Inspection on 19/07/05 for Nutley Hall

This inspection was carried out on 19th July 2005.

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

Nutley Hall 17/01/07

Nutley Hall 07/03/06

Nutley Hall 03/03/05

Nutley Hall 23/06/04

Nutley Hall 13/10/03

Nutley Hall 09/01/03

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

CARE HOME ADULTS 18-65 Nutley Hall Nutley Uckfield East Sussex TN22 3NJ Lead Inspector Paul Endersby Unannounced 19 July 2005 9:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Nutley Hall Address Nutley Uckfield East Sussex TN22 3NJ 01825 712696 01825 713469 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Nutley Hall Limited Mr Paul Bradford Care Home 33 Category(ies) of Learning Disability (LD), 33 registration, with number of places Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated is thirty three (33) 2. All residents accommodated will have a learning disability 3. That a maximum of seven (7) residents can be accommodated over the age of sixty-five as long as their individual needs can be met and are regularly reviewed Date of last inspection 3 March 2005 Brief Description of the Service: Nutley Hall is made up of seven independent living units with each house being shared by houseparents and residents. The Main House is a detached Victorian building set in three acres of grounds. The home was founded in 1959 and is a Rudolf Steiner residential centre for people with learning disabilities. It is registered to accommodate 33 residents. The home is situated on the A22 in the centre of the village of Nutley about five miles north of Uckfield and overlooks the Ashdown forest. In addition to the residents accommodation there are numerous workshops and a bakery shop, which is open to the public. Nutley Hall is essentially a community of residents and staff living and working together which has grown and developed organically over a number of years. Several staff and service users have lived at Nutley Hall for many years. The organisational structure is non-hierarchical although the Registered Manager is ultimately responsible for running the service. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the morning through to mid afternoon. In the absence of the manager, who was on holiday, the Inspector met with senior staff plus other staff members. He met many of the residents including spending time specifically with five of them from different houses. The inspection included a tour of the premises as well as a review of some care plans, records and other documentary information. The inspection lasted 6½ hours. What the service does well: 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. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 & 5 The Statement of Purpose and statement of Terms and Conditions provide prospective residents and their families with helpful information when making a decision about admission to the home. The pre-admission assessment procedures ensure that the home only accepts those people whose needs can be met by the staff team. EVIDENCE: A comprehensive Statement of Purpose has been developed and is available to residents and their representatives. Many of the residents have lived at the home for many years and there have been no recent admissions into the home, although there is currently a vacancy. A policy on admissions has been prepared which outlines the various stages involved. The majority of referrals are through the Steiner community, and prospective residents or their representatives usually have specific interest in Steiner philosophy and Anthroposophy. A needs assessment format has been developed to assess prospective residents in accordance with the homes requirements and that meet the needs of the residents. The registered manager assesses prospective residents in conjunction with the house parents and advice is sought during the assessment process from Health Care Professionals, and others who know and understand the needs of prospective residents. Families and carers wishes are actively sought through the various stages of assessment and admission. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 8 A detailed statement of Terms and Conditions of Residence has been prepared which is divided into two parts. The first is the resident’s contract and part two is a contract for the resident’s representative. The previous practice whereby bedding and towels were provided by residents has been revised and these are now supplied as part of the overall service, unless individual resident chooses to purchase their own. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 The absence of clear goals in care plans could lead to inconsistent care. The potential for conflict between the ethos of the home and resident’s personal choices in regard to decision making in daily living, needs to be clarified. There is evidence that residents are supported and encouraged to expand and develop their daily living skills and that staff work with individual service users within a risk assessment framework. EVIDENCE: Care planning documentation has been prepared for all residents. A sample from the Main House were inspected and were found to be of a good standard. All contained a considerable amount of information on each resident with their needs and abilities identified. However there is some confusion between the assessment information and the subsequent care plan. Specific action required to meet identified needs or problems needs to be set out more clearly and, as at the last inspection, the Inspector recommended that personal goals and aspirations be included in care plans. Risk assessments have been carried out and included in the care planning documentation. As has previously been reported and referred to in documentation prepared at the home, Nutley Hall is based on the acceptance of spiritual uniqueness of each human being. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 10 Residents and staff live and work together within a small community. Although it is evident that residents rights and decisions are respected, considerable discussion took place in regard to how this is reflected in some aspects of daily living as identified at the last inspection. Staff acknowledged that there are some limits placed on residents, in such areas as the use of television. However they believed that this is in keeping with the philosophy and ethos of the home, which encourages participation and group activities, and is made clear in the pre-admission documentation. Further, prospective residents and their families select Nutley Hall, at least in part, for this philosophy. Staff were able to demonstrate their understanding of the residents rights to make choices regarding life decisions and why this needs, at times, to be limited. The recommendation in the last inspection report that the Statement of Purpose for the service be reviewed in order to make clear where the ethos of the service conflicts with individual choice and the reasoning for this, is in hand and will be implemented before the required date of 30 September 2005. A variety of risk assessments have been completed on an individual basis. Staff encourage service users to take responsible risks and the core staff group are experienced and competent to ensure that risks are assessed and that unacceptable risks are avoided. