Inspection on 26/01/06 for Nightingale House (Nightingale Lane)

This inspection was carried out on 26th January 2006.

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

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

Other inspections for this house

Nightingale House (Nightingale... 10/07/06

Nightingale House (Nightingale... 25/08/05

Nightingale House (Nightingale... 10/01/05

Nightingale House (Nightingale... 28/05/04

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Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Nightingale House 105 Nightingale Lane London SW12 8NB Lead Inspector Jon Fry Unannounced Inspection 26th January 2006 10:15 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 Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 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. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Nightingale House Address 105 Nightingale Lane London SW12 8NB 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) 020 8673 3495 020 8675 2258 info@nightingalehouse.org.uk www.nightingalehouse.org.uk Nightingale House Soobhug Awatar Care Home 253 Category(ies) of Dementia (39), Old age, not falling within any registration, with number other category (253) of places Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total number of beds that are residential is 144 The total number of beds that are nursing is 109 Date of last inspection Brief Description of the Service: Nightingale is a large home providing care for older people who are Jewish or of the Jewish faith. The home has three residential units and three nursing units. A fourth unit (previously in use as residential) was closed for re-development at the time of this inspection. The home benefits from having a large activities department in addition to its own Therapies Department. Other facilities include a Synagogue, concert hall and landscaped gardens. The home is situated close to local amenities and public transport. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by three regulation inspectors on the 26th January 2006 for approximately seven hours. This visit focused on two units only – the Balint nursing unit and the Wine residential unit. During the course of this visit the inspectors had the opportunity to speak with twenty residents, three visitors, six members of care staff, the personnel and finance managers, the registered manager and the chief executive of the home. A specialist Pharmacist inspector undertook a further announced inspection visit on the 31st January 2006. What the service does well: What has improved since the last inspection? What they could do better: The management of medication could be improved at the home. Progress was noted during this inspection but the home must now aim to fully meet this National Minimum Standard. The service should continue to develop care plan documentation to be more ‘person centred’ and better reflect the individual. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 6 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. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 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 Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. Resident’s benefit from their needs being appropriately assessed before admission. EVIDENCE: There is an appropriate procedure to make sure that the individual needs of a resident are assessed before they move into the home. Assessments were fully completed for the residents whose care plans were examined. Improvement in the completion and update of care plan documentation was again noted during this inspection. This means that changes in assessed needs can be fully addressed by the service when required. Comments from residents were generally very positive about the service they were receiving at the home. These included “they care for me very well”, “I’m better off than being at home” and “I like it immensely”. One resident said that the home was “the best I’ve come across” whilst another thought it was “poor”. One visitor stated that the care was “just about ok” but there was room for improvement. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 9 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): 7, 8, 9 and 10. Care plans are subject to a monthly review process and are updated as required. There are opportunities to develop the care plans to be more person centred and to better reflect the individual’s life, experiences and preferences. Resident’s benefit from good access to health services. Significant improvements in the management of medication in the home have been made around development of standard procedures, recording and auditing. Minor inconsistencies and omissions in recording along with inappropriate disposal arrangements were found that might have an effect on the health and welfare of residents and identify further areas for training and improvement. EVIDENCE: Care plan documentation for three residents was examined within the residential unit on the day of inspection. These were seen to be fully completed and subject to a monthly review process. Care plans within the nursing unit had also been recently been reviewed and these contained good information on areas such as the individuals likes and dislikes. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 10 Daily notes made by staff have improved with more accurate information being recorded regarding the actual care being given to residents. One instance was observed however where a resident was described as ‘demanding’. It may benefit care staff to discuss care planning around areas such as sexuality and loss to make sure that good information is recorded as required. The home should additionally make staff aware of how or if they should be filling in the “resuscitation status” section within the care plans. The home should make sure that the resident and / or their representative have been consulted regarding the care plan and the content agreed. As recommended following the August 2005 inspection, there are opportunities to develop the care plans to be more ‘person centred’ and better reflect the individual resident. The registered manager reported that the home was reviewing the care planning system being used and planned to introduce new documentation by April 2006. The new care plans are being developed to make sure that they are an effective tool for use by all staff involved with the resident. Feedback from residents regarding access to healthcare was very positive. Comments received from individuals included “very good”, “good” and “I can see the GP at any time”. The findings of the Pharmacist Inspector following the visit undertaken on the 31st January 2006 were as follows: The main building, one residential unit and two floors on both nursing units were inspected. All medications administered by staff along with the records relating to receipt, storage, administration and disposal of medication were examined. Staff on each unit were interviewed and medication for eleven residents was counted and compared to the records of receipt and administration to monitor whether residents were administered their medication in accordance with the prescribers’ directions. From these observations and discussions it was seen that residents are able to self-administer medication after an appropriate risk assessment. This is monitored within a risk management framework. New standard operating procedures for the home have