Inspection on 17/04/08 for Mountbatten Lodge

This inspection was carried out on 17th April 2008.

CSCI found this care home to be providing an Adequate service.

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

Mountbatten Lodge 14/04/09

Mountbatten Lodge 23/10/07

Mountbatten Lodge 19/02/07

Mountbatten Lodge 20/01/06

Mountbatten Lodge 25/06/05

Mountbatten Lodge 14/01/05

Mountbatten Lodge 17/08/04

Mountbatten Lodge 26/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Mountbatten Lodge Old Crabtree Lane Hemel Hempstead Hertfordshire HP2 4EX Lead Inspector Jeffrey Orange Unannounced Inspection 17th April 2008 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000019476.V362232.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000019476.V362232.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountbatten Lodge Address Old Crabtree Lane Hemel Hempstead Hertfordshire HP2 4EX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01442 244188 01442 282546 www.quantumcare.co.uk Quantum Care Limited Mrs Roslyn Renimida Turton Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60) DS0000019476.V362232.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 23rd October 2007 Brief Description of the Service: Mountbatten Lodge is situated in the Jarman Park Area of Hemel Hempstead, close to the town centre with its local shops and facilities and adjacent to a large supermarket and leisure park. Mountbatten Lodge is a purpose built home for up to sixty older people. The home is on two floors and divided into four individual units with single en-suite bedrooms, a lounge, dining room and assisted bath and shower rooms. Two units cater for people with dementia and these are on the ground floor with access to an enclosed garden area. Parking for cars is available. Fees range from £420 to £605 per week (as at 17/04/08). Additional charges apply for personal toiletries, newspapers, hairdressing and dental and chiropody services. Information about the home, the services it offers and the fees payable are contained in its “Personal Guide” A copy of this and the most recent CSCI inspection report are available on request in the home. DS0000019476.V362232.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out in response to concerns raised with the Commission for Social Care Inspection in the period since the last key inspection in October 2007. The inspection was unannounced and started early in the morning, which provided an opportunity to see the routine of the home as people living there were getting up and being helped to prepare for the day ahead. We talked to people who live in Mountbatten Lodge together with members of the staff team who were on duty. Survey forms for the use of those staff that wished to complete them were also provided. The manager was present for most of the inspection and telephone conversations were also held during the day with a member of the senior management team for Quantum Care. Key records were inspected including those for recruitment, care planning and medication. Feedback was mixed, with comments from people living in the home varying from “The carers are pretty good” and “They do very well for me” to “you have to wait a long time” and “they’re too busy, especially at night”. Discussions with staff likewise reflected the period of transition that the home is undergoing, with some seeing positive signs of progress and others being less sure of the benefit of any changes being made. Comments received from staff ranged from “The manager has definitely improved the home” to “It’s virtually impossible” What the service does well: Concerns raised with us about the overall care outcomes for people living in Mountbatten Lodge were not supported by the records seen and care observed. The standard of care delivered by the manager and her care staff team remains good. The permanent staff team are well supported by training and supervision and those spoken to demonstrated a genuine concern for the people living in the home and knowledge of their care needs. DS0000019476.V362232.R01.S.doc Version 5.2 Page 6 The manager is realistic about the challenges facing her and her staff team and showed a clear sense of purpose and determination to make the changes necessary to achieve further improvements in the care experience of people living in Mountbatten Lodge. 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. The summary of this inspection report can be made available in other formats on request. DS0000019476.V362232.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000019476.V362232.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 (Standard 6 does not apply to Mountbatten Lodge) Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a range of detailed information, available in various accessible formats, that ensures anyone considering the service as a possible home for themselves or someone they are responsible for is able to make a wellinformed decision. The pre admission assessment process is through and people being assessed can be confident that they will only be admitted to Mountbatten Lodge if their needs can be appropriately met. DS0000019476.V362232.R01.S.doc Version 5.2 Page 9 EVIDENCE: The Quantum Care ‘Personal Guide’ for the home was seen to include exceptionally comprehensive information about the home, including what is offered and what the terms and conditions that apply are, all in a very clear and accessible format. This information is also available on-line. This means that people considering Mountbatten Lodge as a home either for themselves or someone they are responsible for have access to the clear and detailed information they need to enable a well-informed judgement to be made about the home, A series of assessment files for recently admitted service users were seen and these contained the detailed information that staff would require in order to both identify and meet service user’s needs. It was confirmed by the manager that visits to the home, prior to any decision about permanent residence being made are encouraged, so that people considering the service as their home can have the chance to see round it, to meet key staff and people already living there in order to judge if it will meet their needs and be a place they feel they could be happy. DS0000019476.V362232.