Inspection on 12/07/05 for Laurels Nursing Care Centre

This inspection was carried out on 12th July 2005.

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

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

Other inspections for this house

Laurels Nursing Care Centre 01/06/09

Laurels Nursing Care Centre 11/08/08

Laurels Nursing Care Centre 13/06/07

Laurels Nursing Care Centre 11/07/06

Laurels Nursing Care Centre 11/01/06

Laurels Nursing Care Centre 11/05/04

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

CARE HOMES FOR OLDER PEOPLE The Laurels Nursing Care Centre The Laurels 70 Union Street Clapham London SW4 6JT Lead Inspector Sonia McKay, Vashti Maharaj & Paul Ballatt Announced 12 & 13 July 2005 th th 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. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Laurels Nursing Care Centre Address The Laurels, 70 Union Street, Clapham, London SW4 6JT 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) 020 7498 7500 020 7498 9833 The Laurels Care Centre Limited Mr Teeluckdharry Ramparsad CRH Care Home 68 Category(ies) of Care home with nursing registration, with number of places The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 up to 21 frail, elderly patients aged 55 years and above. 2 up to 47 patients aged 55 years and above with dementia. Date of last inspection 8th November 2004 Brief Description of the Service: The Laurels is a purpose built nursing home for older people, some of whom may have a physical disability or mental health need. The home has three floors with the categories of need being grouped separately on each floor. The ground floor supports elderly people who may have a physical disability. The first and second floors support people with dementia or mental health needs. The home is located in a residential street in Clapham with good links to bus and underground train services. There is a small parade of shops within short walking distance of the home, with larger shops and supermarkets available in Stockwell and Clapham. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out over two days. Three inspectors visited the home on the first day for nine hours. One inspector visited the home on the second day for seven hours. The inspection began at 9 a.m. on the first day and 8 a.m. on the second day. Comment cards were sent to the home before the inspection to be given out to service users, family representatives, staff and visiting professionals. There were fifty-five service users living at the Laurels at the time of this inspection. Sixteen service users, six relatives, two health and social care professionals in contact with the home and one general practitioner (G.P) replied. The home manager completed a pre-inspection questionnaire that supplied the CSCI with information about the service users living in the home and the staff employed there at the time of the inspection. The two day inspection consisted of tours of the premises, examining care records, staffing records and records of building maintenance. The home manager, deputy manager, staff on duty, fifteen service users and seven relatives/visitors were spoken with. One of the inspectors had lunch with service users on the ground floor on both days of the inspection. What the service does well: What has improved since the last inspection? The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 6 The communal bathrooms have been refurbished. The last bathroom was being completed at the time of the inspection. Ten bedrooms have been redecorated as part of the ongoing refurbishment programme. The recently appointed activities coordinator has developed a range of weekday group activities. The programme of these activities is available. Medication handling and administration records have improved and these improvements have been maintained. 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. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 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 The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 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, 2, 3, 4 & 5. The statement of purpose and service users guide are inadequate and do not provide sufficient information for prospective service users to be clear about the services the home provides. Service users had moved into the home without having their needs fully assessed or an opportunity to visit first. Relatives or friends have the opportunity to visit and assess the quality, facilities and suitability of the home before a prospective service user moves in. This opportunity has not been extended to the service user themselves. There is a need to increase the number of specialist mental health trained nurses. EVIDENCE: The statement of purpose and service users guide are given to service users and their family members. The home can admit service users aged 55 and over. The age range detailed in the statement of purpose says 60 years of age and over. There is also insufficient information about the size and number of communal areas available to service users. The service users guide indicates that the Laurels is aiming for a completely non-smoking environment. It says new admissions to the home from 1st of January 2003 will be on a strictly no-smoking basis. This is not the case. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 9 A smoking room is available and service users who smoke are still being admitted to the home. Service users seeking a non-smoking environment would be misled. Information in the statement of purpose and the service users guide must be reviewed and amended. (See requirement 1). The information about making a complaint available in the service users guide does not provide a contact telephone number for the local CSCI office. This must be included to ensure that service users (or representative) who wish to make a complaint can do so with ease. (See requirement 2). Each service user has a contract/statement of terms and conditions of occupancy on file. Contracts had been signed by the service user (or their representative) and the home manager. There is an admissions procedure that involves extensive pre admission assessment. This procedure had not been followed for one recently admitted service user. The service user said that he was very unhappy to find that his bedroom and ensuite washing facilities were not suitable to meet his physical needs. A professional assessment of the suitability of the bedroom/ensuite facilities had not been carried out. This has reduced his level of independence. (See requirement 