Inspection on 14/09/05 for Chestnut Lodge

This inspection was carried out on 14th September 2005.

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

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

Other inspections for this house

Chestnut Lodge 01/06/09

Chestnut Lodge 10/07/08

Chestnut Lodge 19/07/07

Chestnut Lodge 20/07/06

Chestnut Lodge 30/01/06

Chestnut Lodge 02/11/04

Chestnut Lodge 18/05/04

Chestnut Lodge 29/01/04

Chestnut Lodge 06/08/03

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

CARE HOMES FOR OLDER PEOPLE Chestnut Lodge 135-137 Church Lane Handsworth Wood Birmingham B20 2HJ Lead Inspector Jill Brown Announced 14 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chestnut Lodge Address 135-137 Church Lane Handsworth Wood Birmingham B20 2HJ 0121 551 3035 0121 551 3035 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) Evelyn McIntosh Catherine Mc Hugh Evelyn Mcintosh Care Home 15 Category(ies) of old age, not falling within any other category registration, with number (15) of places Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2 November 2004 Brief Description of the Service: Chestnut Lodge is a home providing residential care for up to 15 older people. The premises consist of 2 large houses that are joined, and situated on a busy main road with shops nearby. The home has a well-maintained garden at the rear, with a paved patio area, and furniture for those residents that wish to sit outside in fine weather. There is parking for 2-3 cars at the front of the property. Residents accommodation is on three floors consisting of a mix of single and double rooms. There are ample communal bathing and toilet facilities. The home has two sitting rooms, one at the front of the house and another at the rear overlooking the garden. The atmosphere of the home is very homely. A shaft lift gives access to upstairs rooms. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_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 over approximately seven hours on a day in September. The home was fully occupied at the time of the inspection. A tour of most of the building was undertaken. Two residents care records were sampled as well as some maintenance and inspection records of services such as gas, lifting equipment and fire safety. The inspector spoke to seven residents (a number in a group and some individually); three care staff and a health professional during her visit. Twenty-three comment cards were received; ten from health and social care professionals, eight from relatives and visitors and five from residents. The home completed the pre-inspection questionnaire and made it available in good time. What the service does well: Without exception the comment cards received were positive about the care provided in the home. Relatives commented that they were made to feel welcome when visiting, and that the staff were kind and caring. Health and social care professionals had no concerns about the home and one said the residents appeared content and that the manager was good. It was clear that the manager assessed residents prior to admission and made sure that they could meet new residents needs. The home was able to provide a homely environment with a good standard of meals for both the majority of white UK residents and for African Caribbean residents. Residents were offered a choice at every meal. Residents said the food was very good. The home offered activities and residents felt they had enough and described playing cards, games and bingo with staff. They also said they had a formal exercise session once a week, occasionally went out to places like the Botanical Gardens and sat out in the home’s garden when the weather was nice. The home has good contact with the local churches and residents that wish can join in service held at the home. Residents had access to appropriate aids to assist them with their daily life. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 6 The majority of staff have achieved an NVQ2 in care and have recently received training in adult protection issues and this ensures the safety of residents. What has improved since the last inspection? What they could do better: The home had admitted a resident that had a diagnosis of dementia and this is not within the home’s category of registration. The home has several residents that have developed dementia whilst they have been at the home. Several of the residents are highly dependent on staff for care and admissions of any more very dependent people will mean that staffing levels are not sufficient to manage the care needed. The home needed to improve on the care and health planning on some occasions where there were not clear details on how care was to be provided or behaviour and risks managed. This lack could lead to poor and inconsistent care. The home had yet to implement a quality assurance system and this lack has meant that the home has not got a method of improving care in the future. For example the home does not link in weights of residents with nutrition, skin care and falls. Also the home has to improve staff supervision and replacement of well-worn furniture. The home had a few gaps in the maintenance and inspection records expected. On this occasion this was an independent passenger lift inspection and a fire evacuation procedure. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 4 The registered manager assessed residents prior to admission, which ensured the home could meet the residents’ needs. The home must ensure it remains within its category of registration for new admissions so as it can continue to meet the resident needs effectively. EVIDENCE: The manager undertakes an assessment of residents prior to their admission and where funded by social care and health receives appropriate information about the resident. The home was looking to improve its system of recording information about residents to ensure that it was more easily retrieved. The home’s registration category states that the home offers accommodation and care for older people that do not fall into any other category of registration, however some of the residents are now showing clear signs of advanced dementia. It was clear that the home had admitted a person with a diagnosis of dementia, which was outside their category of registration. Whilst the home was managing the care of the residents well, increasing numbers of Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 10 high dependent residents could cause issues about staffing and management of behaviour common for people with dementia in future. The home must consider its future given the inherent trends of a number of residents who show significant changes in needs due to the onset of dementia. A comment card stated that the home provides culturally appropriate care and food for residents from an African Caribbean background and the home have an African Caribbean food option on the menu. