Inspection on 08/06/05 for Margaret Roper House

This inspection was carried out on 8th June 2005.

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

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

Other inspections for this house

Margaret Roper House 07/02/07

Margaret Roper House 17/03/06

Margaret Roper House 28/09/04

Margaret Roper House 06/05/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Margaret Roper House 447 Liverpool Road Southport Merseyside PR8 3BW Lead Inspector Mike Perry Unannounced 8th June 2005 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 and Care Homes for Adults 18 – 65*. 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. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Margaret Roper House Address 447 Liverpool Road Southport Merseyside PR8 3BW 01704 574348 01704 570432 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) Nugent Care Mr Iswurdut Busgeeth N - Care Home with Nursing 23 Category(ies) of MD - Mental Disorder - 23 registration, with number of places Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 23 MD. 2. The home must at all times employ a suitably qualified and competent manager who is registered with the CSCI. Date of last inspection 28.09.04 Brief Description of the Service: Margeret Roper House is a 23 bedded purpose built home situated in the larger St Thomas Moore complex, which also incorporates a residential home. The home provides long term accomodation for people with enduring mental health needs. Care is provided on four family units on 2 floors. The home is set in its own grounds and garden areas. It is on the main Liverpool/Southport Rd with regular bus services into Southport town centre [2 - 3miles]. The home is owned by the Nugent Care Society and the Registered Manager is Mr Iswurdut [Fred] Busgeeth who is a Registered Nurse [General and Mental Health] and has long experience at this level. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 8 hours. It was an unannounced visit and was carried out as part of the regulatory requirement for care homes to be inspected at least twice a year. There has been no cause for any further visits to the home since the last statutory inspection in September 2004. For this inspection a partial tour of the home was conducted. Care records and other nursing home records were inspected. The manager, 4 care/ ancillary staff were spoken to. 8 residents were also spoken and their views obtained. What the service does well: The home has devised a very good set of information booklets including a ‘welcome guide’ that is attractive and easy to read. This helps residents to both choose the home as well as settle if they are admitted. There are good assessments carried out by nursing staff before residents are admitted and there is good liaison with health and social care professionals in the community so that the home has a clear idea of residents needs and can look after them effectively. All care needs are included on care plans, which are drawn up with the resident’s involvement as much as possible. Residents are encouraged to socialise and develop skills so that they can become more independent. This ranges from self care issues such as washing and dressing to managing money and socialising outside the home. Some residents attend training / education courses. The home has a strong commitment to planning and providing activities for residents. There are now more activities planned outside the home to encourage residents and improve their confidence in this area. Residents spoken to described trips out shopping and in the mini bus. Some residents are planning a group holiday in Wales in the summer. Residents feel that they are included in the running of the home. They commented that staff are approachable and listen to their concerns. There are regular meetings to discuss any concerns and there is an in-house newsletter, which keeps every body informed. Resident’s have input into the recruitment and selection process for staff. The recruitment of staff is very thorough with all required checks carried out so that residents are protected. Margaret Roper is a purpose built home and is very well maintained. There are four units in the home, each with its own facilities such as lounge and dining area, which helps residents, feel at home. The home is bright, clean and the Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 6 general atmosphere is relaxing. Residents commented that they feel very much at home. The Registered manager of the home is well qualified and experienced so that residents benefit from a well run home which helps ensure a good quality of life for the residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6-10 and 18–21) (Standards 11–17) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37–43) Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. 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. Prospective service users have an opportunity to “test drive” the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) 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, Information is provided to residents before and during admission, which assists in the process of choosing the home and settling in. The manager assesses all care needs prior to and during the early stages of admission to the home. This ensures that the home is capable of caring for and meeting the needs of residents. Residents can visit the home prior to admission, which gives an opportunity to get used to the routine and lifestyle in the home. EVIDENCE: The home has three booklets that give information about staff and services as well as outline the general philosophy of care. Both the ‘Statement of Purpose’ and ‘Residents guide’ are very detailed. These are supported by the ‘Welcome’ Guide, which is easy to read and gives information about the staff and activities as well as the arrangements for care in a more readily accessible format. A new admission to the home that was spoken to had found the information helpful. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 9 The manager or senior nurse visits prospective residents before they are admitted to the home in order to assess their care needs. The care notes contained a full range of nursing assessments completed in the early stages of admission covering areas such as Risk, social profile, self-medication assessment and mobility. From these assessments a care plan is drawn up. The assessments also included information from health and social care professionals outside the home so that these informed the care plan. Residents who had recently been admitted to the home had been given the opportunity of visiting and were undergoing a trial period in the home so that they were fully able to get used to the routine and lifestyle that Margaret Roper offer. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6-10 and 18 –21 (Adults 18-65) 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. Including their physical and emotional health needs. 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. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. Service users receive personal support in the way they prefer and require. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 7, 9, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 [OP] and 6,7,8,9,18,19 [YA] Residents health, personal and social care needs are addressed in care plans and the health care needs are met effectively which ensures a very good overall standard of care in the home. Residents feel consulted about their care and that they can contribute to the running of the home, which enables a good quality of life. EVIDENCE: Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 11 Individual plans of care are available and identify relevant aspects of health and personal care and plan accordingly. The care plans are drawn up with the involvement of the resident and signed by them. Reviews are also signed. Residents spoken to varied in their understanding and willingness to take part in this process but were pleased that staff spoke to them on a regular basis about their care. The care plans seen were clear in their aims. One care plan for a new admission had not been finalised but the immediate care needs had been identified from the various admission assessments and these were relevant and gave a useful outline of the current care. All residents spoken to were aware of their key worker and felt that this relationship was important to them. Residents are able to make decisions about their lives and this is considered within the overall measurement of risk in individual cases. A good example of this is a couple who have a close relationship and wish to support each other in domestic arrangements outside the home. Staff supported this by careful assessment of risk and ability, which included external professionals and advocates. The residents concerned were able to come to some conclusion about the immediate future and plan accordingly. Residents spoken to felt they were consulted on matters regarding the running of the home. There are regular meetings so that residents can air their views and can make suggestions for activities, outings and holidays. There is a small representative ‘committee’ of residents who also have some input into the staff recruitment process. There are varying levels of personal care needs in the home. Some of the more elderly residents are in need of support for washing and dressing. Care plans include reference to personal care needs and staff interviewed were able to describe individual residents care in some depth. One resident spoken to was pleased with the way these care needs were being met and felt that staff were supportative and sensitive in their approach. Residents were observed to be clean and appropriately dressed. Other residents felt likewise that staff were supportative and respectful of there privacy. The skill mix of the nursing staff in the home supports both mental health care and general nursing care. Care records clearly document GP attendance, and events such as chiropody and other health referrals. Psychiatric reviews are carried out routinely and residents felt supported as they are accompanied by staff to appointments and a full review of the care in the home is written by nursing staff providing information for the consultant and Mental Health team. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 11 – 17 (Adults 18-65) are: 12. 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. Including opportunities for personal development. Service users engage in appropriate leisure activities. Service users maintain contact with family/ friends/ representatives and the local community as they wish. And have appropriate personal, family and sexual relationships. 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. 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15, 16 and 17 (Adults 18-65) the 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 [OP] and 12,13,14,15,16,17 [YA] Meal times and social activities are both very well managed and help create a varied and positive day for the residents in the home. Residents feel included in all aspects of the running of the home and are consulted on a regular basis. There are opportunities for personal development and residents feel listened to. These aspects contribute to a good quality of life for people living in the home. EVIDENCE: There are 2 activity coordinators employed who organise a weekly activity programme for residents and this is displayed in the conservatory, which acts as the main meeting area for residents and staff. The activities coordinator role is flexible to cover evening activities if required. Residents were able to describe activity on a daily basis; some individually care planned and other group activity. Much of this activity is based in the immediate community and on trips further afield. Residents described local shopping trips or visiting town. There are also evening outings to pubs and restaurants on occasions. Residents spoke about this year’s holiday and how it was being organised and Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 13 how they had enjoyed previous holidays and outings. Information about local events and services such as library, pubs, and churches are advertised in the welcome guide as well as on various notice boards in the home. Despite the enduring nature of some of residents mental health needs there are opportunities for personal development. One resident is engaged as a volunteer working in a charity shop in Southport. Other residents have attended further education courses in the past. One resident spoken to was engaged in an in-house art group and expressed a wish to continue this outside the home by attending a local college course. The resident felt that staff encouraged her to do this and the care plan addressed this need. Two residents are employed locally delivering papers door to door. There is an inhouse newsletter, which residents regularly contribute to. A development since the last inspection is that residents are now encouraged to shop outside the home for their own toiletries etc rather than relying on key workers to organise this. Residents described life at Margaret Roper in very positive terms. Staff are ‘very helpful and approachable’ and there were positive comments around the role of key workers. The daily routine was described as ‘relaxed and friendly’. Residents contribute to daily chores such as table setting and washing up which helps maintain daily living skills as well as contributing to a general feeling of community. Meal times are social events and each unit has its own dining area where smaller group numbers encourage interaction. The food served is both varied and appetising. A menu is displayed. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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. Including neglect and selfharm. The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 There is a complaints procedure so that residents feel that their concerns are listened to and acted on. EVIDENCE: There is a complaints procedure and this is included in the resident information booklets and also advertised around the home. Residents interviewed were aware of the procedure. Nobody interviewed had any complaints to make about the home. Residents felt that staff were approachable and that any concerns they had would be listened to. A complaints book is kept and monitored by the administrator. There have been no complains since the last inspection. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) 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. Shared spaces complement and supplement service users’ individual rooms. Service users have sufficient and suitable lavatories and washing facilities. Provide sufficient privacy and meet their individual needs. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. And lifestyles. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 [OP] and 24, 30 [YA] The quality and maintenance of the environment is of a high standard which ensures that residents live in surroundings that are safe and comfortable. EVIDENCE: Residents live in four “family” units – each with own lounge and dining area. Bedrooms exhibit high levels of individuality and evidence the occupier’s lifestyle, interests and hobbies. All residents have free access to a conservatory which is the focus of group meetings, activities etc. A separate activities room is also available. The general ambiance is bright and relaxed. There are high standards of internal and external maintenance. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 16 Residents were very appreciative of he quality of the accommodation. One described it as ‘ a hotel’ and other comments included ‘ it feels very homely’ and ‘this is my home’. All areas seen were clean and tidy. The Home has its own grounds and has access to garden areas. The Home is on the main Liverpool / Southport road and has bus services into Southport Town Centre (2 – 3 miles). Future plans for the home were discussed with the manager and, although in the early stages there are possibilities of developing a rehabilitation kitchen with laundry facilities (particularly needed once the ‘cottage’ is no longer usable). These ideas evidence an ingoing development of the rehabilitation philosophy of the home. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 36 (Adults 18-65) are: 27. 28. 29. 30. • • • Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. 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. Service users benefit from clarity of staff roles and responsibilities. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 [OP] and 34 [YA] The home is appropriately staffed which ensures that residents care needs are met. The recruitment procedures for staff are robust and ensure that residents are protected. EVIDENCE: For 22 residents the staffing numbers are 1 trained and 3 care staff [reduced to 2 care staff in the afternoon]. There are 2 part time activity coordinators who support the care staff. There is a full time administrator, ancillary staff including domestic and kitchen staff. The manager is in addition to these numbers and works 9 – 5. The duty rota supports the consistency of these numbers. Residents and staff spoken to felt that these numbers were sufficient to carry out the care. Residents feel supported and the key worker role was commented on as being particularly useful and relevant. Residents felt that staff were ‘helpful’ and that there approach to car was sensitive and supportative. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 18 The home has very thorough recruitment procedures. A new member of staff was able to explain the various checks made including references and criminal records bureau checks prior to employment. The interview process includes input for residents in the home. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 37 – 43 (Adults 18-65) are: 31. 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 a well run home and from competent and accountable management of the service. 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. Service users are confident their views underpin all self-monitoring, review and development by the home. 32. 33. 34. 35. 36. 37. 38. • The Commission considers standards 33, 35 and 38 (Older People) and Standards 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 The manager of the home is well qualified and competent so that residents benefit from a well run home. EVIDENCE: Mr Iswurdut [Fred] Busgeeth is the Registered Manger. Mr Busgeeth has much experience over 36 years working as a nurse and senior manager at Mersey Care Trust [28 years at management level]. He has had contact with and has carried out nursing duties at Margaret Roper over the past 16 years. Mr Busgeeth has a double nursing qualification being both Registered Mental Nurse [RMN] and General Nurse [RN]. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 20 He is able to demonstrate continual professional development over the past few years having completed courses in clinical governance, NVQ assessing, and risk assessment in mental health. He has commenced a management qualification at NVQ level 4. He feels he has slotted into his new role well and has been able to update some of the systems in the home and gave examples of this. Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 x 3 3 4 x 5 3 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 4 x x x x x x 4 Score Standard No 7 8 9 10 11 Score 3 3 x 3 x Standard No 27 28 29 30 3 x 4 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x x MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 x 34 x 35 x 36 x 37 x 38 x Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 22 no 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 none Regulation none none Requirement Timescale for action 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 none Good Practice Recommendations none Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Burlington House, 2nd Floor, South Wing Crosby Road North Liverpool L22 0LG 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 Margaret Roper House F53 F03 Margaret Roper House S17250 V232355 08.06.05 Stage 4.doc Version 1.30 Page 24 - 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!