Inspection on 01/11/05 for Gilby House Care Home

This inspection was carried out on 1st November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gilby House Care Home 31/07/09

Gilby House Care Home 19/05/09

Gilby House Care Home 16/10/07

Gilby House Care Home 15/01/07

Gilby House Care Home 06/03/06

Gilby House Care Home 29/11/04

Gilby House Care Home 26/05/04

Gilby House Care Home 02/03/04

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

CARE HOME ADULTS 18-65 Gilby House Care Home High Street Winterton Scunthorpe North Lincolnshire DN15 9PU Lead Inspector Stephen Robertshaw Unannounced Inspection 1st November 2005 09:30 Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 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 Gilby House Care Home DS0000002787.V267016.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 Adults 18-65. 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. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gilby House Care Home Address High Street Winterton Scunthorpe North Lincolnshire DN15 9PU 01724 734824 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) Prime Life Limited Ms Diane Lawrence Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service accommodated is over the age of 65 years (SM). This individual can continue to be accommodated in the home until there is a change of their individual circumstances which means the home can no longer appropriately meet their assessed needs. 29th November 2004 Date of last inspection Brief Description of the Service: Gilbly House is registered to provide nursing care to adults who experience mental health problems. The home is situated in Winterton, a village close to Scunthorpe. The home is a converted Victorian building in the centre of the village. There have been more recent extensions to the premises. Its location gives service users good access to shops, pubs and other facilities within the village community. There is also a regular bus service in to the town of Scunthorpe. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? The recording of service users trial periods at the home has improved since the last inspection. The protection of vulnerable adults training provided to the staff is more comprehensive and appropriate to the needs of the service users. The frequency of the evaluation of individual care plans has improved in the home but they still do not meet the minimum requirements. The homes records of the regulation 26 visits have improved however the management do not forward a copy as required to the commission. Gilby House Care Home DS0000002787.V267016.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. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 1,2,3,4 and 5 The service users are provided with the opportunity to choose to live at the home or move elsewhere in conjunction with their assessed needs. EVIDENCE: The homes statement of purpose includes most of the information required, however there is no identification of how individuals may be charged for transport costs to activities, family visits and health appointments. There are varying rates of what individual service users pay. The formula for how this is worked out must be produced. The inspector observed all of the case file information in relation to three service users. All of these included comprehensive assessments of their individual needs. The assessments included care management, and specialist mental health team assessments and the homes pre-admission reports. All of these included identification of service users individual needs. The care files showed that outside health and social care staff support the home and individual service users need. This included regular contact with social workers, community psychiatric nurses, and GP’s. The diary records for individual service users supported the evidence that they are given the opportunity to visit the home and meet the other service users Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 9 before the make a decision to move there on a more permanent basis themselves. The pre-admission contact included overnight stays and joining in activities at the home. Discussions with service users confirmed that this was the usual practice in the home. All of the case files observed by the inspector included terms and conditions of their residency at the home including details of timescales for termination of their contracts. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 6,7,8,9 and 10 The service users at the home are provided with services that meet their individual needs and allow for them to choice how the services will be delivered. EVIDENCE: The care plans seen by the inspector had not all been evaluated on a minimum of a monthly basis to ensure that the service users needs remained the same. The quality in the content of the care plans varied greatly in the description of the individual needs and how they should be met. The majority of the care plans had been signed in agreement by the service users. Service users spoken to by the inspector were aware of who their keyworker was in the home and who was responsible as their care manager and CPA coordinator. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 11 Observation of care plans and discussions with service users confirmed that service users are supported and encouraged to make decisions for themselves in their daily lives. This included what time to rise from and retire to bed and what activities to become involved in at the home and in the community. Care plans where appropriate are supported with clear risk assessments for individual needs of service users. There was no evidence to support that the risk assessments are re-evaluated once they have been completed. Records observed showed that the service users are encouraged to maintain their personal finances and to budget appropriately. Service user meetings had been recorded on a regular basis. The records supported that the service users are consulted in relation to the activities that they want to be introduced at the home, or alternatively activities in the community that they would like to access. There were repetitive issues in the service users meetings in relation to choices at meal times. The indication was that the service users are not consulted in relation to the homes menus and choices are not made available at meal times. No action appears to have been taken in the home by the staff or management in relation to these issues. Staff training records and interviews with staff confirmed that they understand what confidentiality is and when the information given cannot remain in confidence. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 11, 13,14,15,16 and 17 The service users at the home are encouraged and supported to develop their individual lifestyles and personal interests. EVIDENCE: The care plans observed by the inspector supported the information that the service users are provided with the opportunity to maintain and develop their social, emotional, communication and independent living skills. The service users care plans and discussions with the service users showed that they are supported to develop relationships outside of the home and to access services in the community including the cinema, swimming pool and visiting local shops and adult education centres. Advocacy services are advertised in the home. Since the last inspection the home has visited several activities in the wider community including day visits to Twycross Zoo, York, Bakewell, Bridlington, Mablethorpe (Seal Trust), Goathlanes and Cleethorpes. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 13 Service users stated to the inspector that they preferred to go out for day visits and did not wish to be away from the home for any longer periods of time. The standard for contact with service users families (NMS 15) and friends continues to be exceeded. Family contact is very well maintained and service users are transported to family in other local authorities when they wish to visit them. The individual care plans and discussions with service users confirmed that they are supported and encouraged to promote and develop their independence skills. Service users movement is not restricted unless there is a clear risk assessment to explain why the restrictions are in place. The care plans also identified the service users preferred terms of address. The inspector observed staff knocking on service users doors and requesting to enter the room before going in. There are designated smoking areas in the home. The service users are provided with a fairly balanced diet but no choice is made available to service users at meal times. Service user meeting records observed by the inspector evidenced that at consecutive meetings the service users had requested that they are provided with a choice at meal times. These requests do not appear to have been acted upon. Individual care files evidenced that individual service users have their nutritional needs assessed and are included on their care plans. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 18,19 and 20 The service users personal and healthcare needs are generally met within the home. EVIDENCE: The individual case files observed by the inspector and discussions with service users confirmed that they are supported to maintain their privacy and dignity at the home and this in turn supports them in the development and maintenance of their independent living skills. The home provides nursing care to the service users. The nurses are also supported by the local GP practices, district nursing service, and specialist healthcare workers based in the local hospital including consultant psychiatrists. Service users preferences in relation to how they should be moved and supported were identified in their individual care plans. Discussions with the service users showed that the care plans were always followed. The care plans identified where outside professionals were supporting the service users with their needs, and who was responsible for maintaining these Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 15 needs. This included care programme approach co-ordinators, community nurses and social workers. The inspector observed the administration of medication to service users in the home. The administration was carried out by a qualified nurse and appropriate good practice guidelines and legislation were followed. The medication was well recorded and the records were up to date and accurate. The medication room was well organised and tidy. The floor of the medication room was worn and was starting to lift which could cause a trip hazard. It was also catching dirt. There were no controlled drugs in the home at the time of the inspection. However the home had the provision and records available to store controlled drugs. The majority of the medication in the home was delivered to it in monitored dosage containers. All of the Medication Administration Record sheets in the home were up to date and were accurately recorded. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 22 and 23 The service users at the home are protected from potential abuse and understand how to make a complaint about the services that they receive if they wish to. EVIDENCE: The homes complaints procedure has been updated to include the contact address for the local office of the Commission for Social Care Inspection. There had been no complaints recorded at the home since the last inspection. Service users spoken to by the inspector were aware of how to make a complaint if the service that they received were not appropriate to their needs. The companies policies and procedures for the protection of vulnerable adults does not meet the appropriate requirements and suggests that the management of the home should undertake interviews in relation to suspected abuse. The inspector interviewed the manager and staff at the home and they understood the requirement to allow the appropriate authorities to conduct the interviews and would not take this on themselves. Training records at the home and interviews with the staff confirmed that in the last year they have received protection of vulnerable adults training provided through the local authority and a local training provider. The training provided by the training agency included care of vulnerable adults, abuse scenarios, confidentiality and disclosing confidential data. This training was also mapped to the TOPP’s standards. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 17 However staff working at the home are employed before they have received the appropriate safety vetting procedures. This could place the service users at risk of abuse from potential high-risk individuals that could be employed at the home. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 18 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 the following standard(s): 24,27,28 and 30 The environment of the home is appropriate to the needs of the service users. EVIDENCE: The home has a variety of communal spaces that they can use to socialise with their peers. Service users confirmed that they could choose which communal area that want to use. There has been a programme of redecoration in the home since the last inspection. The home does not have CCTV coverage. However around the time of the inspection there had been a series of vandalism events in the local community. This included a large firework being placed in the homes letterbox. Fortunately there was a closed wooden box that the mail falls in to. The explosion of the firework destroyed this. The local authority requested that a small CCTV camera was placed in one of the homes windows to try and identify who was causing the vandalism and trauma to the service users. A small camera was fitted but it did not intrude on the service users in the home and was not able to film them. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 19 The toilets and bathrooms in the home were clean and were located close to the their individual rooms and the communal areas. The home was free of any offensive smells. The home has a range of communal space that includes areas for smoking and nom smoking. One of the lounges had been decorated for Halloween and the service users stated that they had enjoyed a Halloween party. The cobwebs were decoration and nothing to do with the cleanliness of the home. The home does not have sluicing facilities but the washing machines in the laundry are programmable to disinfection and sluicing standards. The laundry was well organised and service users stated that generally they always receive their washing back from the laundry promptly. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 20 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34, and 35 The employment of the staff at the home does not ensure the safety of the service users or protect them from possible abuse. EVIDENCE: The inspector observed the personnel and training files for four members of staff. All of these included job descriptions and work specifications. Interviews with the staff confirmed that they understood their own roles and the roles and responsibilities of the other staff that they work with. Staff confirmed that they had received individual copies of the General Social Care Councils codes of conduct. Direct observation of the care staff working with the service users confirmed that they have the right attitude and characteristics to support the service users to meet their needs. Staff training records and speaking to the care staff supported the evidence hat they have the necessary skills and experience to meet the needs of the service users. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 21 Discussions with the service users and observation of the staff rotas showed that there are always appropriate numbers of staff available to help them to meet their needs. Staff were observed communicating with the service users in appropriate tones and language. The staff personnel files provided evidence that staff are employed to work with the service users before the company have assured their safety through POVA first and Criminal Record Bureau clearances. This could place vulnerable service users at risk from unvetted staff. The remainder of the staff file requirements were met including two references, interview records and personal identification documents including photos. The induction and foundation training undertaken by staff at the home meets the requirements of the Sector Skills Council specifications on the principles of care and safe working practices. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 22 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,40,41 and 42 The management of the home is accessible to the service users and the service users believe that the management is very approachable. EVIDENCE: The manager of the home has almost completed her Registered Managers award and is a qualified nurse. The manager has also completed a certificate in supervisory management. Training records in the home identified that the manager undertakes periodic training with her staff. Staff interviewed by the inspector and discussions with service users confirmed that the management approach to the home is open, positive and inclusive. There is a clear sense of direction and leadership in the home. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 23 The staff are provided with a small booklet of the companies policies and procedures. These are not full policies and procedures but statements to prompt the staff. The manager stated that the staff should refer to the policies and procedures that were in a ring binder in the medication room. The policies and procedures in the ring binder were more comprehensive but they had not been reviewed for several years. A business and financial plan was available in the manager’s ring binder. This projected the business of the home and identified its viability. The external management of the home visit the home on a monthly basis and complete a record as required by regulation 26. The management do not send a copy of the regulation 26 report to the Commission for Social Care Inspection as the regulation requires. The home carries out PATT testing on the electrical appliances in the home but it does not have a current safety certificate for the electrical systems in the home. This is an outstanding requirement. The sink in the green bathroom was falling off the wall, and the shower room near the laundry required attention with the drainage system. The remainder of the homes requirements for the health and safety of the service users were met. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 24 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 2 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 4 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 1 3 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gilby House Care Home Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 2 1 X DS0000002787.V267016.R01.S.doc Version 5.0 Page 25 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 YA34 Regulation 18 Requirement Timescale for action 01/11/05 2 YA40 17 3 YA42 23 The registered person must ensure that all new staff working at the home have received a minimum of a POVA first clearance before they have any contact with the service users. This must then be followed up by a completed enhanced CRB clearance. The registered person must 01/01/06 ensure that all of the relevant policies and procedures required by the home are in place, available to staff, and service users, and must be reviewed on a minimum of a yearly basis. The policies must be explicit. Original timescale of 26 May 2004 has not been met. The registered person must 01/12/05 ensure that the home has a current safety certificate for the electrical systems in the home. The original timescale of 26 May 2004 has not been met. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 26 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 9 10 11 Refer to Standard YA1 YA6 YA6 YA9 YA17 YA35 YA37 YA41 YA42 YA42 YA42 Good Practice Recommendations The registered person must ensure that the service users are made aware of the costs of transport in the statement of purpose and service users guide. The registered person must ensure that all of the individual care plans in the home are evaluated on a minimum of a monthly basis. The registered person must ensure that issues raised in service users meetings are acted upon. The registered person must ensure that individual service users risk assessments are evaluated on a regular basis. The registered person must ensure that the service user have a choice in the meals that are provided in the home. The registered person must ensure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent by 31st December 2005. The registered person must ensure that the manager of the home has achieved the registered Managers award or equivalent by 31st December 2005. The registered person must ensure that copies of the homes regulation 26 reports are forwarded to the local office of the Commission for Social Care Inspection. The registered person must ensure that the sink in the green bathroom is safely secured to the wall. The registered person must ensure that the drain problem in the shower room is repaired. The registered person must ensure that the flooring in the medication room is either repaired or replaced. Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Gilby House Care Home DS0000002787.V267016.R01.S.doc Version 5.0 Page 28 - 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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