3). Although prospective service users are not routinely offered the opportunity of visiting the home before moving in for a trial placement, relatives said that they had visited the home before making the decision for their relative to be placed there. In some cases this may be sufficient. However, if a person is able to communicate their views, they should be offered the opportunity to look around themselves before commencing the trial placement. (See recommendation 1). Long-term residential nursing care is provided. The home does not offer respite or intermediate care. Each of the three floors has a qualified nurse leading a team of care assistants at all times. Service users living on the first and second floors have dementia. The home manager said that recruiting specially trained nurses (R.M.Ns) was proving difficult and the home did not have enough RMNs to provide 24-hour cover. The home manager has provided the general nurses and care assistants with on-the-job training in the care and support of service users with dementia. This does not negate the need to have an RMN on duty at all times on the first and second floors. This is essential to ensure that service users receive the specialised services for people with dementia offered by the Laurels. (See requirement 4). The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 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. Service users health needs are being met. Specific risks relating to infectious diseases must be addressed to ensure that service users are protected. The systems for the administration of medication are good with clear and comprehensive arrangements in place to ensure service users medication needs are met. Plans to support personal and social care needs are inadequate. Care plans are not person-centered and do not cover the full range of each persons needs. The care and support provided to service users who are assessed as challenging should be reviewed. EVIDENCE: The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 11 Eleven care plans were examined. A sample from each floor of the home. They were examined against the nursing and social services assessments of need and care plans and the records of care provided also held on file for each service user. Each care plan is produced from a standardised template. Staff tick each element of the suggested plan if it is required. This is not person-centred and has reduced the opportunity for staff to devise individualised care plans with service users and their relatives. Staff may need specific training in how to devise person centred care plans . (See recommendation 2). The plans set out the health-care needs of each individual and are accompanied by logs of the health care provided by relevant outpatient or visiting specialists. The home has input from the Care Homes Nursing Support Team who provide continence, tissue viability and falls prevention support. Comments recieved from other health professionals were generally good, although they did note an apparent shortage of adequately trained nursing staff. One service user had MRSA at the time of the inspection. A member of staff was completing domestic duties in the service users bedroom along with other bedrooms in the vicinity. She was not observed to take any preventative actions. The home manager said that specific MRSA risk assessments are not in place although the home did have a general infection control policy and procedure. This must be addressed to ensure that infections such as MRSA are not transmitted to staff and other vulnerable service users in the home. Current advice on good practice for the control of MRSA must be sought. (See requirement 5). Nutritional screening is undertaken on admission and there are falls and tissue viability risk assessments in place. Care plans are reviewed each month. Where possible the initial written care plans are discussed with the service user and their relative/representative and their signature obtained as evidence of this. Service users with behaviours viewed to be challenging are accommodated away from the general population in secure annexes on the first and second floors. Access to these annexes is via keypad door entry only. Many of these individuals do not leave their bedrooms at all, taking their meals in situ. These annexes are staffed by the trained nurse and two carers available on each shift on each floor of the home. These service users have little or no opportunity for social interaction, or fresh air. The activities coordinator said that she tries to visit the annexes each weekday but generally only has minutes to spend with each individual. Carers were reported to find supporting service users with challenging needs difficult at times, and this, along with restricted staffing levels, may contribute to increased social isolation. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 12 As the home has an inadequate number of mental health specialist nurses there is a need for extra input in this area. (see recommendation 3). The care plans did not adequately document how specific personal care support needs would be met (for example, a plan identified that a service user required partial assistance with personal care/bathing but did not specify what assistance was/was not required). This may reduce the opportunity for service user to maintain their personal care skills. Social care needs had been identified by placing authorities and health professionals. These needs had not been transferred to the homes own care plans (for example, strategies to reduce confusion and encourage socialisation). The care plans must cover the full range of identified needs. (See requirement 6). Of the comment cards completed by service users, thirteen service users said they felt comfortable, safe and well cared for living in the home. Two felt they were not well cared for and one felt cared for only sometimes. A number of relatives said that personal items of clothing had often gone missing in the homes at laundry system. This must be addressed. (See requirement 7) The previous inspection report had required that resuscitation forms be removed from all care plans. Discussions were to take place with service users and their families about their decisions in these eventualities. The forms had been removed and discussions are now taking place. Progress with this difficult area will be examined during the next inspection visit. Medication Administration Record (MAR) charts on all three floors were inspected. The home previously had serious issues with recording. However all previous