Inspection on 16/01/06 for Nazareth House

This inspection was carried out on 16th January 2006.

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 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

Nazareth House 03/06/09

Nazareth House 12/06/07

Nazareth House 13/09/05

Nazareth House 14/03/05

Nazareth House 27/09/04

Nazareth House 23/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Nazareth House London Road Charlton Kings Cheltenham Glos GL52 6YJ Lead Inspector Mrs Helen James Unannounced Inspection 16th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 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. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Nazareth House Address London Road Charlton Kings Cheltenham Glos GL52 6YJ 01242 516361 01242 547696 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) The Congregation of the Sisters of Nazareth Mrs Elaine Lesley Woof Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (63) of places Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered Manager to obtain the Registered Manager`s Award by 31st December 2005. 13th September 2005 Date of last inspection Brief Description of the Service: Nazareth House, a purpose built care home, is situated on the outskirts of Charlton Kings, within walking distance of the local shops and public transport. It is registered to provide accommodation for sixty-three elderly residents who require personal care. The Home is owned and managed by the Sisters of Nazareth, an order of Roman Catholic nuns, but residents of any religious faith are welcome at the Home. All the bedrooms offer single accommodation; many have en suite facilities. All bedrooms are being converted to provide en-suite facilities over the next six months. The communal areas consist of five lounges/quiet areas, three dining rooms plus a large function room and sun lounge. There is also a Chapel attached to the Home. A shaft lift, stair lift and stairs provide assisted access to the upper floors of the home. The residents have the benefit of a large attractive garden, which is easily accessible and may be enjoyed in all weathers. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours on one day in January 2006 and was completed by one inspector. Sixteen Care Standards for Older People were assessed on this occasion. Of these three exceeded the standard, eight met the standard, four almost met the standard and one was not applicable. Time during the inspection was spent speaking with the Manager Mrs Woof, residents and visitors at the home. The information gained was then crossreferenced with information gained in discussion with the Manager, care records and documentation examined. The inspector spent time with the Manager cross-referencing information about aspects of health and safety in relation to care and welfare of the residents at the home. The inspector observed interaction of staff with residents and noted the interpersonal skills being used by carers. Three residents who were able to converse with the inspectors discussed their care, lifestyle and day-to-day life within the home. There was also one visitor who was spoken with during the inspection. What the service does well: All comments from residents were very positive about the Managers and the staff and the care they receive. They felt that they were given choice and their wishes were always respected. Several residents commented that, “the staff are so nice”, “everyone who comes here is well looked after” and one visitor said she had “ complete confidence in the home and the care given “. Even though some of the residents could not speak their wishes to the care staff, the staff appeared to pre-empt what was required for them and their needs appeared to be always met. They were seen talking, guiding, supporting, assisting with meals and reassuring residents during the visit. Each prospective resident has all their care requirements fully assessed before they are admitted to the Home. This ensures that the Home can fully meet their needs and can obtain any aids or adaptations the resident may need before they are admitted. Recruitment procedures are adhered to and staff receive appropriate induction training when new to the Home. Other training is updated appropriately. The staffing skill mix is adequate to meet the needs of residents and supervision of staff has been implemented to assist in improving their skills to meet the everchanging needs of the residents. The staff continue to enjoy working at the home and to be attentive in their care of the residents. There continues to be a good staff team who work hard to ensure the needs of the residents are met. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 6 The management continues to safeguard and protect residents at the Home by using the systems that are in place and by adhering to the Care Home Regulations, albeit there are some minor improvements necessary. The home and management are committed to an ethos of ‘continuous improvement’ for the service they provide for residents. This is reflected in their approach to the inspection process and their openness. What has improved since the last inspection? What they could do better: The Management must ensure that the residents or their representatives have a copy of their contract and terms and conditions of residency and that one is kept on their file. A review must be made of the Abuse policy and procedures and the reporting of accidents under RIDDOR. The recruitment process must ensure that all new staff have within their reference a written verification of why they left any position previously held in the care of children or vulnerable adults. Also there must be no gaps in employment history on the application form or if there are they must be verified with the applicant and evidence kept of this. This will ensure the protection of people living at the home. As part of the Quality Assurance in the home the Manager must implement auditing of Systems and Processes to ensure that standards are being met and provide evidence of this for the inspection process. The Manager must also seek the views of residents/their relatives/representatives/GPs and Community Staff who visit the home regularly to evidence that the service is meeting the needs and expectations of those at the home. Please contact the provider for advice of actions taken in response to this Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 8 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 Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 6 The Statement of Purpose and Service User Guide give residents staying at the home and people wishing to use the service information about the services provided, enabling them to make an informed decision about coming in. EVIDENCE: Residents funded by Social services have a contract, but those privately funded only have a confirmation letter stating fees, level of care, direct debit information and room on admission. There is no statement about periods of notice or information about terms of residency signed by each party. This information is clearly available within the available documentation given to the resident /representatives and prospective residents/representatives. But it is essential that all residents and/or their representatives have a signed copy of the contract and terms of residency and the Providers keep one on the personal file of each resident. These also need checking with the Office of Fair Trading to ensure they comply with their guidance. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 10 One residents is being reassessed by another Provider today as the home can no longer meet their needs fully; they are wandering out of the home and as the home has an ‘open door’ policy they are now no longer suitable for this environment. Staff are being very vigilant and monitoring where the person is during the day and night until the transfer can be made. A regulation 37 notice was sent to the Commission recently when he left the home and did not return. The appropriate action was implemented. It was at this point the process for looking for an alternative placement was discussed with the family and resident and was begun. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 &10. Improvements in the care planning systems are still underway. Residents are treated with respect and dignity. No other standards were examined in this section. EVIDENCE: The Manager is to implement an auditing system of the care records to ensure that care records are consistently and appropriately completed on both floors in the care home. This will be reviewed at the next inspection. One resident was identified at the inspection as not wishing to move into the main area of the home when their physical health is deteriorating. This was discussed and it is required that specific documented risk assessments pertaining to this must be completed and put in their care plan. They must also sign a disclaimer so they are made aware of the risk that this poses to them. All Medication issues identified at the last inspection have been addressed. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 12 Residents who were able to converse with the inspector confirmed that they were treated with respect, they had choice in their daily routine and they were addressed in a manner that they were comfortable with. The visitor spoken with was very happy with the care, the staff and generally with the way the home was run. She stated that all staff were ‘polite, pleasant and very kind and caring, always helping appropriately and that the food was very good’. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 14 Residents continue to have a full and varied activity diary that caters for the varied needs of residents living at the home. Residents continue to be able to exercise choice and control over their lives and maintain contact with family and friends. EVIDENCE: A record of the activities is displayed in the home and a copy given to each resident. There was photographic evidence of recent Christmas festivities at the home, showing everyone clearly enjoying themselves and the few residents spoken with confirmed this. Residents meetings are held regularly. Minutes seen were very thorough in dealing with the issues that arose for residents. Residents continue to be free to furnish their rooms with their own furniture and personal belongings. Those rooms seen were personalised. Clear records of personal property are maintained on file. Each resident is free to spend their day as they choose, within their own limitations. Residents who were able to speak with the inspector confirmed that they were treated with respect and they had choice in their daily routine. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home has arrangements in place for the protection of service users. EVIDENCE: All staff have completed Abuse awareness training except for those who are new. This is now being arranged as well as an update for all staff. One incident recently has necessitated the disciplinary process to be instigated and has led to the dismissal of a carer and them being reported to the POVA list, this was discussed during the inspection and records were examined. It was felt that the Manager and those involved had learnt a lot through the experience. These amendments are required to the Policies and Procedures that are in place: • Add notify the police. • Add the Manager must always notify the Commission for Social Care Inspection (CSCI) immediately of any incident. • Add a section to reflect actions if police investigate the incident. • Add statement about notifying the County ‘Adults at Risk’ team. • Add Manager to complete and send a report of the allegation, incident, investigation and outcome to the CSCI. A complete report is to be sent to the Commission with all the relevant details. There have been two serious accidents involving staff at the home, which has resulted in hospitalisation for one and a period off sick for another. It appears neither were the fault of the home and whilst they have been appropriately Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 15 notified to the Health and Safety Executive (HSE) under RIDDOR, they have not been reported to the Commission. This is required forthwith under Regulation 37 (f). Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Residents live in a homely environment, which benefits from an ongoing maintenance and refurbishment programme making sure that the home continues to meet the needs of the residents living there. The home continues to maintain a high standard of cleanliness. EVIDENCE: The Home is well maintained with an ongoing programme of decoration and replacement of furniture to ensure the environment maintains a homely comfortable ambience for the residents. No maintenance issues were identified during the inspection. The programme to equip all rooms with en-suite facilities is continuing and nearly all rooms have this facility now. Cleanliness is of a high standard and no infection control issues were identified. The laundry was not examined as it met all the standards at the last inspection. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Staffing is adequate to meet the care needs of the residents living in the Home at the present time. Resident’s safety and well-being is paramount at all times. The procedures for the recruitment of staff are robust and provide the safeguards to offer protection to the residents at the home. EVIDENCE: On the day of the inspection, there were thirty-nine residents upstairs and twenty-one downstairs in the Home. In the morning upstairs from 7/8am to 2pm there were five care staff (two had telephoned in sick and no agency was available) and from 2 pm to 8 pm there were four care staff. Downstairs from 8am to 2pm there were three care staff and from 2pm until 8pm there should have been three care staff but one had telephoned in sick. During the night from 8pm to 8am, there were four staff on duty for the home. There were eleven general assistants who deal with catering, laundry and cleaning on duty between 8am and 7pm. There are also two Nuns who also assist during the morning and afternoon and at night there is a nun on call. In addition there are receptionists from 8am until 8pm, a personal assistant, business manager, a gardener and the maintenance man each day. There are no staff less than 18 years of age employed for care duties. The Home does occasionally use agency staff. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 18 There have been seven new staff at the home and the CRB/POVA checks for all these staff were seen during the inspection. These can now be destroyed in line with Data Protection. A sample of three new staffs recruitment records (personnel files) were examined. Two out of the three fully complied with Regulation 19 but on the third file for a carer there was a two-year gap in her employment history. This was discussed with the Manager and she will address this and ensure that this is not missed on application forms in the future. All reference requests forms must request the written reason for the person leaving from the referees. The registered persons must obtain from any previous care position held by the applicant written confirmation of the reason for leaving, where it is practicable. All mandatory training is completed for all staff and updating is being arranged at the present time. Approximately 85 of staff have completed National Vocational Training (NVQ) level 2 or 3. The Manager is doing supervision of the deputy managers, domestics/laundry staff, general assistants and some care staff. Records were seen for these and were good, although the Manager must ensure that the record of supervision records the agreed actions or outcomes of the session and who is responsible for their completion. The Deputy Managers are reportedly undertaking supervision with care staff on their floors these records weren’t examined. The Manager must audit the supervision practice in the home to ensure the frequency meets the requirements. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 38 There is good leadership, guidance and direction to staff from the cohesive management team at the home. This ensures residents receive consistent quality care and results in practice that promotes and safeguards the health, safety and welfare of the people using the service and staff. EVIDENCE: The registered manager has completed the Registered Managers Award at NVQ Level 4 and will provide the Commission with a copy of the certificate when it arrives. Certificates of insurance and registration were displayed correctly at the time of the inspection. The registered manager always shows a willingness to work with the Commission, meeting with requirements issued at the previous inspection and sharing information at this inspection. The registered manager was open and transparent. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 20 Risk assessments for the home and the residents’ rooms have been completed. LPMS undertake a yearly Risk assessment for the organisation and this will be done in April 2006. Fire Safety records were examined the Fire system was tested in April 2005 and fire training is due in June 2006. Weekly tests are completed and these are fully compliant with the requirements. Evidence was seen of the following: The central Hearing system was checked in April 2005. The Water and Legionnella check was completed in May 2005 Weekly hot water temperature checks are made by the handyman and recorded. There is a waste contract in place. The lift is serviced quarterly next due in July 2006. The hoists are serviced yearly and were last done in July 2005. The boiler was serviced in March 2005 and is done yearly. The emergency call system is serviced quarterly. Portable appliance testing is completed yearly. If new residents come into the home their electrical appliances are not tested until the next cycle of testing. This needs to be reviewed as this could potentially cause a hazard to the home. All mandatory training is completed but it was identified that COSHH is needed for all new staff. Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP2 Regulation 5 • Requirement Ensure that all residents and/or their representatives have a signed copy of the contract and terms of residency. • Ensure that the Provider keeps a copy of both on the resident’s personal file. The Manager and Provider must ensure that the following care planning issues are addressed: • That care plans evidence that residents have been involved in the preparation of these plans through signature/initials. • That care plans reflect the current needs of the residents. • That there is a Homes’ standard relating to how often the daily care record should be completed for all residents. • That the Homes’ care record reflects the care being provided by the Community Nurses. (Brought forward as compliance date not expired) DS0000016506.V272985.R01.S.doc Timescale for action 28/04/06 2. OP7 15(1 & 2) 28/04/06 Nazareth House Version 5.0 Page 23 3. OP18 37 (1g & e & 2). The following amendments to the Abuse Policy and Procedure are required: • Add notify the police. • Add Inform/notify the Commission for Social Care Inspection (CSCI) immediately of any incident. • Add a section to reflect actions if police investigate the incident. • Add statement about notifying the County ‘Adults at Risk’ team. • Add Manager to complete and send a report of the allegation, incident, investigation and outcome to the CSCI. Ensure all accidents involving staff in the care home that necessitate reporting under RIDDOR are reported to the Commission. • The Registered Person must ensure there are no gaps in the employment history for an individual. • The registered person must otain written verification of the reason a person left any former care position where practicable. • Reference request forms must request the reason for the person leaving from the referee. As part of the Quality Assurance in the home the Manager must implement auditing of Systems and Processes within the home. Review the portable Appliance testing for new residents. 28/04/06 4. OP18 37(f) 28/01/06 5. OP29 19 schedule 2(4 & 6) 28/04/06 6. OP33 24 28/06/06 7. OP38 13(4c) 28/04/06 Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP30 Good Practice Recommendations Ensure the residents contract and terms of residency comply with Office of Fair Trading Standards. Ensure that the record of supervision records the agreed actions or outcomes of the session and who is responsible for their completion. Implement audits of the following within the home as part of the Quality Assurance programme: • Care records. • Care practice. • Supervision system. 3. OP33 Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nazareth House DS0000016506.V272985.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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