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15 & 16 The educational and training programme provides a wide range of positive experiences for residents. Residents are able to maintain contact with family and friends with assistance if required. The overall approach taken by staff respects resident’s rights. EVIDENCE: The ethos of the home is to provide an enabling environment for residents to reach their full potential. Residents participate in workshops on site. These include candle making, bakery, weaving, gardening, woodwork, furnishings and musical instrument making. In addition education classes are held and emphasis is placed on writing skills and awareness of the wider world. A music therapist and an art therapist work at the home. No residents are currently involved in further education or paid or voluntary employment outside Nutley Hall. Again the ethos of the home is to encourage and facilitate contact between residents and their family and friends. This is reflected in the statement of terms and conditions. Staff confirmed that they are involved in welcoming resident’s families and offer them tea or a meal as appropriate. Visitors are invited to stay for social events. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 12 However it is requested that visits and holidays normally take place at weekends and in designated holiday periods. Likewise telephone calls are requested to take place outside of workshop hours. There are facilities for service users to receive visitors in private. Residents are supported to read correspondence received, send letters and cards. Photographs of friends and relatives were displayed in resident’s bedrooms. The home enjoys the benefit of an active community group, which is made up in part of resident’s family members. The group is actively involved in fund raising activities on behalf of the home, e.g. the annual Garden Party. All residents are encouraged to play a role in the daily routines of the houses, according to their individual capabilities. This includes washing up, laying the dining table, taking responsibility for their own laundry and maintaining the grounds. Throughout the inspection it was evident that there is a high standard of interaction between staff and residents. Staff are respectful of residents privacy and were observed to knock on doors before entering. Considerable efforts are made by staff to understand and be responsive to resident’s wishes and feelings. There is a strong emphasis on structure to the day, which the home refers to as “rhythm”. This rhythm enables residents to be independent within a supportive structure and is broad enough to allow individual choice. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 The arrangements made by staff ensure resident’s health and medication needs are met. EVIDENCE: Residents are registered with a local GP practice and have access to all community medical services including GP’s, Dentists, District Nurses and Speech Therapists. Residents see a doctor in private and are enabled to access health professionals, being taken to appointments as needed, either by staff or members of their family. Anthroposophical medicine techniques are used to complement the orthodox medical practices and at the request of individual residents and/or their representative, arrangements can be made for them to see a doctor who specialises in anthroposophical medicine, from which therapies, remedies and medications may be provided. Since the last inspection the home has received a visit from CSCI’s Pharmacy Inspector. As a result new policies and procedures have been put in place and further training has been arranged for staff to take place in September of this year. There are individual drug cupboards in each of the houses with appropriate records maintained for all residents who are taking prescribed medication. Whilst GP’s are responsible for prescribing generic medication, a homeopathic doctor visits on a quarterly basis. Policies and procedures are in place for the use of homeopathic medicines. A few residents self-medicate for which risk assessments have been undertaken to identify and minimise potential risks. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Arrangements for receiving complaints and protecting residents from abuse are satisfactory. EVIDENCE: A complaints procedure has been prepared and is publicly displayed. Residents confirmed that they are aware of how to make a complaint. The policy makes clear that complainants should be responded to within 28 days. A record of complaints is maintained, although this was not available for inspection on this occasion. No complaints regarding the home have been made to the Commission for Social Care Inspection since the last inspection. An adult protection policy and procedure has also been prepared. Many staff have attended training on Adult protection and managing challenging behavior. Further training in these areas is planned. A whistle blowing policy has been prepared. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 28, 29 & 30 The overall standard of the environment and maintenance of the home is good, providing residents with an attractive and safe place to live. The layout and décor of the buildings, including bedrooms and shared space, provide safe and comfortable accommodation for residents. EVIDENCE: The home’s premises are suitable for their stated purpose. The house is made up of four distinct satellite houses within the grounds. One further house is located within the close proximity of the grounds. Each house has its own style and character. Those areas seen at the inspection provide clean bright accommodation and are furnished to a high standard. Orchard House, a community hall has recently been built in the grounds of the home and provides extensive and flexible communal facilities for residents. There has been a recent visit by the Environmental Health Officer. The home meets the requirements of the Fire Brigade. One member of staff has been designated as the fire safety officer and received relevant training. He is responsible for ensuring all staff receive regular training in fire safety. The records of testing of fire alarms points, fire fighting equipment and emergency were up to date. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 16 The home has a maintenance programme in place and the buildings are in a good state of repair. House-parents submit a written quarterly list of items needing attention. There is more than adequate communal space across the houses. This comprises of the new Orchard House hall, lounge-diners in each house, and workshops areas. The outdoor space consists of extensive well-maintained grounds. Seating areas are provided at various locations around the grounds along with a water feature making the grounds a very pleasant social space for residents and their visitors to enjoy. The pathways around the grounds enable easy access for wheelchairs. Aids and adaptations for individual residents are provided, although at this time these are minimal. However it was confirmed that should residents require further equipment this would be provided following appropriate assessments and a referral to an Occupational Therapist on an individual basis. The areas inspected were clean and hygienic throughout. There is a main laundry facility and each house also has domestic laundry equipment. There is a procedure on the control of infection. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 36 Staff are clear as to their roles and responsibilities. The formal arrangements for staff supervision and appraisal need further improvement. EVIDENCE: All staff have a job description. Staff members seen by the Inspector were clear about their roles and responsibilities and felt supported in working to their job description. There is an appropriate balance of staff with regard to age and gender reflecting the diversity of residents. Many of the core staff have been at the home for many years and the House Parent system enables staff to develop a relationship with residents over a significant period of time. Residents have moved around the houses when their needs or preferences change. There is a system of weekly, fortnightly and monthly meetings between the various staff groups (house parents, workshop leaders, core group and management team) where issues relating to life at Nutley Hall are discussed. There are weekly staff meetings to discuss residents. Individual supervision is being developed using “supervision circles” for senior staff. House parents however supervise those working in their house. In is planned that staff responsible for undertaking supervision will receive relevant training. However the deployment of the staff team means that staff live with one-another and informal supervision occurs regularly. A system for annual appraisal of core staff is has been introduced but is yet to be fully maintained. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, & 42 It is evident that the home is well managed and that residents views are listened to. Appropriate arrangements have been made for providing a safe environment for residents. EVIDENCE: The home’s structure is non-hierarchical. Instead a core and management group meet weekly to discuss issues and the management of the home. Both groups are made up of senior staff, including long serving staff, and management. Staff and residents spoke positively about the management of the home. Staff felt they were supported and encouraged to put forward their own ideas and suggest new ways of doing things. Visits by the Responsible Individual are undertaken and reports prepared with a copy forwarded to CSCI. A system of quality assurance, “Ways to Quality” is being introduced but is still in the early stages. As at the previous inspection it is recommended that resident’s views be emphasised as part of this process. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 19 However the culture of the home is that the views of residents are sought on a regular basis and informal mechanisms are in place to consistently monitor quality assurance. These include seeking the views of residents during formal reviews, and through the daily contact with house parents. An annual development plan has been introduced involving staff, residents, families and health care professionals to identify aims and outcomes for the home. Safe working practices on moving and handling, fire safety, first aid, and food hygiene are covered in staff induction. Training is yet to be provided in infection control. The home has a Health and Safety Policy that all staff are taken through during their induction. A member of staff with specific skills and experience in health and safety issues has been appointed. Risk assessments are completed on the home. Hot water taps on baths plus all showers are fitted with pre-set valves. However there are no such controls on wash hand basins. Risk assessments have been completed for all residents on the use of outlets were hot water is delivered in excess of the recommended temperature. Window restrictors have not been fitted on all upper floor windows and therefore risk assessments need to be undertaken. Assessments of radiators and pipe work have been carried out to establish whether these pose a risk of scolding to residents, and guards fitted accordingly. Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x x 4 3 3 Standard No 11 12 13 14 15 16 17 x 3 x x 3 3 x Standard No 31 32 33 34 35 36 Score 3 x x x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Nutley Hall Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 2 x x 3 x H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 6(a) Requirement The statement of purpose should be revised to include details of where the ethos of the service may conflict with residents rights to make decisions and why this is so. (Outstanding from the last inspection). A risk assessment must be undertaken on all windows and restrictors placed as required. Timescale for action 30.09.2005 2. 42 13(4)(c) 31.10.2005 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 6 6 Good Practice Recommendations That residents personal goals and aspirations for the future be included in care plans. (Outstanding from the last inspection). There should be a clear separation between the assessment and the subsequent care plan, with the agreed action to be taken in response to assessed needs clearly identified. All staff involved in giving supervision should receive training in this. (Outstanding from the last inspection). 3. 36 Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 22 4. 5. 6. 39 43 A quality assurance system based on receivng the views of residents should be introduced.(Outstanding from the last inspection). Staff should receive training in infection control. (Outstanding from the last inspection). Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Nutley Hall H59-H10 S21176 Nutley Hall V236251 190705 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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