requirements have been met and improvements to medication handling and recording have been maintained which is a positive observation. One requirement has been made about the use of creams. Instructions are not always given by the GP, leaving it up to the staff to decide how and when to apply. The GP is required to add instructions for all prescribed medication, and prescriptions should be returned to the surgery if they do not contain instructions for use. Because of this, on some MAR charts external products have not been used consistently for example, last month applied three times a day, this month twice a day. The Medication policy has recently been reviewed. It contains good information on most aspects on medication handling. The following additions/changes are recommended at the next review: The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 13 • • • • • • Due to recent changes in environmental legislation, which now do not allow unused medication from nursing homes to be returned to retail pharmacies, the home will have to make arrangements with their clinical waste management contractor to remove unused medication. The drug recall section states that medication must be withdrawn by the home. Good practice would be to speak to the GP and arrange for a review as an alternative item may need to be prescribed before withdrawing treatment as this could be detrimental to the service users health. Verbal orders by a GP cannot be accepted to initiate treatment, only to make changes to an item already prescribed. Leave medication should be considered for all periods of absence from the home for example, attendance at day centres, leave with relatives as the home must ensure continuity of medication. For emergency admissions to hospital, consideration should be given to supplying the service users medication as out of normal working hours it may not be possible for the hospital to obtain certain medications. Guidance has been written by the PCT and a copy has been provided to the home. The when required (PRN) section should be made more detailed. There should be written protocols for PRN antipsychotic medication as staff need to have clear guidelines from the GP as to when this medication should be given, the frequency of administration and the maximum dose in 24 hours. This relates to medications that are presribed to be administered only on occasions when specific symptoms are noted. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 14 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. Some service users find the lifestyle experienced in the home matches their expectations and preferences. However, the social, cultural, religious and recreational interests and needs are not addressed for all service users. Service users are able to exercise choice and control over their lives for as long as possible. Although wholesome and appealing balanced meals were available during this announced inspection, records of meals served previously had not been kept. It is therefore not possible to judge the quality of meals provided to service users. EVIDENCE: A programme of activities is available to service users on weekdays. Group activities facilitated by the homes activities coordinator during the two days of the inspection included bingo and reminiscence. A written programme of activities is available and distributed to service users. However, the planned activities are suitable for some of the service users living in the home. There is a need to develop activities programmes for people with dementia and other cognitive impairments and for those with visual, hearing or dual sensory impairment. The activities coordinator is keen to develop the range of activities and would benefit from specific training in devising and facilitating activities for service users with specific needs and disabilities. (See recommendation 4). The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 15 The program of activities should also be extended to the weekend. (See recommendation 5). Service users are able to have visitors at any reasonable time and some have links with the local community. Five service users planned to go to the seaside with a local church group. Visitors and relatives seen on the day of the inspection were able to meet with their relative/friend in either the communal areas or their bedrooms as they wished. Visiting relatives said that on some occasions they were able to take their relative out shopping in the local area or to visit other members of family. For service users without visiting relatives or friends there is little opportunity to access the community. One service user was reported to miss regular attendance at his local church service. It is recommended that strategies to achieve community access for all who wish are developed. (See recommendation 6). Service users are entitled to bring personal possessions with them into the home providing they can be stored in their bedrooms. Service users can have access to their personal records in accordance with the Data Protection Act 1998, although most said that they chose not to. The home employs a chef and kitchen assistant. Menus are planned by the head office. A new menu was introduced in the week of the inspection as a result of surveys of the views of service users about the food served in the home (as required in the previous inspection report). Unfortunately records of the meals served prior to the inspection had been destroyed. These records must be kept for examination. (See requirement 8). Breakfast served on the second day of the inspection consisted of cereals, bread-and-butter, soft fruit or porridge. The meal was served at the dining tables in the communal lounge, on small tables in front of the lounge chairs or in the service users own bedroom. As the weather was good lunch was served for some service users on a table in the small courtyard garden. A new Caribbean menu is now available. Lunch on the first day consisted of a beef casserole with mashed potato, carrots and potatoes croquettes or steamed snapper fish. Dessert consisted of home-made ginger cake and custard. Lunch on the second day consisted of pork chops, mashed potato vegetables or jerk pork with white rice and sweet potatoes. Dessert was home-made rice pudding and slices of fresh watermelon. Service users said that the food was good. The meals had been well cooked, portion size was adequate and the meals were served hot. Service users needing assistance with eating a meal were helped by staff who were patient and respectful. Service users who needed a soft or puréed meal were served a puréed or mashed version of the menu available. The meal served differed slightly from the planned menu. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 16 The chef said that this was an issue of produce availability. Hot and cold drinks were available. Staff paid close attention to ensuring that cold drinks were available throughout the day as the weather was very warm. Care must be taken to ensure that service users who remain in their bedrooms are also provided with access to drinks on a regular basis. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 & 18. Service users and their relatives/friends are not all confident that their complaints will be listened to, taken seriously and acted upon. Service users would benefit from access to independent advocacy to ensure that their legal rights are fully protected. Systems are in place to protect service users from abuse. EVIDENCE: The home manager had responded appropriately to formal written complaints. One relative said that the home had responded swiftly to a verbal representation and taken appropriate action to resolve the issue. However, a number of relatives and service users said that they had often complained to members of staff without a successful outcome. There is a satisfactory complaints policy and procedure. This had not been followed on all occasions. It is essential that staff respond appropriately to verbal complaints made by service users and their relatives/representatives. There is a need for a system of recording the issues raised so that responsible staff have the opportunity to take any necessary action and respond to the complainant accordingly. This will ensure that service users and their relatives feel that their concerns are listened to and acted upon. (See recommendation 7). The CSCI has recently received an anonymous complaint. It related to staffing matters. The complaint was found to be unsubstantiated during this inspection. Service users do not have access to independent advocacy services. Where service users lack capacity, the registered persons should facilitate this access. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 18 (See recommendation 8). Robust procedures for responding to suspicion or evidence of abuse or neglect (including whistleblowing) are in place to ensure the safety and protection of service users, including passing on concerns to the CSCI in accordance with the Public Interest Disclosure Act 1998 and the Department of Health guidance No Secrets. The registered manager is aware of the process for referring staff for consideration for inclusion on the Protection of Vulnerable Adults register. The home has policies and procedures to ensure that physical and/or verbal aggression by service users is understood and dealt with appropriately and in addition, that physical intervention is used only as a last resort and in accordance with good practice guidance. Service users are able to handle their own financial affairs for as long as they wish to and as long as they are able to and have the capacity to do so. When they are unable to do this relatives or the company that runs the Laurels manage their financial affairs for them. A spot check of individual financial records and cash held in safekeeping by the homes administrator for service users indicated that these finances are being managed effectively and safely. Staff are trained in abuse awareness. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 19 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, 22, 23, 24 & 26. The home is reasonably well maintained and decorated. However, adequate checks are not in place to ensure environmental health and safety. Both communal and private areas of the home presented hazards to service users. Service users do not all have the specialist equipment that they require to maximise their independence. Service users bedrooms do not suit their individual needs in some cases, but are generally comfortable. EVIDENCE: There is an outstanding requirement from the previous two inspection reports for the home to obtain a full occupational therapy assessment of the premises. (See requirement 9). The home is purpose-built and provides service users with accommodation on three floors. The ground floor has a central courtyard garden accessible from the ground floor lounge and hallway. The first and second floors have their own separate communal areas. Each floor of the home is separated by a security keypad access. The second floor communal areas are small, and arrangements are in place for service users from the second floor to access the The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 20 communal area on the first floor on occasion. Service users said that they liked the home and that they were comfortable in their bedrooms. Relatives said that the home is generally clean and tidy. The home is large and moving around the building is confusing for service users and visitors. This is compounded by the fact that bedroom door numbering is complex. For example, bedroom door numbering is complex. Service users and relatives said that they often get lost in the building. This is not ideal for a home offering services for elderly people who may be confused or people with dementia. More could be done to plan decoration/colour schemes to assist service users to move around the building confidently. (See recommendation 9). Emergency lighting is available throughout the home. Lighting in the communal areas and bedrooms is inappropriate to meet the needs of the service user group in some areas (downlighting creating shadows on the floor in the second floor dining area and overhead bedside lights are not available). The required occupational therapy report will provide advice on these issues. (See requirements 9 & 10). The home is generally clean and tidy and well decorated. Bedrooms and bathrooms are fitted with fixed cord call alarm systems for use by service users who need assistance. A test call was placed from a service users bedroom and a member of staff responded by attending the room within two minutes. However, some service users could not easily use the call alarm system. A preferable system would have the option of a pendant alarm call as an alternative method for service users unable to access the wall mounted cords. (See recommendation 10). Service users bedrooms range from personalised and homely (relatives said they assisted by bringing things in) to bare. More must be done to ensure that each service user has a bedroom personalised to their own taste. Some of the bedrooms did