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Mountbatten Lodge can be assured that they will receive the personal and healthcare support they need to maintain their well-being and that the system of care planning and review in place provides care staff with the up to date information they require to enable them to appropriately meet their personal and healthcare needs. Although the home has a comprehensive medication policy, supported by procedures and practice guidance this is not always fully followed and this could compromise the safety of those people in the home who rely on care staff to support them with their medication. DS0000019476.V362232.R01.S.doc Version 5.2 Page 11 EVIDENCE: Those care plans seen, including those for people recently admitted to Mountbatten Lodge included the basic information needed to help staff identify care needs and how they were to be met. There was evidence of a regular review process to make sure that changes in care needs were identified and acted upon and care plans also included risk assessments to identify and eliminate or reduce risks where possible. Care plans included details of visits by a range of healthcare professionals to people living in the home. This confirms that people living in the home have access to the routine healthcare services they need. People living in the home were generally very positive about the way permanent care staff treated them “They are very good to me” was one comment and throughout this visit the attention to the rights and dignity of people living in Mountbatten Lodge by staff was seen to be good. The standard of recording found when looking at medication records was variable. Some gaps in records were found, variable dosages were not always recorded with the exact dosage given. Some medication was being inappropriately stored, although this was rectified immediately it was discovered. The home now has one senior member of the care staff taking overall responsibility for medication and it is expected that this will improve the consistency of practice, provided that he is given the support needed to enable him to address what has been a consistent area of failure over recent inspections. Although all permanent care staff are trained to administer medication in line with Quantum Care’s policies and procedures, the persistence of errors suggests that further training is necessary in order to make the medication practice in Mountbatten Lodge sufficiently robust to support and protect people living in the home on a long-term basis. Previous issues with medication storage temperatures had been addressed and should ensure that people’s medication is not being adversely affected by being stored above the approved temperature for it. DS0000019476.V362232.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Mountbatten Lodge benefit from the opportunities they have to take part in activities appropriate to their needs and personal inclinations. They can be assured that they are able to develop and maintain personal and family relationships and that they can continue to exercise control over the daily routines of their lives including what and when they eat. EVIDENCE: The basic activities programme was discussed with the activities organiser on duty. It includes some special events including evening activities, for example to celebrate St.Patrick’s day as well as routine activities such as bingo and ‘sing-along’. There are regular film sessions that include refreshments and also sherry mornings. Some of the activity sessions depend on care staff to organise, which can be problematic if they are under pressure. In general comments by people living in the home were quite positive although one person noted that “bingo can be a bit boring”. DS0000019476.V362232.R01.S.doc Version 5.2 Page 13 Not all activities staff have received specific training in the provision of activities for people living with dementia, if this was provided it might enable them to make activity sessions more relevant for that particular group. One person living in the home helped setting tables for mealtimes, which provided them with a meaningful activity as well as being of benefit to staff. “The food is good” and “We can have cooked breakfast if we want” were two comments received about food. The home’s menu was seen to be varied and included alternatives and vegetarian options, this should provide appropriately for the specific nutritional needs of people living in the home in line with their personal preferences. The dining areas in the home were seen to be attractively set with bright coloured tablecloths and with music playing in the background to help enhance the dining experience for people living in the home. DS0000019476.V362232.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Mountbatten Lodge and those responsible for them can be assured that they are protected from abuse and that their views are listened to, taken seriously and acted on appropriately. EVIDENCE: Mountbatten Lodge has a complaints policy and procedure that is clearly written and easy to understand. It is available on request in a number of formats and this means that anyone living in the home or responsible for them can complain or make comments about the care experience and outcomes in the home. Staff spoken to confirmed that they were aware of the ‘whistle-blowing’ policy of Quantum care and felt able to use it if required. (Whistle-blowing is the name given to the procedure that allows people within an organisation to raise any concerns they may have at a senior level within the organisation). The manager indicated that many concerns or complaints are dealt with informally without always being recorded. Whilst this may be appropriate in some minor instances, it can prevent information being available to identify trends or patterns in concerns or complaints raised, however minor they may at first appear. It is recommended that all complaints or concerns, however minor should be fully recorded with the outcome. DS0000019476.V362232.R01.S.doc Version 5.2 Page 15 Staff training records seen included training in the recognition of abuse and what action to take if it is seen or suspected. This should provide people living in the home with confidence that staff will be able to protect them appropriately from any form of abuse. Concerns have been raised with the CSCI about what are said to be poor care outcomes for people living in the home arising from poor management, low staff morale and a high use of agency staff due to an increased turnover of permanent staff. One staff survey returned described the mood in Mountbatten Lodge as being “terrible” and stated that care staff do not feel able to take up their concerns with the local or area management team as “nothing will be done.” This contrasts with responses given by staff as above when asked about “whistle-blowing” The concerns with staffing are addressed in this report under standards 27, 28, 29 & 30 where it is recognised that members of care staff are under pressure and that there has been an increased reliance on agency staff that is currently being addressed through the recruitment of more permanent staff. The views of care staff about the home’s management team were mixed with some being more supportive and positive than others. There is some evidence from care staff and people living in the home to support the view that the management team does not always have as high a profile as might be expected. The overall standard of care observed and described by people living in the home during this inspection was good and no evidence of neglect or abuse was given or alleged to the inspector either by staff or people living in the home. DS0000019476.V362232.