been introduced along with a self-audit tool for each unit to monitor medication management. The receipt of the current month’s regular medication had not been recorded on one unit. Staff on these units did not seem to be aware that the receipt was to be recorded on the administration record. It is practice in the home to record the quantity of medication carried over from one month to the next. This had not been done for two residents making if difficult to assess if the residents had received their medication as prescribed. One unit continues to have medication entries on the administration record written by hand. Printed Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 11 sheets are being introduced with the next supply of medication in the monitored dosage system. The dose to be given was written in code and figures rather than in words on all hand-written entries. Two residents on one unit had missing entries on the administration record indicating administration/non-administration of medication. This had not been picked up in the self-audit tool. Two residents on another unit were not being administered their creams as prescribed on the label. No information was available to indicate the change in dose. This had not been picked up in the audit. One incident in December 2005 had not been reviewed by the manager or pharmacist. Other incidents around medication had been detected in the audit system. The return of medication is recorded in a duplicate book. All the necessary details are recorded along with the reason for return. Medication for disposal is stored in the home’s pharmacy. There is no audit trail for what happens to the medication once it is received. Medication containers for disposal were not sealed and no containers were available for the appropriate disposal of controlled drugs. Expired items were found on one unit. On two units inappropriate waste had been put in the sharps container including an inhaler. Medication not supplied in the monitored dosage system could not be compared to the amount that should be in stock for two residents, as the quantity of medication carried over from one month to the next had not been recorded. One item in the monitored dosage system was not labelled with important additional directions for administration. No patient information leaflet was available for this medication. Three residents on one of the nursing units did not have clear guidelines in place for the administration of medication prescribed when needed to control behaviour. It was noted that the rooms used for medication storage could be better equipped with worktops and appropriate cupboards. Differences in how to measure the fridge temperatures were found between staff members. On the day of inspection all temperature were within the normal range. All other records were completed accurately, medication was stored safely under the appropriate conditions and administered by trained staff ensuring the health and welfare of residents are protected and a pharmacist is employed in the home for advice, developing the policies and procedures, training of staff and highlights to the GP residents needing medication review. This is reflected in the low use of sedative medication to control behaviour on the dementia unit and input into the medication incident reporting system. A service level Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 12 agreement is being negotiated with the supplying pharmacist to include advice and training. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 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 and 15. Residents are offered an impressive range of activities and social opportunities. Visitors are made welcome at the home. The dietary needs of residents are appropriately catered for. There are appropriate systems in place for residents to give feedback to the home about the food provided to them. EVIDENCE: Each unit has a notice board showing a range of future events and activities. These include guest speakers, films, tai chi and mini-Olympics. Residents spoken to confirmed they were aware of activities and that they could choose to take part as they wished. One newer resident said that they had bought lots of books in to read but had not yet had time to start reading any of them. Another resident stated that the activities were “very impressive”. A leaflet entitled ‘What’s on at Nightingale’ is regularly given to all residents. Many residents were seen to be attending an afternoon dance on the day of inspection. Care plans looked at lacked details of resident social interests and daily logs did not include a record of social activities. A new activity co-ordinator for one Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 14 unit said that they were introducing a system to improve the recording of activities. The introduction of a new care planning system at the home should also serve to better reflect the social interests of individual residents. Residents confirmed that they were able to receive visitors at any time. One resident said that they were able to have visitors “late at night”. The home makes good use of volunteers, one of whom spoke positively about her role as a visitor to residents who wanted to chat. Residents are all Jewish and the food provided at Nightingale is strictly kosher. Feedback regarding the food provided was mixed during this inspection and comments included “quite good”, “OK”, “it has got better recently”, “mediocre” and “good food ruined”. One resident reported that the vegetarian food was “good”. The wide variety of comments were reported to the management of the home at the time of this inspection. They confirmed that there had been no major changes in the catering since the previous inspection took place in August 2005. There are appropriate systems in place for residents to voice their opinions about the food provided. These include comment books in the dining rooms, a food forum and the residents meetings held on units. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 15 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): 16 and 18. An appropriate complaints procedure is in place at the home. Policies and procedures are in place to protect residents from abuse. Training on the Protection of Vulnerable Adults (POVA) is provided to care staff. EVIDENCE: A record of verbal complaints was seen to be kept within the residential unit. Outcomes for each complaint were recorded with timescales and were signed off by the unit manager. Residents spoken to generally expressed their confidence in the home to deal with any concern or complaint they might have. One resident and their relative said that they had complained to staff within the residential unit about a particular issue but were unsure if it had been satisfactorily addressed. The concern had not been documented within the unit record but action had been taken by the home to resolve the issue. It is strongly recommended that all issues raised by residents or their representatives are fully logged and outcomes recorded. The home keeps a central record of complaints along with actions taken and outcomes. Each complaint is rated to a scale indicating level of risk and seriousness of the complaint. This record was not examined during this inspection. No complaints have been received directly by the CSCI since the August 2005 inspection visit. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 16 The induction training for new staff includes abuse awareness and the in-house training programme includes instruction on awareness and the procedures to follow. One POVA issue was being investigated at the time of this inspection visit. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 17 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 and 26. The standard of accommodation is very good providing residents with a comfortable place to live. The home is kept clean and hygienic. EVIDENCE: Residents are provided with comfortable accommodation that is maintained to a good standard. No maintenance issues were seen during this inspection and all areas of the home were kept clean and tidy. Comments made by residents included “the housekeeping is excellent”, “the maintenance is first class” and “always very clean”. The new nursing unit was nearing completion at the time of this inspection visit. This will offer residents very spacious en-suite accommodation along with impressive communal facilities. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The home has sufficient staff on duty to meet the needs of the residents. An organisational training programme is in place and care staff attend a wide range of training courses. EVIDENCE: Comments from residents and their visitors about the staff included “nice”, “very good”, “polite” and “they care for me very well”. One relative visiting the home said that the staff were “very good”. Other comments made included “nice – the odd one isn’t so nice but I can’t complain” and “some are angels and some are not”. These were discussed with the management of the home at the time of inspection. The numbers of staff on duty in each unit were satisfactory at the time of this inspection. Staff and residents spoken to generally reported that they felt there were enough staff on duty to meet individual care needs. One resident said they felt there were “too many managers and not enough staff” whilst another said that the “nurses here look after me very well”. Care staff spoken to were very positive about the opportunities available for training and development. Staff training includes in-house courses for pressure sore prevention, Fire Safety, dementia, medication administration and report writing. Training records are kept that are well organised and up to date. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 19 The NVQ training provision is again commended given the scale of the training provision required. The home far exceeds the 50 national target for trained care staff. The home is planning to change shift patterns in order to allow for more opportunities for staff training. This will include sharing knowledge between departments to promote good practice throughout the home. It is recommended that the home considers further training around sexuality, bereavement and person centred planning. The home carries out appropriate checks including Criminal Records Bureau (CRB) checks on staff before they start work in the home. This process helps to ensure the protection of residents. Recruitment records examined for care staff were well maintained and included application forms and identity documents. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38. An organised and experienced management team is in place at the home The home makes sure that money held on behalf of residents is kept safe. Resident’s financial interests are protected. The health and safety of residents is protected by regular checks being carried out within the home. EVIDENCE: The registered manager has been in post since 2004. A nursing strategy is in place which includes a key aim to develop a workforce that is highly professional and puts ‘quality at the heart of everything we do’. The majority of residents hold Resident Safekeeping Accounts for day-to-day expenses. Individuals holding these accounts can sign for purchases in the Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 21 home and these amounts are then taken out of their account. One resident confirmed that they are able to deposit money in their account to buy things from the shop. Accounts and finances are monitored by the home’s finance team. The Finance Manager reported that an external audit is carried out annually with two additional unannounced visits to audit the payroll and petty cash. Regular checks are carried out to the building, furnishings and equipment to ensure the Health and Safety of residents and visitors to the home. Records were seen for checks of First Aid boxes, maintenance checks on hoists and for Fire Safety drills. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 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 X X 3 3 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 4 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 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 The Registered Persons must ensure that the receipt of all medication is recorded accurately and consistently across the home. The Registered Persons must ensure that all items of medical waste are disposed of appropriately with a clear audit trail. The Registered Persons must ensure that staff remove expired items from use. The Registered Persons must ensure that staff are fully trained in the monitoring of fridge temperatures and the use of the audit tool. The Registered Persons must ensure that changes of medication doses are clearly recorded and medication administration records completed appropriately. The Registered Persons must ensure that clear written guidelines are place for all medication prescribed when needed to control behaviour DS0000019109.V281298.R01.S.doc Timescale for action 01/03/06 2. OP9 13 (2) 01/03/06 3. 4. OP9 OP9 13 (2) 13 (2) 01/03/06 01/04/06 5. OP9 13 (2) 01/03/06 6. OP9 13 (2) 01/03/06 Nightingale House Version 5.1 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. Refer to Standard OP7 Good Practice Recommendations It is recommended that the care plans be developed to ensure that they are person centred. Information such as the individual life history, experience and likes & dislikes should be expanded within the individual documentation maintained. Care plans should consistently evidence that the resident and / or their representatives have been consulted and the content of the plan agreed. 2. 2. 3. 4. 5. 6. 7. 8. OP7 OP9 OP9 OP9 OP9 OP9 OP16 OP30 It is recommended that further guidance be provided to care staff filling in the resuscitation status within care plans. It is recommended that the dosage of medication be written fully in words on the administration record. It is recommended that the quantity of medication carried over from one month to the next be recorded on the administration record. It is recommended that patient information leaflets are available for all medication. It is recommended that medication training be reviewed in line with Skills for Care recommendations. It is recommended that the medication storage rooms be refitted with appropriate working surfaces and lockable cupboards. It is strongly recommended that all concerns raised by residents or their representatives are logged within each unit. It is recommended that the home considers the provision of further training around sexuality, bereavement and person centred planning. Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Nightingale House DS0000019109.V281298.R01.S.doc Version 5.1 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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