not have overhead and bedside lighting or comfortable seating for two people. Minimum requirements for furniture and fittings in individual accommodation must be provided for each service user. (See requirement 10 and recommendation 11). Service users had profiling beds, pressure relieving mattresses and bed rails if they needed them. Pipework and radiators are fitted with guards to prevent contact burns. Each room is centrally heated with individually controlled thermostats. Bedroom doors have locks, but these locks are not of a type that would allow the service user to lock the door when they left their room. This type of lock should be available unless a risk assessment suggests otherwise. (See recommendation 12). The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 21 Each of the bedrooms has a small ensuite bathroom facility consisting of a W.C and a handbasin. Two bedrooms had an unpleasant odour. Floor coverings in these rooms may be unsuitable for service users with continence needs. (See requirement 23 and recommendation 15). Continence aids (packets of continence pads) are stored in bedrooms and in the other areas of the home. These aids are personal and should not be visible. To preserve the dignity of service users, suitable storage in both bedrooms and other areas of the home is recommended. (See recommendation 16). At the time of this inspection bathroom refurbishment was in the final stages of completion. Ensuite bathrooms are in need of redecoration, skirting boards are split and paint is peeling in some rooms. (See requirement 11). Aids, slings, hoists and assisted toilets are installed. However, a recently admitted service user is unable to use his toilet facilities as the aids in place are not appropriate. The maintenance log for the slings and hoists could not be examined at the time of the inspection but was supplied to the CSCI as a result of the draft inspection report. (See requirement 12). Hot water temperatures are thermostatically regulated at each hot water and outlet to prevent scalding. Records of hot water temperature testing indicate that hot water temperatures are too low. This must be addressed. (See requirement 13). The home manager said that he felt that the communal lounges could also be made to look more homely and inviting. The lounges each had armchairs and small tables, a television and radio. Air cooling fans are not available in all communal areas and some bedrooms. This is recommended to ensure that service users are protected in hot weather. (See recommendation 13). There is no ramped access to the courtyard garden from the communal ground floor lounge. The service users find the step difficult to manage. As the courtyard garden is the only outside facility, it is essential to make the best use of it. Creative planning to maximise use and comfort is recommended (in addition to occupational therapy advice as required). (See requirement 14 and recommendation 14). The home has a passenger lift between floors. Staff and service users said that the lift often broke down. The record of breakdowns and lift maintenance could not be examined during the inspection, but were supplied to the CSCI as a result of the draft inspection report. (See requirement 15). The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 22 During a tour of the premises a number of health and safety concerns were noted. Two immediate requirements were issued as a result. Three ensuite facilities have floor drain covers that do not fit. This presents a trip hazard and an uneven, dangerous surface that feet and walking frames may get caught in. (See immediate requirement 16). A number of fire doors were also wedged open throughout the building. (See immediate requirement 17). Other fire doors have self-closing devices that are not operating effectively. (See requirement 18). The first floor lounge has a cracked pane of glass in the window. (See requirement 19). There are no records of routine environmental health and safety checks conducted by an appropriately trained member of staff. Trip hazards caused by trailing wires and carpet ripples are evident in some areas (pointed out to staff during the inspection). This is not good practice. (See requirement 20). The London Fire and Emergency Planning Authority (L.F.E.P.A)) inspected the home in June 2004. Their report indicates failures to comply with workplace fire precautions legislation. Six requirements were made. Three requirements were unmet at the time of this inspection. Fire alarm procedures require a delay in contacting the fire brigade whilst a search is completed to determine the area of the fire. Fire resisting doors not closing effectively. A premises fire risk assessment and emergency plans in accordance with Fire Precautions (Workplace) Regulations 1997. (See requirement 21). The Health and Safety Executive (H.S.E.) inspected the home in February 2005. Their report indicated a number of areas requiring attention. The management of health and safety by appropriately trained staff. Lifting equipment and its maintenance and user identity marking. The management of contractors. Legionella control. Risk assessments in general and specifically plugs being left in baths when not in use (the H.S.E officer was concerned that a confused service user would set a bath without staff assistance and possibly injure themselves). (See requirement 22) Water utility authorities inspected the premises in October 2004 and confirmed that the home complies with the Water Supply (Water Fittings) Regulations 1999. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 23 A pest control contract is in place. Recent inspections indicate that the home is presently free from pests and vermin. