be assessed before/on admission and for weight loss/gain to be monitored. Timescale for action 01/04/06 2. OP8OP3 12 01/04/06 3. OP29 19 4. OP38 12, 23 Previous requirement date of 01/05/05 and 01/10/05 not met, although the home have gone some way towards meeting this requirement. 01/03/06 The registered person must demonstrate that robust recruitment procedures are maintained. This refers to the need for applicants to fully identify their employment history so that any gaps in employment can be explored. The reccommendations of the 01/03/06 DS0000018064.V270294.R01.S.doc Version 5.0 Page 23 Broadoaks fire service should be actioned by the fitting of a door guard to the laundry door. Previous requirement of 01/10/05 not met. Staff practice in moving and handling at the home must be monitored to ensure residents safety. 5. OP38 13 14/02/06 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. 2. 3. 4. 5. 6. 7. 8. Refer to Standard OP7 OP7 OP9 OP16 OP26 OP26 OP30 OP33 Good Practice Recommendations The practice of keeping daily records separate from care plans should be kept under review to ensure that care staff make full use of residents care plans. The format of care plans must be kept under review to ensure that they are able to identify all residents needs and the actions needed to meet theses needs. The best practice issues in relation to medication identified in the report should be addressed. The homes complaints procedure should be on display for residents and visitors. Ventilation in the homes laundry area should be monitored. A risk assessment in relation to the control of legionella should be completed. In order to keep an accurate and clear record of staffs training, individual training and development assessments and profiles should be developed. Monthly visits undertaken by the registered provider under regulation 26, should show that residents and/or their representatives have been spoken with and had the opportunity to express their views on the service. Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Broadoaks DS0000018064.V270294.R01.S.doc Version 5.0 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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