Inspection on 07/12/05 for Harefield Hall

This inspection was carried out on 7th December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Harefield Hall 06/09/07

Harefield Hall 14/12/06

Harefield Hall 12/05/05

Harefield Hall 31/01/05

Harefield Hall 17/09/04

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

CARE HOMES FOR OLDER PEOPLE Harefield Hall 171 Bath Road Willsbridge South Glos BS30 9DD Lead Inspector Odette Coveney Unannounced Inspection 7th December 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Harefield Hall Address 171 Bath Road Willsbridge South Glos BS30 9DD 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) 0117 9323245 0117 9328884 Banff Securities Limited Ms Susan Anne Evans Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 21 persons aged 65 years and over requiring personal care only 12th May 2005 Date of last inspection Brief Description of the Service: Harefield Hall is a well-established care home situated in its own large grounds, between the villages of Longwell Green and Willsbridge. The centre of Bristol is six miles away and can be accessed by the buses that stop at the bottom of the driveway. The home is easily accessible to the local shops and the post office, plus there are two areas of interest nearby, namely the Willsbridge Mill and the Bitton Railway Station. Both have tearooms and provide a pleasant area where visitors can take their relative. The house has been extensively adapted to provide accommodation for 21 people, both male and female. The private rooms are spread over three floors and there is a passenger lift ensuring that all areas are accessible. The home has a pleasant lounge and dining room and the large hallway is also able to accommodate seating for several of the service users. The kitchen is on the ground floor; the laundry and the storerooms are in the basement. There is self-contained private accommodation in the basement. The home provides care for older people and aims to do this in a personalised way, ensuring that as much independence is retained and that a fulfilling and meaningful lifestyle is offered. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided and monitor the progress in relation to the recommendations from the last inspection that was conducted in May 2005. During this inspection any standards, which were not reviewed at the previous inspection, were examined. The inspection took place over the morning and early afternoon. During the process ten residents, two staff, visitors and the deputy manager were spoken with. The inspector looked around the building and a number of records were examined. Prior to the inspection regulation 37 reports were reviewed and one of the reported incidents was discussed with the deputy manager of the home in order to confirm how the situation had been dealt with and to look at the outcomes. What the service does well: What has improved since the last inspection? What they could do better: Of the recommendations made at the previous inspection one has not been met, one will be reviewed at the next inspection due to a new system being implemented at the home. The other two recommendations will also be reviewed at the next inspection and are within a realistic timescale to be met. In order to ensure the safety of resident’s the home must ensure that risk assessments for individuals have been completed following an identified area of need. This requirement was made in respect of one resident who required a risk assessment for one specific area of care support. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 6 In order that resident’s can be assured that medication is being recorded appropriately it is recommended that stock held medication is recorded and accounted for. In order to demonstrate that individuals have been individually given their travel tokens as issued by the local authority it is recommended that residents sign to record they have received them. As these token are issued once per year in April the home will be unable to fulfil this recommendation until April 2006. In order that residents can be assured that they are supported by trained staff it is recommended that care 50 of staff achieve National Vocational Qualification at level 2 in care. 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. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 Individuals are supported appropriately during their admission to the home with their needs being identified, evaluated, recorded and met. EVIDENCE: The home is registered with the Commission for Social Care Inspection to provide residential care for 21 older people; at the time of the inspection there were three vacancies. The deputy manager, Debbie Halton was able to fully explain the admission processes for individuals moving into Harefield Hall. The deputy manager said that the home has a written admissions process, which has been reviewed along with the home’s statement of purpose at the previous inspection. These were found to contain all of the required information as outline within the National Minimum Standards. The admissions policy and procedure to the home has not changed. Mrs Halton said that upon initial enquiries to the home individuals are sent a brochure; this provides information about the services and facilities provided at the home with personal accounts from people who lived there. Mrs Halton explained that for local authority funded residents the care manager would have undertaken a full assessment of the person’s needs Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 9 and this would be provided to the home in order to inform them of the service to be provided. Individuals initially look around the home and are then invited to stay for a meal or for the day as a guest of the home. Mrs Halton also said that once an individual has decided to come into the home the home requests for the individual or their family information about the resident’s next of kin, important contacts and previous history of the person, this information assists staff with their understanding of the person, which in turn will ensure needs are met. Mrs Halton gave a number of examples of how individuals had chosen Harefield Hall as their home and was also fully aware of those who are not able to be cared at the home. One of the residents spoken with said that they had only been at the home for a short space of time; they said they had made friends and moving into the home had ‘been like heaven’. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 11 Care plans are well written and reviewed and updated on a regular basis. Health and medication needs of individuals are met; further evidence is needed to fully demonstrate that medication has been disposed of appropriately. There is information in place outlining the needs and wishes of resident’s in the event of their death, this is handled sensitively. EVIDENCE: A review of the care files and associated information revealed that records are reviewed and updated on a regular basis. Records are held securely. As previously recorded care plans in place have been based on an assessment of need. The inspector viewed a random number of resident’s care plan records. Care plans had been based on a care manager led assessment of the individuals needs. The care plans clearly stated how to assist individuals with full aspects of their care. Care plans have been reviewed consistently on a monthly basis and any changes are recorded and responded to appropriately. All of the resident’s at the home are registered with a general practitioner. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 11 As the inspector arrived at the home a district nurse was leaving. Debbie Halton told the inspector that the nurse had been to take some samples of behalf of the general practitioner. District nurses also undertake a health needs assessment of individuals if the home is unable to meet their needs on an ongoing long-term basis. Records evidenced that those residents who wanted them have had vaccinations against influenza and Pneumonia. Records seen also evidenced that residents have been fully supported with their healthcare and that a multi disciplinary approach has incorporated speech and language therapists, dentists, and psychiatrists. The procedures for the receipt, storage administration and disposal of medication in the home were reviewed. A random number of resident’s medication administatration charts were reviewed. The charts included the initial of the staff member giving medication as well as the reason for any omissions. There was a photograph of each resident maintained with these records. The home is currently being supported with medication systems by a new pharmacist who dispenses resident’s medication to the home and has recently introduced a new monitored dosage system for medication administration and the effectiveness of this is being monitored by the manager of the home. Systems for administration of medication are generally good with clear and comprehensive arrangements in place to ensure that resident’s medication needs are met. The home maintains a record of returned medication and a staff member signs to confirm what is being returned. A recommendation was made at the previous inspection that stock medication be recorded and audited, due to the new medication system being in place for only three days this will be reviewed at the next inspection. The home has sought the individual’s wishes in the event of their death and specific requests of individual’s are recorded. One of the resident’s has recently died and was supported with their terminal care by staff at the home and also the individuals general practitioner and district nurses, staff members spoken with were able to demonstrate that the individual was fully supported with their needs and was treated with respect and dignity during this time. Staff through discussion showed an empathy and awareness of the emotional support that the individual’s family requires. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Resident’s lifestyles at the home matches their expectations and preferences, individuals are supported to maintain important relationships and to participate in activities of their choice. EVIDENCE: Records of food provided along with the menu for the home was seen and indicated that balanced and nutritious meals are provided. All of the resident’s met expressed very positive comments about the quality and choices of food. It is evident that the home is providing food that resident’s feel is of a very high standard. Residents meetings are held regularly at the home where they can voice preferences about day-to-day living at the home eg: menu choices, activities programmes etc. The kitchen was found to be clean and tidy with fridge and freezer temperatures being maintained. Fresh foods were found to be stored safely. A recommendation was made at the last inspection that dry food stores to have a use by date written on them. A review of food held in the pantry showed that this has not been done for all foods and will be reviewed at the next inspection. A visitor to the home said that they were more that happy with the quality of life their long-term friend received at the home they also said ‘ I can’t fault this Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 13 place at all, it’s wonderful here’. ‘The care is second to none, an A1 service’ another commented that the home was ‘a gorgeous place’ and that their relative was ‘well looked after’ The deputy manager confirmed that a number of the residents are supported by family members, residents consulted as part of the inspection said that their families are always made welcome During the inspection an entertainer who was performing at the home said that the home was ‘a top place’, ‘I have always found the staff to be very polite, ‘excellent place’. A poster was on prominent display inviting resident’s family and friends to a raffle, entertainment and mince pie evening to be held at the home later in the month. Resident’s said they enjoyed a range of activities at the home which include table skittles, bingo, radios, books and cards. Regular residents’ meetings are held at the home, these are well attended and provide an opportunity for issues to be discussed. The last meeting was held at the home in November with appropriate agenda items discussed, points raised and actions taken were well recorded. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Complaints are handled objectively and residents are confident that their concerns will be taken seriously, listened to and actioned. EVIDENCE: A copy of the home’s complaints procedure is on display within the home’s entrance hall. The home has a sound complaints procedure, which contains all of the required information in order that complaints are handled objectively and with the welfare and wellbeing of the residents being paramount. Residents were reminded of the homes complaints procedure at the last residents meeting held in November. There was evidence in place to show that staff have undertaken protection of vulnerable adults training, this training is also covered within a unit of the National Vocational Qualification at level two in care. A staff member who attended the Protection of vulnerable adults Alerters training said that the training had ‘enlightened’ them. At the last inspection it was noted that residents had been issued by the local authority with either travel token or a bus pass. There was no evidence in place at the home to show that residents had received these. It was recommended that residents sign to record that they have their travel tokens. As these are only issued in April each year this was unable to be reviewed at this inspection and therefore will be completed at the next. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 15 The home holds small amounts of money at the home for some resident’s; two of the records and the money held on their behalf were checked and found to be accurate. Money is held securely with only limited access by senior staff. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 25, 26 The home is well managed and safe and the quality of furnishings and fittings in the home is good, providing a warm comfortable and homely environment ensuring individuals needs are met. EVIDENCE: There is a high standard of décor and furnishings in the lounge and dining areas, which were also spacious. Residents were observed sitting in the communal areas of the home and looked very relaxed and settled in their environment. No areas of health or safety concern for those living at the home were seen at this inspection. The home was clean, tidy and odour free throughout. Domestic staff are employed at the home and were carrying out their duties during the inspection. Infection control at the home is well managed with staff being provided with protective clothing and alcohol gel. A staff member told the inspector that a number of the team were currently undertaking infection control competency Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 17 in the form of a distance learning booklet and questioning, which they have found to be useful and said that areas had been covered in depth. Continence is also well managed at the home with contractual arrangements in place for the appropriate disposal of clinical waste. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 Resident’s needs are met by the appropriate numbers of staff who have been appointed within robust and effective recruitment and selection procedures. EVIDENCE: There is a core of well-established staff with varying abilities most of who are skilled and experienced to meet the needs of the residents in the home. Observation of staff practice demonstrated that they were approachable, good listeners and communicators and were comfortable with residents who were at ease with them. There were sufficient numbers of staff on duty at the time of the inspection. The deputy manager was asked to explain the recruitment process for the home, the information given, in conjunction with documents seen in staff files confirmed that staff are employed following robust recruitment and selection. In place were references from the most recent employer, criminal records and protection of vulnerable adults check. Job descriptions record the duties and responsibilities of staff and that they are to enable, encourage and support residents to make choices. Staff members spoken with were able to demonstrate a clear understanding of their role and responsibilities within the team. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 19 A recommendation was made at the last inspection that 50 of staff are to achieve National Vocational Qualification at level 2 in care. Staff spoken with spoke of the benefits this training has been to them in their role and that they feel they have been well supported by their assessors and that it is anticipated that for a number of staff the full achievement of this award will be completed within the next few months. This recommendation will be reviewed at the next inspection. Copies of the General Social Care Council code of conduct are available to staff. A review of training records showed that 17 staff attended abuse training in October, a further 16 staff attended manual handling training in July with first aid and fire instruction also being undertaken within recent months. New staff undertake a fully comprehensive induction programme. Evidence was seen that the most recently appointed staff member had covered topics such as emergency procedures, fire safety, training needs and C.O.S.H.H (Control of Substances Hazardous to Health) within their induction programme. The inspector saw that night staff are offered a free annual health needs assessment by the home. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 38 There is a sound management team at the home with the registered manager being able to discharge her responsibilities fully. The health, safety and welfare of resident’s at the home are promoted and protected, however further risk assessments are needed to encompass the full needs of residents. EVIDENCE: A certificate of registration was on display at the home, the information it contained was accurate and reflective of the service provided at the home. Evidence was in place to demonstrate that the home has ensured as far as is reasonably practicable the health and safety of those who live, work and visit the home. The fire fighting equipment had been checked regularly over the previous twelve months, weekly and monthly checks of the fire safety within the home have been consistently completed. During the inspection a Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 21 representative from Avon Fire Brigade rang and arranged to undertake an inspection of fire safety in the home later that week. At the time of the inspection a requirement was made in respect of the home’s obligation to review control of substances hazardous to health assessment sheets on a minimum of an annual basis. Records at the home demonstrated that these had last been reviewed in 2002, with others dating back to 2000. The registered manager Susan Evans contacted the inspector after the inspection and forwarded evidence that these had been reviewed within the last twelve months and therefore the requirement has been removed. The home completed comprehensive risk assessments on other areas of potential danger within the home. The assessments seen cover the severity and the likelihood of an incident occurring and categorises it accordingly. Those seen included window safety, boiler maintenance, first aid and training needs assessments, all of the assessments are reviewed on a regular ongoing basis. Assessments of risk were seen for residents with records of individual’s falls. It was found that there was a resident who was lacking a risk assessment in order to support them in a specific area of their life. It is required that specific risk assessments in respect of individual support needs are evaluated and recorded. Staff are encouraged to air their views and discuss care practices with the management at the home, there are regular staff meetings with a variety of subject matters covered. It was noted that the next meeting is booked to take place in January 2006. During a meeting held at the home on Monday 23rd between the inspector and Mrs Evans some discussion took place about the scoring of the National Minimum Standards which are assessed during an inspection. A score of 4 is given when the standard is exceeded, a score of 3 is when the standard has been met and there are no shortfalls. The home has maintained consistent scoring of 3 of those standards assessed. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 x X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X x 2 Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? NA 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 OP38 Regulation 13(4)b Requirement Specific risk assessments for residents must be completed. Timescale for action 07/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5 Refer to Standard OP9 OP15 OP18 OP30 OP9 Good Practice Recommendations Stock medication to be recorded and audited. Dry food stores to have a use by date written on them. Resident’s to sign to record that they have their travel tokens. 50 of staff to achieve National Vocational Qualification at level 2 in care. Two staff members to sign the medication returns book. Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Harefield Hall DS0000003326.V265844.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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