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 24 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, 28, 29 & 30. There is a need to review the adequacy of the staffing levels. Progress is being made to ensure that staff are trained to national vocational standards. Service users are protected by the homes recruitment policy, although practice must be strengthened to ensure maximum protection. The home manager has developed a good training programme. EVIDENCE: Staff duty rotas record that a qualified nurse is is on duty on each floor at all times. Two care assistants are also on duty on each floor. The home manager and recently appointed deputy manager are both R.M.Ns (registered Mental health Nurses). There is a shortage in mental health qualified nurses in the home. This must be addressed. (See requirement 4). The home employs an administrator, a nursing sister in charge, an activities coordinator, seven registered general nurses, five mental health nurses (two of whom are bank employees), two enrolled nurses, 20 care assistants and five senior carers. There are five bank care assistants (bank employees provide additional cover when staff are on leave). Five domestic operatives, three chefs, two kitchen assistants and three laundry assistants complete the team. As the first and second floor annexes are separated from the the main accommodation by two doors and a hallway, service users in these areas are often left unattended. Service users accommodated in the annexes have high support needs and presently most spend their time in their bedrooms. This report recommends a review of this practice (see recommendations 3, 4, 5 and The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 25 6 and requirement 6). However, there is a need to review staffing levels in these areas to ensure that they are appropriate to meet the assessed needs of the service users, given the layout of the first and second floors. (See requirement 24). The registered manager said that the home is making progress in attaining the required 50 trained members of care staff (National Vocational Qualification level 2 or equivalent). Two members of staff have finished the NVQ level 2. Seven members of staff are completing the NVQ level 2, and two members of staff are completing the NVQ level 3. This is the subject of a previous requirement. (See requirement 25). A sample of staff recruitment records showed that enhanced Criminal Records Bureau checks had been processed for each member of staff. If a member of staff was recruited prior to the complete police check being returned they were checked against the P.O.V.A register (Protection of Vulnerable Adults). Two references had been taken up for each member of staff. Records did not include a photograph of each staff member and a contract/statements of terms and conditions were not available in all cases. (See requirements 26 and 27). Health questionnaires completed by staff are held on file. They do not request information in regard to hepatitis B. vaccination and the company does not provide staff with written guidance. This is recommended. (See recommendation 17). Interview notes are not available for recently appointed care staff, some of whom have no previous care experience. It is recommended that a record of these interviews be kept as evidence that the homes recruitment procedures test the persons fitness to work at the home, and examine their skills, integrity and good character in line with equal opportunities and ensuring the protection of service users. (See recommendation 18). Staff are issued with the G.S.C.C code of conduct. The home manager pays close attention to staff training and has maintained detailed individual staff training records. The record of statutory training undertaken indicates that each member of staff has undertaken safe moving and handling, prevention of adult abuse and fire prevention and awareness training. Training in dementia care, Alzheimers disease, National Minimum Care Standards and accidents to service users and staff have also been provided. Staff are trained to use specific health aids such as oxygen concentrators as the need arises. All new staff undergo induction training. The home provides a combination of external training and in-house training The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 26 from senior staff. Requirements and recommendations have been made in this report in regard to additional staff training. (See requirements 20 & 22, and recommendations 2 & 4). The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 37 & 38. The home is run and managed by persons with relevant qualifications and experience. There is a need for coordinated management of health and safety issues to ensure that service users and staff are protected. Service users financial interests are safeguarded, although arrangements in place cannot be regarded as being in the best interest of individual service users. The service users rights and best interests are not adequately safeguarded by the homes record-keeping and procedures. The health, safety and welfare of service users and staff are not fully promoted and protected by the systems in place in the home. EVIDENCE: The home manager is competent and qualified. He is assisted in managing the home by a recently appointed deputy home manager and a sister in charge. There are clear lines of accountability within the home and with external management. A representative of the registered provider visits the home on a monthly basis to conduct unannounced monitoring inspections under regulation The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 28 26 of the Care Homes Regulations 2001. Reports of these visits are maintained in the home and sent to the CSCI Southwark office. The home manager is a qualified registered mental health nurse, with extensive experience with the service user group. He has yet to undertake the required Registered Managers Award (R.M.A). (See requirement 28). There is a need for the home manager to recognise his responsibilities for the management of health and safety at the Laurels, systems for which are lacking. (See requirements 3, 5, 22, 16, 17, 18, 20, 21 & 22). The company acts as an appointee for state benefit collection and banking for some service users. These are satisfactory arrangements providing that a number of safeguards are in place. The bank account holding these monies must be seperate from the main business account of the home. Individual account records must be separate and itemised and the home must be able to demonstrate how each individual service user will receive any interests applicable to their individual savings. The home manager said that interest is not being accrued to these accounts. The CSCI has published new guidance on this issue (April 2005). (See requirement 29). Home records are stored in the managers office, the administrators office and at nursing stations on each floor. Individual care records stored in the nursing station areas are not secure. Nursing stations are situated in public areas. Individual care records are confidential and steps must be taken to ensure they are stored securely. (See requirement 30). Records are kept of the names of any visitor to the home and of any accident or fall. Records of all of medication administered, incidents of pressure sores and treatment provided are kept. A record has been kept of every fire practice, drill or test of the fire equipment and actions