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Inspection on 01/09/05 for Carmen Lodge

Also see our care home review for Carmen Lodge for more information

This inspection was carried out on 1st September 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

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

What the care home does well

The home has a group of staff who work hard in order to improve standards of care. The home provides training to its staff members including the NVQ level 2 training in care. The management completed a detailed strength and needs list for all service users. The home ensures specialist services input in developing care plans for service users.

What has improved since the last inspection?

The management worked hard with the staff team to meet all previous requirements. Members of staff received training in various areas including NVQ level 2 in care. Staff interviewed expressed their satisfaction with the training opportunities provided by the management.

What the care home could do better:

The management must review all service users risk assessments with input from health professionals for example, CPN and Psychiatrist. The management must ensure that all staff receive a minimum of six individual supervision in a year.

CARE HOME ADULTS 18-65 Carmen Lodge 13 Bushwood Leytonstone London E11 2AY Lead Inspector Harun Rashid Announced 1 September 2005 st 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Carmen Lodge Address 13 Bushwood, Leytonstone, London E11 2AY 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) 020 8532 9789 jennifermkhan@hotmail.com Ms Jennifer Khan Mr Paul Wright Care Home Eleven (11) Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia (11) of places Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 1st March 2005 Brief Description of the Service: Carmen Lodge is a privately run care home for 11 adults with Mental Health problems and is registered with the Commission for Social Care Inspection. The home is situated in a quiet residential area at 13 Bushwood, Leytonstone, in the London Borough of Waltham Forest. The home has easy access to Leytonstone shopping centre and to the underground station. The Statement of Purpose states that the service provides a high professional care service for clients with mental health problems who may have learning difficulties, “with a personal touch. Carmen Lodge aims to provide its service users with a secure, relaxed and homely environment in which their care, well-being and comfort are of prime importance. Carers strive to preserve and maintain the dignity; individuality and privacy of all service users, within a warm and caring atmosphere and in so doing will be sensitive to the service user’s every changing need. The home was first established in May 1993. Most of the current service users are living there as long term residents in the home since their discharge from psychiatric hospital. Accommodation is on two floors, with kitchen, lounge and dining room on the ground floor and single bedrooms for the service users on both floors. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on a weekday morning of 1st of September 2005. The Inspector was able to speak to three members of staff including the registered manager and the proprietor. The Inspector also spoke to five service users and received seven feedback cards from both staff and service users. They all expressed their satisfaction with the standard of care provided in the home. The Inspector also investigated a complaint made against the Carmen Lodge staff and found not substantiated. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3 and 5 The service carry out a pre-admission assessment prior to a new admission to the home. The home can demonstrate that service users’ assessed needs are met adequately. All service users are provided contracts which included terms and conditions of the service. EVIDENCE: The home has admitted a service user in May this year. The service user was transferred from a psychiatric hospital to the home. The registered manager who is a qualified nurse carried out a pre-admission assessment. The home also received a copy of the health professional’s assessment of needs. Copies of assessments were available in the service user’s care file. From discussion with staff members, feed- back cards received from service users and examining care files it was evident that staff can demonstrate if any specific needs are identified, specialist advice is sought, such as community psychiatrist nurse, psychiatrist. All nursing input required by service users is provided through the Primary Care Team or through the Community Psychiatric Nurse. Following the recommendation of the previous inspection report service users’ contract letters were updated. The updated contracts have included a description of rooms to be occupied by the individual service users in the home. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 8 Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 All service users have care plans, which are reviewed on a six monthly basis. Staff respect service users’ right to make decisions about their lives. All service users have risk assessments, however, these are required to be reviewed with input from health professionals. EVIDENCE: Evidence from care files suggest that staff completed a detailed ‘strength and needs’ list of all service users, which included service users personal, social, leisure, educational, health, emotional and communication needs. The care plans had been developed with involvement of service users, their family members and professionals. It also identified how the assessed needs of the service users will be met and by whom. Staff review service users care plans on six monthly basis. All service users have a yearly review, which is attended by psychiatrist, and community nurses. All staff had attended Non-Abusive Psychological and Physical Intervention (NAPPI) training and staff were confident to deal with any aggressive behaviour with positive planned interventions. Staff respect service users’ right to make decisions about their lives by providing information and assisting them with managing finances. Service Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 10 users were given information in order to access advocacy services like North East London Advocacy (NELA). All service users have risk assessments. Service users are supported to take responsible risks as part of their independent lifestyle and are enabled to take decisions about their lives. Staff encourage service users to travel independently in the community within the risk assessment framework. However, the Inspector advised the management to review service users’ risk assessments with input from health professionals. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16 and 17 Service users have opportunities for developing further education within their dependency levels and they are encouraged to access local amenities. Family and friends are welcomed in the home. Choices of menus are offered and service users have opportunities to cook meals. EVIDENCE: Service users of Carmen Lodge take up opportunities for developing further education within their capacities. One service user is currently attending various courses in a local college and another service user is doing a voluntary work in Quest where he assists older people with serving tea. Another service user is doing unpaid administrative work in a clubhouse. Staff are proactive to help service users to find and take up opportunities for further education and training. All service users have structured activity plans, which were displayed on the notice board. Service users attend various activities in the community, for example, visits to cinema, bowling and travelling to the local shopping centre. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 12 Staff also provide information and advice regarding available local activities offered by specialist organisations. Staff also ensure service users’ have access to transport for example advice is provided on how to obtain a taxi card. Staff support service users to maintain family links and friendships inside and outside the home. Families and friends are welcomed, and their involvement in daily routines and activities is encouraged with the service users’ agreement. Staff and service users informed the Inspector that they had a BBQ this month, which was well attended by family and friends. Service users can choose whom they see and they see visitors in their bedroom in private. Daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in care plans. Service users are offered bedroom keys, however some of them choose not to hold keys by themselves. Service users have opportunities to choose when to be alone or in company, and when not to join an activity. Staff do not open their mail without their agreement. From viewing weekly menus and discussion with service users it was clear that the home provides meals of their choice (minimum choices of two meals) and these were varied and balanced. At the time of the inspection it was observed that a member of staff assisted a service user to prepare a snack. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20 The service can demonstrate that service users health needs are met adequately. Staff seek specialist support in order to meet service users assessed needs. Staff are provided training on medication administration. EVIDENCE: Care files demonstrate that specialist support and advice is made available to service users who would benefit from this. Individual working records set out the preference routine, likes or dislikes of service users. The service offers service users choice in areas such as their personal clothes or hairstyle. Health care needs of service users are assessed and recognised and there is a procedure in place to address any issues. Service users are accompanied to outpatients and other medical appointments by staff or family members. For service users able to attend some of the medical appointments staff encourage them to do so. It was evident from the examination of care files and discussion with the management that, an elderly service user who had bilateral hip replacement and has reduced mobility will require nursing care. Her present placement is unable to meet all needs adequately. She is now waiting for an O.T assessment and the placing authority is looking for a suitable alternative placement. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 14 The management to pursue with OT assessment and liaise with the placing authority to find a suitable placement (nursing care) for her. It was clear from discussion with staff and viewing care files that none of the service users are able to self-administer medications. Staff administer medications to all service users. Medication Administration Record sheets were completed after medications were administered. Staff keep records of medication received from chemist and disposed of to ensure that there is no mishandling. The manager seeks information and advice from the pharmacist who supplies the medications to the home. All staff attended inhouse medication administration course conducted by the pharmacist and aware of the policy and procedures for safe administration of medication. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The complaint policy and procedure of the home is simple, clear and was made available to all relevant parties by displaying on notice board. The Adult protection policy and procedure contain sufficient guidance for staff to enable them to protect service users from abuse. EVIDENCE: The home provides a simple and clear complaint policy and procedures for service users, their family members and for other relevant parties by displaying on the notice board. A record of complaints was kept in a complaint book including details of investigation and action taken by staff. The complaints received were minor in nature and those were investigated and resolved accordingly. A complaint was made to the CSCI against Carmen Lodge that a service user was discharged from there to an another service but staff of Carmen Lodge were unwilling to provide information about the service user to the staff of the other service. The proprietor and the manager of Carmen Lodge informed the Inspector that the service user was discharged from Carmen Lodge and he was temporarily accommodated by the placing authority in bed and breakfast accommodation before transferred to other home. Technically the service user was not Carmen Lodge’s client at that point. However, the staff of Carmen Lodge provided all information required/asked by the other home. The proprietor informed that staff asked her to handover the service user’s benefit book and other items. As the proprietor was the appointee for the service user she could not hand over the benefit book to the other home instead she returned the benefit book to the DSS. The manager informed that they have returned service users clothes and other items to the home and was surprised that they made complaint against the staff of Carmen Lodge. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 16 Staff attended adult protection training. The adult protection policy and procedure contains sufficient guidance for staff to enable them to protect service users from abuse. The registered manager understands his responsibility to refer staff who harm service users in their care to the POVA list. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,27 and 30 The home is suitable for its stated purpose. It is safe and well maintained. The home is clean, hygienic and free from offensive odour. EVIDENCE: The home is a non-institutional building, similar to a large family home. The premises are safe, comfortable, bright, airy, clean and free from offensive odour. The home offers access to local amenities and local transport. The furnishing, fittings and adaptations are of good quality. Decoration works were carried out throughout the house in October 2004. The Inspector was satisfied that the home provides service users with toilets and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. The home has four toilets and two bathrooms with shower facilities. The home provides a hand washbasin in each bedroom for service users’ use. Toilets and bathrooms are lockable. Soap, toilet rolls and hand towels were available for service users’ use. The home is kept clean, hygienic and free from offensive odour throughout and a system was in place to control the spread of infection. The washing machine has the specific programming ability to meet disinfection standards. The water supply system had been checked for Legionella and which confirmed that this comply with Water Supply (Water Fittings) Regulations 1999. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35 and 36 The deployment of staff and current number of staff was sufficient to meet service users current assessed needs. The home provides training for staff development. However, the registered person must ensue that all staff receive a minimum of six supervisions in a year. EVIDENCE: Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 19 From discussion with staff it was apparent that they had a clear understanding of their own role and were aware of the roles and responsibilities of others within the team. They demonstrated an understanding of the needs and individual preferences of service users and a general understanding of the aims and objectives of the service. The interaction between staff and service users was observed to be age-appropriate, caring and respectful. At the time of the inspection staffing levels were sufficient in number to provide care and support to the current service user group. There is an effective on call arrangement for evenings and weekends. Staff have attended NAPPI (Non Aggressive, Psychological and Physical Interventions) training. There was evidence of staffing levels being linked to individual needs. The staff team reflects the ethnic/gender composition of the service users and are able to communicate with them in a range of ways. Staff meetings take place regularly, with staff contributing to the agenda. The management informed that 4 members of staff have completed their NVQ level 2 qualifications in care and three other staff are attending the training and anticipating completing this year. A wide range of training has been taking place, some of which is arranged in-house, using the skills of the staff team and others in the community. The home has a training development plan and dedicated training budget. All staff received equal opportunities training; the training and development are linked to the home’s aims and to service users’ needs and individual plans. The home has a staff supervision policy and procedure in place. Usually staff receive a minimum of six individual supervision in a year. However, due to the illness of the registered manager all staff did not receive documented regular supervisions. Staff interviewed confirmed that they have received informal supervisions and advice from the proprietor while the manager was in absent. The registered provider/proprietor must supervise members of staff in absence of the registered manager. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 and 42 There is effective leadership; guidance and direction to staff to ensure service users assessed needs are met. The home ensures service users health, safety and welfare. There is a quality monitoring system in place to measure the success in achieving the aims and objectives of the service. EVIDENCE: Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 21 The registered manager is a RMN and RGN nurse. He also completed an RNMH qualification. He has a BSc in Health Studies and a certificate in Health Management and Health Promotion awarded by the University of London. The manager has also obtained diabetic specialist nurse training. The manager is qualified and experienced to run a care home and is able to meet its stated aims and objectives. The Statement of Purpose stated that within the home there are various systems, which ensure that close monitoring is maintained on all of the home’s services and procedures. The home’s quality programme involves service users and their relatives and seeks their comments on the services. The organisation provides CSCI with a copy of the report of the Regulation 26 visit each month. It was evident from examining documentation, discussion with staff and observation that the registered manager ensures, so far as is reasonably practicable, the health, safety and welfare of the service users and staff. The registered manager ensures safe working practices, including staff training for moving and handling, fire safety, first aid, food hygiene, and infection control. Appropriate supervision is in place for service users in order that the safety of the service user and others in the home and the community is safeguarded. Staff check the fire alarm system on weekly basis and carry out a fire drill in every month. Following the inspection report of LFEPA (dated 5/2/05), the premises now comply with Fire Precaution Regulations 1997. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x 3 x 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Carmen Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13 Timescale for action The management must review all 31/12/05 service users risk assessments with input from the health professionals. The management must ensure 31/10/05 that all staff receive a minimum of six individual supervisions in a year. Requirement 2. YA36 18 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 YA19 Good Practice Recommendations The management to liaise with the placing authority for accommodating an elderly service user to a nursing home, as her present placement is unable to meet all care needs adequately. Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 4th Floor Gredley House 1-11 Broadway London E15 4BQ 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 Carmen Lodge G56 G06 S7243 Carmen Lodge V240710 200905 Stage 4.doc Version 1.40 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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