Inspection on 03/11/05 for Gloucester House Nursing Home

This inspection was carried out on 3rd 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 but made no statutory requirements on the home.

Other inspections for this house

Gloucester House Nursing Home 19/04/07

Gloucester House Nursing Home 06/06/06

Gloucester House Nursing Home 25/05/05

Gloucester House Nursing Home 14/12/04

Gloucester House Nursing Home 29/06/04

Gloucester House Nursing Home 11/02/04

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

CARE HOMES FOR OLDER PEOPLE Gloucester House Nursing Home Lansdowne Road Sevenoaks Kent TN13 3XU Lead Inspector Elizabeth Baker Announced 03 November 05 09:25 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. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Gloucester House Nursing Home Address Lansdowne Road Sevenoaks Kent TN13 3XU 01732 741488 01732741664 Gloucester@agecare.org.uk AgeCare 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) Mrs Philippa Jane Saunders Care Home with Nursing 54 Category(ies) of Old Age (54) registration, with number of places Physical disability (10 Terminally ill (10) Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25 May 2005 Brief Description of the Service: Gloucester House Nursing Home is a care home providing nursing care for 54 Older People. Age Care, The Royal Surgical Aid Society, is the registered provider. The home is a purpose built two-storey building. Accommodation is on two floors. A 13-person passenger lift is available. Bedroom accommodation comprises 42 single and six double bedrooms. All bedrooms have ensuite facilities. The home is divided into four villages. Each village has two day rooms. In addition to these day rooms, a large communal dining room and lounge is situated on the ground floor. A library/computer room is located on the first floor. All rooms used by residents are connected to the nurse call system. The rear gardens are designed to enable physically disabled and wheelchair users to move easily around. The home is approximately one mile from the main A25 trunk road and Sevenoaks Town Centre. Sevenoaks has a good range of amenitities including shops, banks, places of worship, restaurants, cinema and theatre. Sevenoaks is served by public transport, including rail services to London and the Kent and Sussex Coast. There is ample car parking. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 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 seven hours on the 3 November 2005. A partial tour of the home was carried out. Some residents and visitors were spoken with, as well as a number of staff. Three residents and one member of staff were interviewed in private. A separate pharmacy inspection by Pharmacy Inspector Jane Vaughan also took place. The findings of that inspection will be reported separately. At the time of the visit 51 residents requiring nursing care were residing at the home. The Manager, Mrs P Saunders and Assistant Manager/Bursar Mr P Thompson were available throughout the inspection. Some judgements about the quality of care, life and choices were taken from conversations with residents, visitors and staff, as well as direct and indirect observations. Some records were seen as part of case tracking and to assess work on the requirements and recommendations made at the last inspection. In response to the announcement of this inspection the Commission received a total of 37 comment cards from Residents (12), Relatives/Visitors (15), GPs (3), Care Managers (2) and Health Care Professionals (5). Some of their comments have been incorporated into the report. This is the second inspection of this home for the year 2005/06. Not all key standards have been inspected on this occasion, where they were met at the first visit. This report should therefore be read in conjunction with the inspection report dated 17 May 2005. What the service does well: The inhouse physiotherapy treatment is much appreciated by residents. Comment card respondents additional comments included “There is always a warm, friendly, professional atmosphere. Visitors always seem welcome”; “My [relative] is wonderfully well looked after. I certainly have no complaints”; “All the staff are friendly and the atmosphere of the home good”; “Excellent level of professional care led by an excellent matron”; “I have usually asked questions to which good honest answers have been given and information supplied”; “Home and staff always very aware of clients’ needs”; “I have a very good professional working relationship with the manager and home”. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 6 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. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 6 Prospective residents and their advocates are provided with the information they need to make a decision about moving into the home. EVIDENCE: Following a requirement made at the last inspection, management have developed and introduced taped versions of the home’s Statement of Purpose, Service User Guide and Complaint’s procedure. This will ensure that residents who are visually impaired, or just prefer this version, are fully informed of what Gloucester has to offer and is registered for. The home is not registered for intermediate care. Standard 6 is not applicable. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 11 Care staff continue to develop their record keeping skills. However the records do not contain full and precise details so residents’ complete needs and wishes are met. EVIDENCE: Three care records were inspected as part of the case tracking process. Care records comprise care plans and clinical risk assessments including moving and handling, pressure sores, falls and wound care. Although there is evidence that staff continue to strive to improve record keeping content, the records inspected did not provide full details of residents’ individual needs and wishes or indeed all the actual care being provided by staff. For example hygiene needs did not include specific details of residents’ actual preference to what type and how they wished to be shaved. For a resident who requires oral hygiene care, there was no precise information about this. There was minimal information in respect of residents’ background and previous social and occupational interests. Whilst acknowledging the home has a good range of communal activities for those residents who choose to join in, sadly the records inspected did not include any evidence of one to one input for residents receiving this provision of care. An assessment to assist staff in transferring a resident was deficient of the resident’s actual pain sites. The Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 10 resident is often in pain. The abbreviation “BO” was used on the daily records for one resident. Abbreviations should not be used. There was no glossary of terms on the document either. Some care records were incomplete of all the information required