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 &10 Arrangements for care planning, monitoring health and risk assessment needed improvement in some areas to ensure the good and consistent delivery of care to residents. The systems for medicine management have improved since the last inspection. Residents are treated kindly and appropriately, which helps resident’s care delivery. EVIDENCE: The home’s care plans did not assist staff in delivering the care to residents. Information was not easily accessible and on some occasions there were no clear instructions on how, for example to manage behaviour or continence issues. Care plans were reviewed monthly and this review was extensive and looked at all areas of the plan. Some areas of risk were not assessed, such as the use of bedrails. The district nurse spoken to during the inspection said that the home give good care but with residents that have very frail skin they continue to monitor after any pressure area had resolved. Residents’ weights were not uniformly taken and therefore any action to ensure that the nutrition was appropriate for the person was difficult to assess. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 12 The majority of medication audits undertaken were correct demonstrating that the medicines had been administered as prescribed. The requirements from the previous inspection had been met and this is commended. A number of medicinal creams needed to be discarded to prevent micro-bacterial infection. The residents thought the staff gave medication properly. The inspector observed that all contacts with residents were respectful and staff treated residents kindly. Residents spoken to said staff were kind and helpful. Residents’ rights to privacy were upheld for example if residents needed treatment it was given in their room. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 &15 Arrangements for activities, choice, visits and meals were good and these arrangements enhance residents’ lives. EVIDENCE: The residents thought they had good activities and described playing cards, doing exercise on Thursdays and playing bingo. If the weather was nice they said they go into the garden. A number of residents talked about going to a garden centre and to the Botanical Gardens. It was clear that some residents had time spent on one to one activities such as having nail polish applied. A number of residents had built up close friendships and this was maintained. Residents said that they got up a fixed time ready for breakfast but they could go to bed at any time they wished. The church often comes and they can get involved with this if they want. All relatives’ comment cards were happy with the care provided by the home and said that the staff made them feel welcome. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 14 A resident said that they were shown written records about their care but that she wasn’t bothered about seeing them. Residents said the meals provided were very good and the inspector found the lamb dinner well cooked and appetising. The menu provided showed choice at all meals. The kitchen was not inspected on this occasion. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has been free of complaints and has improved staffs understanding of protection issues by training. This reduces the risks to residents and goes some way to ensuring their safety and well-being. EVIDENCE: The home and the Commission have not received a complaint since the last inspection. The home has received a copy of the reissued multi-agency guidelines on adult protection from Birmingham City Council. Staff have signed to say they have read a copy of this. The home has procedures provided by a company and this is not as clear as the guidelines and must be amended to meet local arrangements as with other policies and procedures described in standard 37. Staff interviewed have had training on adult protection issues recently. Residents’ files contain an inventory of their personal belongings. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21,22,24,25 &26 Internally, the home was generally safe, well maintained and homely. However, the garden posed some risk to residents. Residents had access to appropriate aids to assist them with their daily life. Overall the home provides a clean safe and homely environment to residents ensuring their best interests and well-being. EVIDENCE: The home was generally clean and fresh and well maintained at the time of the inspection. However one bedroom needed some further work on odour management and some furniture was well worn. Residents’ bedrooms were personalised with a number of residents bringing in their own furniture. The home’s garden was beautifully maintained but access to the lawned area was poor with steps that could be a potential hazard. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 17 The home had appropriate assisted bathing facilities. Residents had access to appropriate call alarms and mobility aids such as walking sticks and so on. Residents that needed hoists, slide sheets and so on had these available. The home has bathroom lever type locks on bedroom doors these must be kept under review to ensure that access is only by authorised persons. The home ensures that hot water outlets are restricted to an appropriate temperature and that radiators are covered to prevent scalds to residents. The home has appropriate laundry facilities for the number of residents. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 & 29 The home has a stable, well-trained staff group and this protects residents. EVIDENCE: At the time of the inspection there were sufficient staff on duty to meet the needs of the current service users. Examination of the rotas indicated that this was always the case. At present the home has no cook, and care staff are currently cooking as a temporary arrangement. The levels of staff and hours provided for the delivery of good standards of care are sufficient to cover the absence of a cook in the short term. The manager informed the inspector that they are currently trying to recruit a replacement cook and had been for a long time. The home also takes a number of people on placement and they assist in the provision of activities. The home has approximately 80 per cent of care staff qualified to NVQ 2 level and this meets the standard. It was clear that the home did proper checks before employing staff all the staff had a relevant criminal records bureau check except for one member of staff that had clearance from protection of vulnerable adults register. One record sampled did not have all the proof of identity required and this must be rectified. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 19 The inspector confirmed with staff spoken to the training that they had received and this met the requirements. A full inspection of the staff team’s performance against the mandatory training was not done on this inspection. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,36,37 &38 Arrangements for management of the home were good on a day-to-day basis. Planning in the form staff supervision, quality assurance systems and so on needed to be improved. This lack of planning did not ensure that trends in need for residents and staff are identified or that the home improves year on year. EVIDENCE: The homes manager is a trained registered nurse and has many years experience in care of the elderly. Comment cards received have said that she is a good and caring manager. There had a requirement that the manager attains the Registered Managers Award and the time scale has been extended until April 2006. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 21 The home had purchased a quality assurance system that includes audit trails but had yet to implement this. The inspector advised that quality audits for key issues such as falls, accidents and weights be implemented immediately and other areas of the audit to be added bit by bit throughout the year to make implementation manageable. The home states that they do not handle residents’ money but prefer to pay out for hairdressing chiropody and invoice the resident, relative or responsible person afterwards. The home has yet to meet the requirement for formal supervision of staff at least six times a year. A care company has provided all of the home’s policies and procedures; these need to be read and checked for relevance to this home. A cross gender intimate care policy has been devised and residents’ individual choices noted as to whether they prefer a male or female member of staff to provide personal care. The home had available a range of maintenance and inspection records for services such as gas and electric and lifting equipment. The home needed to ensure that there was an independent inspection for the passenger lift. It was clear that the home manager was keen to ensure safety with fire drills and alarm checks being done weekly. There were some requirements from a recent West Midlands Fire Service Inspection the home stated that these have been completed via a fire safety company. Staff spoken to confirmed they have received fire training. Evidence of the new evacuation procedure must be sent to the Commission. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x 3 3 x 2 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 2 x 3 2 2 2 Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard op4 Regulation Care Standards Act 2000 24 15(1) Requirement Residents must not be admitted if their needs are outside of the homes category of registration. Care plans must contain details of how staff are to care and manage all areas of need including any risks. Weights of residents must be recordly monthly (or other form of measurement if this is not possible) and linked into a nutritional assessment. The steps from the patio area to the lawned garden must be made safe and a rail provided. The home must set in place routine monitoring for repairs in residents bedrooms and keep a record of this and must replace the two handles missing off two identified pieces of furniture and must have a programme of replacement for those items of furniture identified as being too well worn. (this last requirement was outstanding since 31/03/05) Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 24 Timescale for action 31/10/05 2. op7 31/10/05 3. op8 schedule3 3(m) 31/10/05 4. 5. op19 op24 23(2)(o) 13(4)(c) 23(2)(b) (c) 31/03/05 31/10/05 6. 7. op26 op27 13(2) 18(1)(a) 8. 9. 10. op29 op31 op33 19 schedule 2 9(2)(b)(i) 24(1)(a) (b) The home must regularly review the locks on bedroom doors to ensure that these cannot be opened by residents from the outside. The odour in one bedroom must be addressed. A full time cook must be recruited. (this requirement was outstanding since 30/04/05) All staff files must have the required level of proof of identity. The registered manager must attain the Registered Managers award by A formal quality assurance programme is implemented in the home. It is recommended that areas of audit are implemented month by month to complete all areas by 12 months. (this requirement was outstanding from 28/02/05) Formal documented supervision must be provided for every member of the care staff at least 6 times a year. (this requirement was outstanding since 28/02/05) The home must ensure that all policies and procedures are personalised to the home and understood by the staff, this includes the missing persons procedure. (this requirement was outstanding since 31/03/05) The home must ensure there is an independent inspection of the passenger lift and a copy of the inspection certificate must be sent to the Commission by 31/12/05 31/12/05 30/11/05 30/04/06 31/12/05 11. op36 18(2) 31/12/05 12. op37 17(1) 30/11/05 13. op38 23(2)(c) 23(4)(c) (iii),(d) 14/11/05 Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 25 A copy of the certificate of fire training including the names of staff that attended and a a copy of the homes evacuation procedure must be sent to the Commission by Rooms must be numbered to ease evacuation during a fire. 30/09/05 30/09/05 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 It is recommended that highlighting the Medicine Administration Record (MAR) chart that the medicines are not in the Monitored Dosage System to ensure all medicines are administered as prescribed at all times. It is recommended that medicinal creams are sent back at the end of each prescription cycle to prevent microbacterial infection. Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Chestnut Lodge E54_S16897_ChestnutLodge_V236194_030805_Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!