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Mountbatten Lodge enjoy the benefits of living in a comfortable and clean environment and are able to reflect their personal interests and tastes by the way their individual space is decorated and furnished. However, problems with the low temperature of some hot water outlets in the home mean that some people have to use bathing facilities further from their own rooms than would otherwise be the case which can be an inconvenience to them. EVIDENCE: Those bedrooms seen, with the permission of the people concerned, were personalised with their own items of furniture, pictures and ornaments so that they reflected their particular interests and taste. DS0000019476.V362232.R01.S.doc Version 5.2 Page 17 On the day of this visit all areas of the home were clean and tidy and free from any unpleasant smells, which enhances the experience of people living in the home. One person living in the home informed us that “there was no hot water” and that they had to use the bathroom facilities on another unit. This was investigated with the manager and by trying the temperature of some water outlets by hand. It was established that there has been a long-standing problem with this in some parts of the home. Quantum Care are aware of this, and it is understood that a long-term solution is being planned. No date for this was available during the inspection although it was stated that some interim corrective work was to take place the following week. Although adequate hot water is available in other parts of the home it is not acceptable for people living in the affected areas to be subject to long-term inconvenience. DS0000019476.V362232.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Mountbatten Lodge can be assured that there will be enough qualified, competent and experienced staff to meet their care needs although there may be times when they have to wait a short time for staff support and attention. People living in Mountbatten Lodge can be confident that a staff team who have been recruited and trained in a way that ensures that they are suitable and skilled to do so is providing their care. EVIDENCE: Comments from people living in the home were supportive of the quality of the staff team, but also indicated that there were times when they felt they had to wait an unreasonable time for staff attention. “You have to wait a long time”, “You can wait in the evening when staff are on their break” “ There are too many changes in staff” “I never know who is coming for me”. One service user was waiting on their bed at 9.30 am to have their shoes and socks put on by staff and said they had not had their breakfast yet because of this. In observing Pearl unit as breakfast was being served it was noted that there was one member of staff doing medication, (who should not be disturbed whilst doing so in order to avoid errors) plus one permanent member of staff DS0000019476.V362232.R01.S.doc Version 5.2 Page 19 and a young person on work experience who should not have been entering service user’s rooms unaccompanied according to Quantum Care’s protocol for work experience placements seen. Members of the staff team indicated that they felt under pressure at key times and that this was affecting the standard of care they felt they were providing. Chair cushions on lounge chairs were still in the upright position in one lounge at 9.30 am. There are currently a high number of agency staff being used in the home, with six being used the day before this inspection. The manager indicated that there was greater use of agency workers than she would like and hoped the situation would be improved now that she had been able to recruit four more staff who were yet to take up their posts. The use of agency staff is said to adversely affect the quality of care received; “agency staff don’t know the people” was a comment by one person living in the home. “Not enough staff”, “before you could sit and talk to them, now it is all rush” “It is virtually impossible, but we have been told this is all we need” were some of the comments made by staff, with some but not all feeling that staff morale was low because “we feel that the job is not being done properly” Staffing on Emerald unit has been increased recently with an additional person, in recognition of the increased dependency levels of those receiving care there. Staff recruitment and training files were seen and were thorough, comprehensive and robust, this means that people living in the home are well protected by the way staff are trained and recruited. DS0000019476.V362232.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Mountbatten Lodge can be assured that they live in a well managed home, where their interests are protected and their views taken into account when decisions about the way that the home is run are made. EVIDENCE: The system for recording financial transactions made on behalf of people living in the home was found to be robust with receipts given in each case and a system of periodic external audit in place in addition to the regular checks made by the manager. This means that people living in the home can be confident that their financial interests are protected. DS0000019476.V362232.R01.S.doc Version 5.2 Page 21 Routine maintenance and equipment checks are carried out as appropriate in order to protect people living in the home. The problems being experienced by some people in the home due to inconsistent hot water supply could however affect their health and safety if a long-term solution is not found. Call bell monitoring is in place to identify those occasions when response times are excessive, this should provide the manager with good information about how often and when response times may adversely affect the well being of people living in the home. Falls are monitored and audited and these are summarised and sent through to Quantum Care’s head office for further analysis and monitoring. This provides further confidence to people living in the home that their health and safety is given appropriate priority. The continued occurrence of episodes of poor medication recording potentially poses a risk to those people who rely on care staff to assist them with their medication. The manager is well qualified and experienced and her contribution to the efficient operation of the home was recognised by some staff “Manager has definitely improved the home” The general view of people living in the home was also positive although one person noted that they only saw the manager “once in a blue moon” and some staff felt that the managers profile in the home was not high enough. DS0000019476.V362232.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 DS0000019476.V362232.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement Timescale for action 30/05/08 2. OP21 23(2)(j) In order to fully protect people living in the home the home’s policies and procedures for the safe administration of medication must be fully observed and complied with at all times. For the health, safety and 30/06/08 convenience of people living in the home, there must be consistent and dependable sources of hot water available to them in locations convenient for them to use. 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 OP16 Good Practice Recommendations To assist the manager identify and address any trends in concerns or complaints raised and to provide evidence that people living in the home are always listened to, all concerns and complaints, however minor should be fully recorded including any outcomes from them. DS0000019476.V362232.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000019476.V362232.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!