of the forms. This had been identified previously. In one particular case it was difficult to obtain a coherent picture of the residents’ skin condition in that references to different sites were contained in three different care plan components. The composer had not signed the body map in this file and there was confusion as the year the resident was actually admitted into the home. The files contained much evidence of specialist advice having been sought and provided by community clinicians. Two of the three returned comment cards from GPs indicated there is not always a senior member of staff to confer with, and one indicated staff do not demonstrate a clear understanding of the care needs of residents. It was again noted that details of residents’ preferences and wishes in respect of death and dying were missing. This needs to be addressed, particularly as the home is registered for Terminal Illness. Assistance details as to how the home may be able to obtain this sensitive but vital information was provided to the Manager. Only one of the three records made reference to the care plan having been compiled with input from the resident and their advocate. Involving residents and or their advocates in care planning and subsequent reviews may assist the home in ensuring they have a complete picture of their residents needs and wishes, including non-medical matters. Pharmacy Inspector Jane Vaughan carried out a separate inspection of standard 9. This refers to the administration, recording and storage and medications. The findings of the visit will be contained in a separate report. During an interview with a resident it was noted that the resident selfmedicates a medication, which is purchased on the resident’s behalf by a relative. The resident’s corresponding records made no reference to this. As this medication may adversely counteract with the resident’s prescribed medications, the home must take appropriate action to ensure the resident’s safety. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) N/I All the standards were met at the last inspection. re-inspected on this occasion. EVIDENCE: These standards were not Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 12 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 The improved complaints information guides residents on how to complain, if they need to. EVIDENCE: To ensure residents with impaired vision are fully aware of what to do if they have a complaint or concern about their care, a taped version of the home’s complaint procedure has been developed and is currently being tried out. This is a good initiative. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 13 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, 20, 21, 22, 23, 24, 25 and 26 The standard of carpets and décor in certain areas does not present a homely and comfortable environment. The size of double bedrooms does not allow all residents in shared rooms to have furniture and beds of their choosing and comfort. Some residents may be at risk because of the unreliability of the home’s plumbing system. EVIDENCE: Areas and rooms used by residents were clean, warm and odour free. However inspection of the home’s sluice rooms, which are situated near to residents’ bathrooms and bedrooms were noted to be warm and musty. Although the sluice rooms have mechanical ventilation units, these appeared inadequate for purpose. The home has a range of beds to meet the individual needs of residents. However during a conversation with a particular resident, who is mainly bedfast, it was identified that the bed and airflow mattress was not particularly comfortable. The resident had been informed that a different type of bed may Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 14 provide better comfort, but could not be provided because of space limitations of the shared room currently used. The resident also said they would like a table or desk so when they are able to sit out they would be more comfortable when reading or listening to the radio. Bedrooms vary in size and shape. Sadly the size of this resident’s room does not allow for such furniture. Whilst acknowledging the size of the double bedroom meets the original registering authority’s requirements, and as such meets the minimum national standards pertaining to a pre-existing care home, bedrooms must be fit for purpose in that they should be of suitable size to meet the care needs of the individual resident, including special beds and items of furniture. A new carpet was laid in the reception room following the completion of some internal improvements to the home in 2003. It was said at that time and subsequently that it was the home’s intention to replace corridor carpets throughout the home. Indeed these carpets are the original ones and have served the home well since its registration in 1990. However with the passage of time and continuous wear and tear, the carpets look worn out and have large areas, which are now permanently stained. This situation does not provide a homely environment. Arrangements have been made for a representative of Kent Association of the Blind to visit the home and assess the environment. This will ensure appropriate facilities are in place for residents with visual impairments. A comment card respondent added the additional comment “At times, over the past year, there has been no hot water or heating available. I do hope this will be rectified before the predicted cold winter sets in”. Experts have surveyed the water and heating systems and have identified problems. Steps are currently being taken to rectify the matter. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 15 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 and 29 Current vetting practises do not ensure residents are protected from risk. EVIDENCE: As well as care staff, staff are employed for cooking, laundry, cleaning, administration, reception, maintenance and activities. Despite the home’s staffing levels exceeding the minimum requirements of the former regulatory authority’s requirements for a nursing home with 54 residents, six of the twelve returned comment cards from relatives/visitors indicated in their opinion there are not always sufficient staff on duty. Additional comment card comments from respondents included “Carers have more work to do. We need an increase in staff as we do not like the long waits for attention”; “Although overall I feel that the care at Gloucester House is adequate to good, I do feel that they are understaffed. A wait of more than 15-20 minutes for attention is not acceptable”. Three staff files of newly appointed carers were inspected. This again identified that recruitment and vetting procedures are not sufficiently robust to ensure residents are protected. Verbal references had been accepted in two cases. The name of the referee was not recorded and the “generalised” comments undated. For an overseas employee, both references had been obtained from employments not