Inspection on 10/08/05 for Knowles House

This inspection was carried out on 10th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Knowles House 13/03/07

Knowles House 27/01/06

Knowles House 07/03/05

Knowles House 20/07/04

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

CARE HOMES FOR OLDER PEOPLE Knowles House ` Harlesden London NW10 3UN Lead Inspector Bernard Burrell Unannounced 10 August 2005, 10:00am 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. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Knowles House Address 51 Longstone Avenue Harlesden London NW10 3UN 020 8961 9563 020 8963 1946 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) London Borough of Brent Mrs Petrina I connell CRH PC Care Home only 39 Category(ies) of DE Dementia 65 Years and over registration, with number of places Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No Date of last inspection 07 March 2005 Brief Description of the Service: Knowles House is owned by Brent local authority and is registered to provide accommodation and personal care support for up to 39 older people most of whom are experiencing dementia. The home also offers respite accommodation and two emergency care beds. The home is divided into three floors, but only two floors are currently occupied. All bedrooms are single occupancy, equipped with furnishing, washbasin sinks and adequate shower and bath facilities. The home is located in a residential area of Northwest London close to local shopping, transportation, health, social care and leisure services and facilties in Harlesden and Willesden. The residents have access to services provided by visiting health care professionals. The home has a large car park at the front entrance, a paved garden and seating area and also a garden area to the rare. There is a balcony on the first floor, plus several communal lounges, library and relaxation room where private meetings can be held. There is also a day centre attached to the home that is used by non-residents. The home is satffed by a registered manager, deputy manager and a number of care support staff. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over one day with assistance from a CSCI regulatory inspector and pharmacy inspector. The inspection process involved tour of the building, examination of records and cases files, discussions with the manager, staff and residents, plus sampling of meals provided during the lunch period. The findings indicated that a number of requirements from the last inspection were still outstanding at the time of this inspection. Many have been repeated in this report and now require full compliance by or before the new timescales. The findings also indicated the home is managed well in most areas and in line with regulatory requirements and guidelines plus current best practice. Residents who spoke with the inspectors reported their satisfaction with life at the home and the caring attitude of staff. The inspectors were of the view that good effort is being made to help ensure the life experiences of each resident is fulfilling, safe and secure. What the service does well: What has improved since the last inspection? The home has made good effort to improve the administration of medication and also training to staff in this area of work. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 6 The staff are offered opportunities to access a range of professional and development training to help enhance their skills and knowledge. All staff have undertaken the local authority training in prevention of adult abuse. The complaints procedure has been reviewed and summarised in a user friendly format with pictorial references for easier understanding by residents. The home is now providing relevant notification to the CSCI in line with Regulation 37 of the Care Standards Act 2000. Electrical and other appliance testing, including the lift, portable appliances, water testing, fire safety have been carried out with certification records available at the home for 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. Knowles House G62-G11 S33481 Knowles House V242410 100805 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 Knowles House G62-G11 S33481 Knowles House V242410 100805 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) 1,3,5,6. The admission process involves input from the relatives’ of residents, but the manager currently has no input in the long term and intermediate care needs assessment process. Improvement is needed in this area to help ensure the care plans accurately reflect the individually assessed needs of residents and the nature of care support offered. EVIDENCE: The service users’ guide was under review at the time of this inspection and the inspectors were therefore not able to make a judgement about its format and content. There were several areas of requirements relating to the standards in this section in the last inspection report. The manager informed the inspector that she still do not have any significant input in the assessment process when potential residents are planning to move to the home. This was also a recommendation from the last inspection report. It was the view of the inspectors the manager should attempt to carry out joint assessments with the social workers/care managers before decisions is made to offer residency to prospective residents. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 9 Each resident who applies to live permanently at the home is offered a six weeks trial stay and the manager then create a basic care plan. When the six weeks stay ends, the Older People’s Services Panel of the local authority then makes a decision whether to offer a permanent place. The manager reported she carries out individual risk assessments for each resident when they move to the home. The inspectors felt more work is needed to help ensure the care needs assessment of residents applying to occupy the respite care beds, should have appropriate and relevant care plans in place to help maximise and promote their independence and living skills. Improvement is also needed in the planning of care services for each resident. The current care plans are predominantly generic and do not capture the individually assessed care needs of residents. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 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 standard(s) 7,8, 9,10. Recorded documentations on care plans were inadequate and in many cases not linked to assessments, clinical guidance or wishes of residents. Risk assessments also needed to be completed and recommendations recorded on care plans. EVIDENCE: Five case files were examined by the inspectors but only three contained care plans. These care plans were well presented but generic and did not focus on the individuality of each resident’s identified care needs or how they would be met. There was also a recommendation by a social service reviewer on 12 December 2004 for a care plan to be individualised. This action was still outstanding at the time of this inspection. The care plans did not meet clinical guidelines or reflected the assessment and recommendations from clinical professionals such as GPs, occupational, physio therapists and opticians. These services were made accessible to residents and contacts were recorded but care plans did not reflect any interventions. The home has worked hard to meet the recommendations of the last inspection report relating to administration of medication. A generic medicine policy has been purchased and was been adapted for use in the home. Storage Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 11 of medication has improved and the trolley is now securely padlocked. All staff are trained to administer medicines but signatures were missing from some administered medication, plus more evidence is needed to demonstrate their full understanding and for audit purposes. In addition, medicines are still not recorded when received into the home and several omissions in recording were noted by the CSCI pharmacy inspector. The pharmacy inspector has submitted 5 requirements and 3 recommendations to the home that must be met by 1st September 2005. Risks assessments were present in the files but in three of the files that contained care plans, one did not have the completed falls risk assessment. One also had information about three or more previous falls but had no evidence of recommended measures to be taken to prevent further falls. In addition, none for the other care plans contained evidence of interventions to prevent falls. The care plans were not signed by the residents are their next of kin and it was not possible to know if the residents had agreed to the information recorded or their wishes were taken into consideration. There was also no evidence to verify if the residents had been involved in the review process. In addition, there was no record of the psychological health of each resident, despite the fact a majority experience dementia related problems. The inspectors had discussions with the management about daily care for residents and were assured that the level of care met requirements. No documented evidence was available to verify this. The management also reported that at the time of this inspection, no resident had pressure areas. There was however, lack of recorded evidence about current tissue viability for each resident. The manager informed the inspector of action taken to manage incontinence problems experienced by some residents, including dealing with unpleasant odours. The district nurses are asked to make continence assessments and recommendations. Their records are kept separately. Nutritional screening was also outstanding and must be addressed as a matter of urgency. The inspectors talked with several residents and the findings indicated they were happy with life at the home, they received their mails, had access to telephone service and encouraged to dress in their own clothing and socialise with other each other in the communal areas. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 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 standard(s) 12,13,14,15 Social and recreational activities needed to be more creative, individualised and provide greater social stimulation for residents. More work is needed to help ensure appropriate assessment and care planning is carried out to help identify individual residents’ expectations and preferences. Meals are nutritious, balanced and residents are offered varied choices. EVIDENCE: The manager informed the inspectors of activities inside and out of the home that a number of residents participate in. These included exercise movement to music, sing-along, dominoes, bowling and reflexology. However, some of these activities appeared to be generic with lack of individual preferences. There were insufficient evidence of assessment and care planning of individual resident’s expectations and preferences. Some recordings in care plans noted that residents are aware of social activities, able to participate and does so on certain days. The information received by the inspectors indicated the relatives of some residents are very involved in their lives at the home. During this inspection, some relatives were visiting residents at the home and joined them for lunch. The relatives who spoke to the inspectors commented favourable about the quality of life experienced by their relations who live at the home. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 13 The manager reported that the relatives are encouraged and do play pro-active roles in the lives of residents, particularly in view of the dementia problems being experienced by most residents. The inspectors were satisfied the kitchen area is managed efficiently and in line with regulatory food and hygiene practices. Meals are planned on a weekly basis and reflective of resident’s dietary, cultural and ethnic care needs; for example: Kosher, Asian and Caribbean meals. The dining room was spacious and well maintained. Some of the residents and their relatives commented favourable about the range and quality of food and drink provided. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 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 standard(s) 17,18 The home’s complaint leaflet has been reviewed and updated in appropriate format and communication style to meet the needs of residents. Work was till in progress to review and updated the policy and procedure guidelines relating to complaints and protection. EVIDENCE: Each resident and their relatives are given a copy of the home’s complaints leaflet. This was reviewed and updated in 2005. It has been written in large print with pictorial references to meet the communication abilities and needs of residents. The manager informed the inspectors that the complaints policy and procedure guidelines used at the home are the same as the corporate ones used by the local borough council. These were being reviewed and updated at the time of this inspection. The inspectors advised that these documents must be produced in format and styles that meet the communication needs and abilities of residents at the home, most of whom suffer from dementia problems. The information provided by the manager indicated the local social services department manage the financial accounts of some residents. Others have their financial accounts managed by relatives and next of kin and the home maintain a limited financial transaction system called the ‘Residents Fund Account’ for individual residents. This is used for small purchases and personal spending on things like hairdressing and manicure treatments. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 15 The protection of resident’s wellbeing is promoted through adult protection training offered to staff by the local borough council. This is in addition to on going monitoring by the manager plus staff supervision and appraisals. In addition, the home operates individual care group system where individual staff is put in charge on a daily rotation to monitor, record and report each resident’s daily care and activities. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,26 Decoration and repainting work has been carried out throughout the home and is well maintained. Externally the uneven pavements at the front and back of the home continue to present serious potential risks to residents, staff and visitors. EVIDENCE: Since the last inspection, the home has had internal renovation and decoration that has helped to improve the overall physical appearance of individual and communal rooms. The inspectors were satisfied that the home has a good cleaning system in place that is helping to ensure the home is well maintained internally. The main administrative office has also been extended and now offers more working and storage space. There were small flowerbeds and hanging baskets located at the entrance of the home, balconies and other communal areas. These have helped to enhance the physical appearance of the home. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 17 There is also a range of communal facilities in and outdoors, including chairs, benches, grab rails, carpeting wheelchairs, a room set aside for relaxation and private meetings plus specialist bath equipment in most bathrooms. One bathroom needs grab rails and other relevant safety measures and equipment to help enhance the safety of residents when they use the facility. There were adequate numbers of communal bathrooms and toilets on each floor. The bedrooms of service users were appropriately furnished and each had a washbasin sink and adequate heating, windows and natural light. Work is needed to enhance the safety of the steps leading from the kitchen to the balcony in one of the respite flats. The provider will also need to make serious effort to repair the uneven and broken pavements at the front and external areas of the home. This is an outstanding requirement from the last inspection. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The home has adequate staffing cover with the appropriate level of skills, experience to meet the needs of residents. Good supportive services are also available to residents and staff. EVIDENCE: The inspection findings indicated that all staff are encouraged to achieve level 2 NVQ qualification. One staff has achieved level 3 and the manager has the Registered General Nurse (RGN) and other relevant professional qualifications and training. Records were also available of staff qualifications. The inspections findings also indicated that staff numbers and skill mix were appropriate to the assessed needs of the residents and the size of the home. The duty rota showed that 3 night staff are employed and one staff in charge. The agency staff working at the home were all from the same employment agency and have been working at the home on a regular basis and are know to many of the residents. The home employs and activity coordinator in addition to receiving assistance from external activity sources. The local borough social services department who owns the home is also responsible for staff employment and follows equal opportunity regulations for employment. The staffing records held at the home showed that each staff has the required two employment references and the relevant and satisfactory CRB and POVA checks. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 19 Records also showed that all staff received statements of terms and conditions for their employment. A training development officer is employed to plan and supervise the training programme for staff. The inspectors viewed copies of certificates awarded to staff on completion of set training programmes. Induction training is currently been revised. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,38 The home is managed well with good systems in place to help safeguard the interest and welfare of residents and promote their wellbeing and quality of life. EVIDENCE: The home is managed by a manager and deputy manager with additional senior monitoring and managerial input from officers at the local borough council and social services. There are good systems in place to help protect residents, including appropriate employment practices and accountability by staff about their roles and responsibilities. Documentation were organised, easy to cross reference and some were up to date but others were either under review or needed more work to complete required information. For example, risk assessments and care plans linked to individual assessed care needs. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 21 There was evidence to verify that staff receive appropriate training in core health and social care subjects relevant to the performance of their roles and responsibilities. The inspectors were shown evidence of electrical, gas and other appliance testing, including fire drills every 3 months, weekly fire alarm test, water testing and servicing of the passenger lift. The London Emergency Planning and Fire Authority (LEPFA) test was due at the time of this inspection. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x 2 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 2 2 3 3 3 4 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x 3 3 2 Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation Requirement Timescale for action 30 October 2005 2. 5 5,16,sch 4 The provider must ensure the (2) service users guide statement of purpose is made available to all exisiting and new residents. Copies of the revised documents must be sent to the CSCI. This is an outstanding requirment from the last inspection. 14,sch The provider and manager must 3.1(a), 12 ensure that no resident move to (2) 12 (3) the home unless they have an apportunity to visit and assess the quality, facilities and suitability of the home. The provider must ensure that emergency admissions are avoided where possible and do not continue to be standard practice for some admissions. The provider and manager must ensure that residents moving to the home for respite care are supported to develop and enhance their living skills and abilities for when they return to their own homes. The manager must ensure that a care plan is developed for each resident that is reflective of their 30 September 2005 and ongoing. 3. 6 14, 12 30 September and ongoing. 4. 7 15 sch 3.1(b) 30 September 2005 Page 24 Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 individual assessed care needs. 5. 9 13, sch 3.3 (i) (k) The manager must ensure that the requirements outlined in the CSCI pharmacy inspection report are complied with by the timescale of 30 September 2005. 10, 13, 16 The provider and manager must 23. ensure that immediate action is taken to ensure the uneven pavements at the front and back garden areas of the home are made safe. This is an outstanding requirement from the last inspection. The provider and manager must ensure that grab rails and other safety equipment are installed in the bathrooms where they are needed to enhance safety of residents. Action should also be taken to fix the steps leading from the kitchen to the balcony in the upstairs respite flat. 30 September 2005 30 September 2005 6. 19 & 25 7. 20 10, 12,13,16, 23 30 September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 12 Good Practice Recommendations The manager should ensure that more work is done to capture the individual lifestyles, preferences and leisure needs of each resident. These should be recorded in individual care plans and fully supported. Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex HA1 1BH 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 Knowles House G62-G11 S33481 Knowles House V242410 100805 Stage 4.doc Version 1.40 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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