taken to remedy defects in the fire equipment. Photographs of each service user and member of staff are not available. Fire procedures do not comply with fire safety regulations. (See requirements 26 & 31). A record of all meals eaten had not been maintained. (See requirement 8). Some safe working practices are addressed adequately. Hot water temperatures are restricted. Risk of contact burns is removed by covering hot pipes and radiators. All the window restrictors is checked on a regular basis. The premises are secure. Some individual risk assessments for safe practice are in place (for example, the need for bed rails). Accidents, injuries and The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 29 incidence of illness or communicable diseases are recorded and reported. All staff receive induction training on safe working practice topics. Substances hazardous to health are safely stored. Clinical waste is handled and disposed of properly. Food is stored and prepared properly, including labelling and dating of stored food. Catering equipment is checked and serviced on a regular basis. Gas equipment is checked and maintained on a regular basis. An assessment of potential risks from asbestos had not been assessed. The overall management of health and safety at Work and fire safety are not adequate. (See requirements 12, 15, 16, 17, 18, 20, 21 and 22). A safety certificate in regard to the mains electrical supply was not available. The home manager said that is held at the head office, but had recently expired. A schedule of annual electrical small appliance safety testing was not available. (See requirement 32). Potential risks from legionella have not been assessed since 1999. (See requirement 34). The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 30 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 1 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION 1 2 2 1 2 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 2 3 2 x x x 2 x 1 2 The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 31 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 OP1 Regulation 4(1)(c) & 5(1)(a) Requirement The registered persons must ensure that information available in the statement of purpose and service users guide is reviewed and amended. The registered persons must include the telephone number of the local CSCI office in the service users guide. The registered persons must ensure that the needs of all prospective service users are fully assessed by suitably qualified professionals before admission. The registered persons must ensure that at all times a suitably qualified registered nurse is working at the care home (an RMN must be on duty at all times on the first and second floors). The registered persons must take adequate precautions to prevent the spread of infectious diseases such as MRSA. These precautions must be effectively communicated to all members of the homes staff team including domestic operatives. The registered persons must Timescale for action 30 November 2005 30 November 2005 31 August 2005 2. OP1 5(1)(f) 3. OP3 14(1)(a) (b)(c) 4. OP4 & 27 18(3) & 12(1)(a) (b) 18(1)(a) 30 November 2005 5. OP8 12(1)(a) 13(3) 13(4)(a) 13(4)(c) 31 August 2005 6. OP7 15(1) 30 Page 32 The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 7. OP7 16(2) (e)(f) 8. OP15 & OP37 OP22 17(2) & Sch 4(13) 23(2)(a) 9. 10. OP24 23(2)(e) 11. OP19 23(2)(b) 12. OP22 & OP38 23(2)(c) ensure that each service user has a care plan that details how all health, personal and social care needs identified will be met. The registered persons must ensure that the homes laundry procedure is managed effectively (items of personal clothing for some service users had gone missing). The registered persons must ensure that a record of the food provided for service users is kept. The registered persons must ensure that an assessment of the premises and facilities is conducted by a qualified Occupational Therapist. The report must be sent to the CSCI Southwark office. Previous timescales of 31/03/04, 31/08/04 & 01/03/05 not met. The registered persons must ensure that furnishings and fittings for individual rooms are provided in accordance with National Minimum Standards for older people 24.2). Reasons to be documented where there are individual exceptions. The registered persons must ensure that ensuite bathrooms are redecorated as necessary (some ensuite areas have peeling paintwork). A programme of planned refurbishment must be supplied to the CSCI Southwark office. The registered person must supply the CSCI Southwark office with evidence that all the slings and hoists in use at the home are safety check on a regular basis. (Evidence of these checks was provided on 5 September 2005). September 2005 30 September 2005 31 August 2005 30 September 2005 30 November 2005 28 October 2005 5 August 2005 The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 33 13. OP25 23(2)(j) 14. OP19 & OP22 OP19 & OP38 23(2)(n) 15. 23(2)(n) 16. OP19, OP21 & OP38 13(4)(a) 17. OP19 & OP38 23(4)(a) (b)(c) 18. OP19 & OP38 23(4)(a) (b)(c)(i) (iii) 23(2)(b) 19. OP19 20. OP19 & OP38 23(2)(b) & 13(4)(a) 21. OP19, OP37 & 13(4)(a) & 23(4) The registered persons must ensure that hot water temperatures are thermostatically controlled to temperatures close to 43 oC. The registered persons must provide ramped access to the courtyard garden from the ground floor communal lounge. The registered persons must provide the CSCI Southwark office with evidence that the passenger lift is serviced and regularly maintained. (Evidence of these checks was provided on 5 September 2005). The registered persons must ensure that all parts of the home are free from hazards to the safety of service users. Level drain covers must be securely fixed in three ensuite facilities (bedrooms and 15, 12 and 16). Immediate requirement. Requirement met The registered persons must take adequate precautions against the risk of fire. Fire doors must not be wedged open. Immediate requirement. Requirement met. The registered persons must ensure that self-closing door mechanisms fitted to fire doors are fully operational and effective. The registered persons must ensure that the cracked pane of glass in the first floor communal lounge is replaced. The registered persons must ensure that an appropriately trained member of staff conducts regular environmental health and safety checks. Records of these checks must be maintained. The registered persons must ensure that action is taken to 1 September 2005 28 October 2005 5 August 2005 13 July 2005 12 July 2005 31 August 2005 16 September 2005 16 