associated with care. The application form contained details of former care employments. For another member of staff one reference had been returned and this inferred the referee was the employer as opposed to the care home. All three files recorded the applicants having been Criminal Record Bureau checked. However a review of Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 16 information supplied by the home in support of this inspection identified that a long-standing member of staff has still not been subject to this process. Residents could be at risk unless all staff, new and old, are appropriately vetted as to their suitability to work in a care home. When applying for references the home encloses a job description relevant to the post. This is good practice and informs the referee of all the duties and responsibilities involved in order for them to respond appropriately. Management are committed to ensuring staff are appropriately trained in the roles they perform. Future training includes an external study day in respect of swallowing difficulties and legal implications of certifying death. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 17 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, 32, 35, 36 and 38 The manager has a good understanding of what needs to be done to improve in the home. EVIDENCE: The Registered Manager, who is a Registered Nurse, has almost completed her management qualification. When successfully completed this will provide her with the requisite qualifications for managing a care home providing nursing care. Residents, visitors and staff spoke openly during the inspection visit. The home endeavours to keep residents informed of all matters affecting the running of the home. This has included the ongoing plumbing problems, which in one case involved a resident, who formerly worked in property maintenance Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 18 being shown the workings of the home’s water and heating systems for his information. The home was purpose built and registered in 1990. However despite its age and regular servicing and maintenance, recent problems have included inadequate heating and hot water, ineffective ventilation and lift breakdown (resulting in some replacement parts having to be specifically manufactured). The home has just obtained quotes to have the fixed wiring installation system appropriately surveyed. Sadly to finance this work, money has been taken from the home’s furnishings upgrade budget and the replacement carpet programme has stalled. Some doors and doorframes to bedrooms and bathrooms have been scored by wheelchairs and look unsightly. This situation does not present a homely environment for residents. The organisation’s representative supports the home. However not all of these visits are reported to the Commission on a monthly basis as is required by regulation 26. During discussions it transpired the home’s passenger lift was out of action for a couple of days recently. This affected residents on the first floor. The Commission was not informed of this incident as is required by regulation 37. Changes have been made to the recording of residents’ monies and personal possessions, where these are held on their behalf. However the current records still do not contain precise details of the source of the monies. Nor are residents required to sign a record of personal possessions handed over the home for safekeeping. To ensure residents have access to their monies at all times, a system has been introduced for “out of office” requests. However the assistant manager explained problems with this system in that senior staff do not always keep him informed when this provision needs topping up. Neither did he know where such funds are kept. To prevent any allegations of misappropriation of residents’ monies and possessions, a detailed policy and procedure needs to be devised and made available to the appropriate staff. Since the last inspection, a representative of the Health and Safety Executive has visited the home as part of its Backs! 2005 initiative. This resulted in a number of recommendations being made to improve moving and handling practices around the home. The home is now actively working to achieve the matters requiring attention to comply with health and safety law. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 19 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 3 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 2 x 3 2 2 2 STAFFING Standard No Score 27 3 28 x 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 x 2 3 x x 2 2 2 2 Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 20 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 OP36 Regulation 26 Requirement Monthly written reports of the Responsible Individuals visits to the home must be submitted to the Commission. (Timescale not fully met). A programme of carpet cleaning and or replacement must be instigated. (Timescale not fully met) The home must obtain details of all medications brought into the home from advocates for residents to self medicate. Residents must be supplied with appopriate beds and space for their individual needs Ventilation units must be adequate for their purpose The homes hot water problems must be satisfactorily resolved. Robust vetting systems must be in place for staff recruitment purposes All care staff must be subject to criminal record bureau checks Adverse events affecting residents must be reported to the Commission, including lift breakdowns The homes heating system problems must be satisfactorily Timescale for action 03/11/05 2. OP19 23 30/04/06 3. OP9 13(2) 04/11/05 4. 5. 6. 7. 8. 9. OP24 OP26 OP21 OP29 OP29 OP37 16 16 23 19 19 37 27/02/06 28/02/06 31/12/05 15/12/05 04/11/05 04/11/05 10. OP25 23 31/12/05 Page 21 Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 resolved. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard OP11 OP31 OP7 OP7 OP7 OP35 OP19 OP38 Good Practice Recommendations Residents wishes and preferences in respect of death and dying and last rites must be obtained and recorded. The Manager must successully complete the relevant management qualification. Care plans must be complete of all known wishes and needs, including personal hygiene, oral hygiene. Care records must include information on residents social and occupational interests. Abbreviations should not be used in residents care records. Clear procedures must be in place in respect of management of residents personal monies and the safe keeping of personal possessions. Bedroom and bathroom doors must be repaired and kept in a good decorative state. Recommendations made by the Health and Safety Executives visit must be complied with. Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Gloucester House Nursing Home H56-H06 S26173 Gloucester House V248551 031105 Stage 4.doc Version 1.40 Page 23 - 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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