Inspection on 01/02/06 for Hunters Care Centre

This inspection was carried out on 1st February 2006.

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

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

Other inspections for this house

Hunters Care Centre 18/01/08

Hunters Care Centre 28/07/06

Hunters Care Centre 28/09/05

Hunters Care Centre 21/03/05

Hunters Care Centre 10/11/04

Hunters Care Centre 17/03/04

Hunters Care Centre 03/09/03

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Manor Lodge

The Garden House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hunters Care Centre Cherry Tree Lane Cirencester Glos GL7 1AF Lead Inspector Mrs Kate Silvey Unannounced Inspection 1st February 2006 09:30 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 Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 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. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hunters Care Centre Address Cherry Tree Lane Cirencester Glos GL7 1AF 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) 01285 653707 01285 655529 hunters@barchester.com www.barchester.com/oulton Barchester Healthcare Homes Limited Mrs Anne Millan Care Home 89 Category(ies) of Dementia - over 65 years of age (52), Old age, registration, with number not falling within any other category (37) of places Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named service user under 60 years of age in the older persons nursing unit. 28th September 2005 Date of last inspection Brief Description of the Service: Hunters Care is a purpose built care home with nursing for older people, which accommodate older people with both general nursing and dementia care needs. The general nursing accommodation is situated on two floors and comprises of both single and double accommodation with en-suite facilities. There is a large lounge area and dining room on the ground floor with several small lounges on both the ground and first floor. The small lounges offer views across the surrounding landscape and provide privacy to service users and their relatives if they wish to use them. The Dementia Care units offers both nursing and residential care and are situated on two floors. It is divided into four separate units with the more able service users at present accommodated on the first floor. The ground floor units have access to a large ‘wandering corridor’ with seats and a lounge area for service users to sit in. An enclosed garden area can be accessed from this corridor, which service users can freely access. The accommodation on the first floor is divided into two units with an open lounge area and separate dining room offered in one of the units. The other unit provides two lounge areas and one dining area for service users to access. A new enclosed garden area has been developed at the side of the unit for service users to use with staff support. There are assisted bathrooms and toilets situated in all of the areas used by service users. The kitchen and laundry area is situated on the ground floor. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was completed in one day by two inspectors. The registered manager was not on duty. The head of dementia care was spoken to, four nurses, ten care staff, the activities organiser and the head chef. Many service users were spoken to although some were very limited in their ability to communicate others were very able. Relatives visiting were asked about the home and care provided. Care and medication records were seen. The service users financial records were checked. The inspectors observed the service users lunchtime in different units. What the service does well: The service users are not admitted to the home without a comprehensive assessment by competent nursing staff to ensure their needs can be met. Care plans are well recorded and include any support the service users may require from other healthcare professional. Medication is well managed and reviews are achieved as required by the doctor that regularly visits the home. The home has three activities organisers and provides excellent activities for all the service users, including trips out. Massage therapy is available for less able service users to enjoy. The service users spoken to were able to communicate their contentment about living in the home. Several visitors were spoken to and all felt they were made welcome and that the service users benefited from responsive and competent staff. The food provided is of a very high standard and service users nutritionally at risk are assessed and a care plan indicates their needs. The home is well maintained and areas of interest have been developed with memorabilia for service users to enjoy. The service users are protected from financial abuse as the records seen confirm that all was correct. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 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. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 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 Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 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): 3 Pre-admission assessments are completed satisfactorily by competent nursing staff. EVIDENCE: An example of a pre-admission assessment was seen in the dementia nursing unit and was discussed with the head of the unit. Generally the head of the units both dementia and general nursing complete the pre-admission assessments before a service uses is admitted to ensure all their needs can be met. Where appropriate other healthcare professionals are involved in the process. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 The care plans seen were generally well recorded in the dementia nursing unit, some minor improvements could be made to record progress. The records indicated that healthcare needs were well met Medication is managed well and a regular visit by the doctor ensures medication reviews are addressed when required. EVIDENCE: Several care plans were looked at on the nursing dementia unit, in particular the service users who have predominantly physical nursing care needs and will be transferred to the general nursing unit soon. The service users were also seen and spoken to on this unit. Sensitive interaction by the care staff was observed during the lunch period. The care plans seen were well recorded and had clear individual actions for all problems identified. The daily records addressed each problem in the care plan with meaningful comments. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 10 The monthly review of the care plans could be more detailed to summarise what has been effective over the period. A wound care record of a sacral sore was recorded daily and the Continuing Care Nurse had given support to the care staff. The head of the general nursing unit also specialises in wound care and advises the dementia unit on tissue viability when required. The wound record would benefit from clear photographic evidence to record the progress. A nutritional assessment had been completed for a service user who may be nutritionally at risk, and a care plan covering all aspects of eating was well recorded. The daily records indicated whether a sufficient diet had been eaten. The head of the unit intends that every service user has a recorded nutritional assessment. Initially those service users most at risk have been targeted first for an more in depth assessment. A service user who sometimes experiences difficulty eating had clear care records, and it was discussed whether a referral to the Speech And Language Team may be beneficial to support care staff to reduce the risk of choking. The friends of a service user were spoken to on the dementia unit and had very positive comments about the environment and the level of care provided in the unit. Many of the service users were very limited in their ability to communicate with the care staff. It was evident that the staff knew each service user well and responded to their needs while communicating in a dignified and quiet manner. A calm and pleasant atmosphere pervaded the nursing dementia unit and the service users more able to respond were obviously content and did not display any undue anxiety. The mealtime observed looked to be an enjoyable experience for the service users where most of them ate well. Medication was looked at on the first floor of the dementia nursing unit. There is a nurse in charge upstairs who completes the medication administration. A monitored dosage system is used and a random check was completed. The medication was securely stored and the stock levels seen were appropriate. There was no medication administration procedure or a Royal Pharmaceutical Society Guidance on the unit for reference. The British National Formulary was due to be replaced with a more recent version. The medication records were generally well recorded and had a clear picture of each service user. Some transcribed medication records were not signed correctly. The nurse in charge stated that doctor visits the unit every week and completes at least an annual review of the service users medication. The new arrangements for disposal of medication was discussed. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15 There are some restrictions in the lifestyle experienced in the dementia unit due to limited resources. There is a considerable range of activities provided and trips out, which enables most service users to lead the life they chose with opportunities to have contact with the local community, friends and family. There is a high standard of food provided, the environment and careful assessment and support by the staff ensures that mealtimes are a pleasure for the service users. EVIDENCE: Residential dementia unit. Service users who are able can exercise choice over when they get up and go to bed and how they spend their time during the day. However, the routine restricts any choice for those who are more dependent due to the limited staff resources. The inspector was informed that the morning routines often ends late morning, resulting in breakfast and lunch being taken without an appropriate break between the meals. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 12 There is a daily programme of events and activities and the range offered is diverse enough to meet the needs of the majority. At the time of the inspection one group went out after lunch in the people carrier. The programme for January demonstrated the variety of activities and it included music, massage, brass rubbing, cooking and touch and taste sessions and the visiting pat a dog scheme. There are three activities organisers and they continue to make great efforts to provide variety and stimulation that was seen by service users as stimulating. The activity organisers had taken some of the more active service users on the residential unit down to the nursing dementia unit, which has a very pleasant walkway, and safe garden area. It is planned that the more able service users will be transferring to this unit to have the benefit of the facilities. The very dependent service users were able to enjoy massage therapy. A number of visitors were seen and spoken to. They informed the inspector that they were made to feel welcome in the home, starting at reception, and continuing with the staff on duty. They saw the staff as competent and responsive to any requests they made. The provision of meals was discussed with the head Chef, a number of staff and service users. One inspector also sat in with service users in the Unit for residential “dementia” whilst they were having lunch. The home provides three cooked meals each day and each meal consists of three courses and at least two options for each course. There is also coffee/tea and snacks at other times and additional sandwiches in the evenings. The inspector felt that the food was presented in a professional manner and in sufficient quantities to enable extra portions if required. The service users who are able, can make a choice about what they want the day before and they are given a list of choices, which are collected by staff. A number require soft diets and the meals were pureed with the individual ingredients served separately. If requested meals can be taken in the privacy of bedrooms. Service users said that they enjoyed the meals and felt able to comment on any aspect relating to food. The dining rooms were clean and neatly presented, and it was clear that staff made great efforts to provide a pleasant environment for meal times. The requirements made by Environmental Heath Officer (last visit 2004) in respect of the kitchen have been completed. The head chef was spoken to and it was evident that his experience ensured that all the catering staff were well trained to provide varied and nutritious meals. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 13 In the nursing dementia unit kitchen there was a notice board giving care staff clear instruction on what individual service users like and can manage which the care staff said was a great help and was updated regularly to ensure all needs were met. Supplementary food drinks were available on the units, and finger food was provided at each meal. A five week menus was seen. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 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): EVIDENCE: None inspected. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 15 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 The environment was well maintained, however, there was a need to improve some aspects of the dementia care units to aid best practice in this area. EVIDENCE: One inspector looked at the accommodation and this included the communal areas, a number of bathrooms and toilets and 12 bedrooms. The bedrooms were seen at the same time when service users were spoken to, and they had been personalised and providing a pleasant and individual environment. All areas seen were found to be clean in good decorative order and appropriately furnished. The main dining room had been decorated to commemorate the Chinese New Year, and this was seen as very colourful and stimulating by some of the service users. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 16 There was very little contrast of colour schemes in the “dementia” Units. This referred to a number of bedrooms/ensuites where some contrast would assist in service users recognition of different rooms and purposes. One communal toilet did not have any signage to assist identification. There were no malodours. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 17 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, 30 There are times when the staffing resources and skill mix are inadequate to meet the needs of the service users on the dementia care units. The home has a comprehensive training programme for 2006, which addresses most aspects of staff training and will enhance the dementia care knowledge of the care staff. EVIDENCE: The inspector spoke individually to staff in each unit. (10 care staff and 2 nurses) It was evident that staff were making great efforts to provide a caring and sensitive service but it was clear that meeting the complex needs of some service users in the dementia Units presented difficulties with current resources e.g. the inspector observed a number of service users exhibiting difficult behaviour, which required staff intervention. The question of adequate staffing was raised and this was discussed with senior nursing staff but it was felt that until an objective formal assessment of need was undertaken it would be inappropriate to discuss the matter in greater detail until the review has been completed. The home is now being required to undertake a formal assessment of need to determine minimum levels. When the review is completed the Commission can then determine if they feel that standards meet the current regulations. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 18 The inspector was informed by care staff (residential dementia Unit) that staffing levels during the day vary and there are times when there are only two staff on duty, and that this would mean the Unit having only one member of staff physically in the Unit when some meals were collected, or breaks taken. On the day of the inspection there were three members of care staff and eleven service users were being accommodated in the residential dementia Unit. However at one point in the afternoon this reduced to two due to a staff rest break and the inspector saw a number of incidents, which took up the time of both carers leaving some service users unsupervised for a short time. The inspector was advised by a number of staff that the staffing ratios had remained the same for many years but the level of dependencies had significantly increased. The dementia Units accommodate vulnerable service users. All are seen as clinically demented and may also have physical depencies. Their needs are often multiple and complex and some present challenging behaviours. In determining appropriate staffing levels the regulatory requirement, that staffing levels and skills mix are adequate to meet the assessed and recorded needs of the service users, must be met at all times. The review sent to the Commission by the registered manager was unclear. It must be based on individual daily needs to enable the home and CSCI to determine appropriate staffing levels. Staff reservations were expressed about the proposed changes regarding the dementia units and the planned deployment of the existing resources. It is therefore hoped that the proposed changes and review will result in enough staff to meet individual needs. The homes recruitment policy and evidence of the practices were not inspected. The inspector was advised that the records were not in the possession of the administrator who was on duty. In the circumstances the records to include any new appointments will be inspected on the next visit. The home has a committed and experienced nurse who manages the training requirements of the home. The inspector spoke to the trainer who was able to demonstrate her plans for the home and provide a comprehensive objectives and training plan for 2006. Barchester Academy supports the trainer who attends regular monthly meetings with other trainers in the organisation. There is a rolling programme to ensure all staff complete mandatory training and excellent induction training, which is ongoing as new staff commence employment. Fourteen care staff had completed NVQ level 2 three more were working towards it, two had completed NVQ level 3 with four more working towards the same level. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 19 The objective for dementia training is for all staff who work on the dementia care units to complete the accredited course produced by the Alzheimer’s Society called Yesterday, Today and Tomorrow. Professional development forums are also to commence for all qualified staff. Staff are currently completing an ’End of Life’ course with an outside agency. There are many valid and interesting training topics arranged for the year. The staff spoken to felt the trainer supported them well and was available for any queries they had. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 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, 35, 38 The registered manager may not have sufficient resources to meet the needs of all service users. A review of individual needs and staff skills will identify any shortfalls. Service users are protected from financial abuse. Staff training addresses all health and safety issues including fire training. EVIDENCE: The registered manager was not in the home at the time of the inspection. However, the lead nurses in the general and specialist dementia Units were seen as competent to manage the home in her absence. The home manages personal allowances for one service user and there was a detailed record of the income and expenditure. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 21 Two expenditures were checked against the respective invoices and found to be correct. No health and safety issues were identified during the inspection. Staff training regarding health and safety issues are well managed. The maintenance records and any improvement plans will be looked at during the next inspection. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 X X X X X X X STAFFING Standard No Score 27 2 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP27 Regulation 18.1 Requirement The registered manager must plan for and provide suitably qualified care staff/managers in the dementia unit at all times. (This was a requirement from 31 July 2005 and 31 January 2006). The registered manager must ensure that the service users welfare is considered with regard to the call bell system.( This was a requirement from 31/12/05) The registered manager must review the staffing levels to include the needs of the individual service users to ensure their needs are adequately met. The registered manager must improve the identification of ensuite and toilet facilities in the dementia units. The registered manager must ensure staff do not leave the dementia units to collect meals. Timescale for action 31/01/06 2 OP33 12.4 31/12/05 3 OP27 18.1 31/03/06 4 OP19 23.2(a) 30/04/06 5 OP27 18.1 31/03/06 Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 24 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 Refer to Standard OP7 OP7 OP9 Good Practice Recommendations The registered manager should ensure care plan reviews are more detailed. The registered manager should ensure that wounds have clear photographic evidence. The registered manager should ensure that there is a medication administration procedure on each floor/unit and the latest Royal Pharmaceutical Society Guidance for staff reference. Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Hunters Care Centre DS0000016479.V281080.R01.S.doc Version 5.1 Page 26 - 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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