September 2005 16 September Page 34 The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 OP38 22. OP19 & OP38 23(2)(b) 13(4)(a) 23. OP26 16(2)(k) 24. OP27 18(1)(a) 25. OP28 18(1)(a) 26. OP29 & OP37 19(1)(b) (i) Sch 2 27. OP29 12(5)(a) 28. OP31 10(3) meet the requirements made in the London Fire and Emergency Planning Authority (L.F.E.P.A) report of June 2004. Confirmation that these requirements have been met must be sent to the CSCI Southwark office. The registered persons must ensure that action is taken to meet the requirements made in the Health and Safety Executive (H.S.E) report of February 2005. Confirmation that these requirements have been met must be sent to the CSCI Southwark office. The registered persons must ensure that the home is free from offensive odours (two bedrooms). The registered persons must review staffing levels to ensure that they are appropriate to meet the assessed needs of the service users accommodated in the first and second floor annexes. The registered persons must provide the CSCI with an action plan outlining how they intend to meet the ratio of 50 of staff trained to NVQ level 2 by 2005. The registered persons must obtain all records required by schedule 2 of The Care Homes Regulations 2001 in regard to each member of staff employed at the home. A photograph of each member of staff must be included. The registered persons must issue each member of staff with a contract or statement of terms and conditions. The registered manager must undertake to complete the required Registered Managers 2005 16 September 2005 30 September 2005 16 September 2005 30 September 2005 30 September 2005 28 October 2005 31 December 2005 Page 35 The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Award (RMA). 29. OP35 20(1)(a) The registered persons must review the arrangements in place in regard to interest being accrued on the individual savings of service users who are subject to the financial appointee arrangements in place in the home, in accordance with policy and guidance monies held on service users behalf by corporate appointees. The registered persons must ensure that confidential individual care records are stored securely in accordance with the Data Protection Act 1998 and other statutory requirements. The registered persons must ensure that a photograph of each service user is available. The registered persons must supply the CSCI Southwark office with evidence that the homes electrical installations and small appliances have been safety tested. The registered persons must ensure that all prescriptions have full instructions for use including those for external products. The registered persons must supply the CSCI Southwark office with evidence of a Legionella risk assessment and arrangements for annual water system checks. 30 November 2005. 30. OP37 12(4)(a) & 12(5)(a) 28 October 2005 31. 32. OP37 OP38 17(1)(a) & Sch 3(2) 13(4)(a) 23(2)(c) 30 September 2005 5 August 2005 33. OP9 13(2) 31 August 2005 30 September 2005 34. OP38 13(3) 13(4)(c) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 36 The Laurels Nursing Care Centre 1. 2. 3. Standard OP5 OP7 OP8 4. OP12 5. 6. 7. OP12 OP13 OP16 8. 9. OP17 OP19 10. OP22 11. 12. 13. 14. OP24 OP24 OP25 OP19 & The registered persons should encourage prospective service users to visit the home themselves before making the decision to move in to the home for a trial placement. The registered persons should provide staff with training on how to devise person centred care plans with service users and/or their relatives. The registered persons should request additional specialist dementia support and advice. Arrangements should be made for increased psychological monitoring. Opportunities for social interaction, activity and access to communal areas (including the small courtyard garden) should be provided on a regular basis. The registered persons should provide the activities coordinator training to enable her to develop a programme of activities suitable to the needs of service users with dementia and other cognitive impairments and for those with visual, hearing or dual sensory impairment. The registered persons should extend the homes activities programs to include weekends. The registered persons should devise a strategy to facilitate community access for any service user who wishes. The registered persons should devise a system of noting verbal complaints/concerns raised by service users and their relatives/representatives. A log of these complaints should be maintained on each floor of the home. The log should be checked by the registered nurse and the registered persons on a regular basis. The registered persons should facilitate access to advocacy services for any service user who lacks the capacity to do so themselves. The registered persons should consider renumbering the bedrooms. The registered person the should also seek advice on how decor and colour can assist service users to recognise the layout of their home environment. The registered persons should consider installing a caller alarm system with eight pendant call alarm option for service users who find wall mounted call alarms inaccessible. The registered persons should assist service users to personalise their bedrooms. The registered persons should fit bedroom door locks that can be locked from the outside if a service user wishes. The registered persons should provide air cooling fans in all communal areas and bedrooms. The registered persons should further develop the small G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 37 The Laurels Nursing Care Centre 15. OP20 OP24 & OP26 OP24 & OP22 OP29 OP29 OP9 16. 17. 18. 19. courtyard garden to maximise comfort and use. The registered persons should consider changing the floor covering available in some service users bedrooms if they have continence needs. Floor coverings should be readily cleanable. The registered persons should provide discreet storage space for continence aids. The registered persons should provide staff with advice on the need for hepatitis B vaccination. The registered persons should maintain evidence of staff interview in recruitment records. The registered persons should consider the changes to the medication policy suggested under Section 7-11 of this report. The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 38 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark, SE1 0EH 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 The Laurels Nursing Care Centre G52-G02 S7030 Laurels V232637 120705 Stage 4.doc Version 1.40 Page 39 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!