Inspection on 10/05/05 for Tang Hall

This inspection was carried out on 10th May 2005.

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

Other inspections for this house

Tang Hall 30/04/07

Tang Hall 11/05/06

Tang Hall 10/10/05

Tang Hall 07/12/04

Tang Hall 15/06/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOMES FOR OLDER PEOPLE Tang Hall 18 Cottage Grove Bockings Elm Clacton On Sea Essex CO16 8DH Lead Inspector Ray Burwood Final Unannounced 10 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Tang Hall Address 18 Cottage Grove, Bockings Elm, Clacton on Sea, Essex, CO16 8DH. 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) 01255421304 01255 432079 Raju-Ramasamy@hotmail.com Mr Raju Ramasamy. Mr Inayet Patel. Vacant Care Home. 20 Category(ies) of Dementia (20) Mental Disorder (20), excluding registration, with number learning disability or dementia - over 65 years of places of age (20). Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 07/12/04 Brief Description of the Service: Tang Hall is a detached two-storey Care Home, situated in a quiet residential road on the outskirts of Clacton on Sea. The home is within walking distance of a range of local shops and a few minutes drive to the town centre. The premises have been extended several times but remain in keeping with the appearance of those in the surrounding area. Accommodation is provided on two floors, the first floor being accessible by means of a passenger lift. The home offers 18 single bedrooms with one double room, with many benefiting from en-suite facilities. Communal areas include a large lounge, dining room, small lobby and a quiet room set aside for meetings or private visits. There is a small accessible and secure garden to the rear of the property, with access via patio doors from the dining room. Parking is available at the front of the premises. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken on the 10th May 2005 with the assistance of the staff and the service users. The Acting Manager of the home was absent from the home due to a family illness. This unannounced inspection was carried out between the hours of 9.30 am and 3.30 pm. On arrival at the home the inspector found service users’ relaxing, having just had their breakfast. There was a homely atmosphere and service users’ appeared happy. The inspector spoke with service users’ who told him that they liked the staff and thought the standard of care was good. A visiting district nurse and the family of a service user, who had recently passed away, commented on how the home had improved and was offering a good service. A tour of the building was undertaken and both care and staff records were inspected. Staff spoken with included members of the night staff and day staff. Discussions centred around training needs, supervision sessions and the home’s environment, all of which are reported on under the appropriate standard headings of this report. A total of 19 standards were inspected with 9 being met. The remainder were partially met with 5 requirements and 1 recommendation repeated from the homes previous inspection. 4 new requirements were highlighted during the inspection visit. Recently the General Manager had left the company, the home has an Acting Manager in post until such time as the vacancy can be filled on a permanent basis. What the service does well: The home’s strengths are having good relationships with professionals and others who support the home ie General Practitioners, Community Nurses and relatives of service users. Health care referrals are made at the earliest opportunity and appropriate follow-ups made on behalf of service users. Service users’ spoken with acknowledged that their privacy and dignity was respected by staff and they were well looked after. Overall the standard of care is good and provided by a dedicated staff team. Service users’ receive a balanced diet from a comprehensive set of menus, provided by an experienced cook. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: During the course of the inspection it was evident that the home operates on a minimum amount of staff, unless the Acting Manager’s hours are supplementing the care hours. Further development of processes regarding the recruitment of staff, and providing a consistent staff team, would allow the Acting Manager to concentrate more on her managerial duties. Care plans continue to require some further development, particularly in relation to service users’ activities and nutritional screening. The system of formal staff supervision should involve one to one sessions six times annually on a one to one basis, with someone who is trained in providing supervision. The home’s quality assurance and monitoring system should be completed following recent surveys/feedback. Arrangements for appropriate safety checks and the recording of hot water systems should carried out to help ensure the protection of service users. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 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 standard(s) 3 and 4. The home managed the admission process well and consulted other professionals during this period, thus helping ensure that the home can meet individual assessed needs, and appropriate admissions take place. At the time of the inspection, some staff had not received dementia training. EVIDENCE: The files of three service users’ were inspected with clear evidence that preadmission assessments had been carried out by the home’s manager. An additional summary of needs and care plans (health and social services) were also contained within the files inspected. From discussions with the Acting Manager during the inspection process, it was confirmed that as part of the assessment process, the home’s manager would discuss with the prospective new service users’ General Practitioner, any specific issues that may be relevant in terms of the home being able meet their needs. On admission further assessments were carried out during the trial period, recording the individuals social needs and interests. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 10 Some staff members spoken with were experienced in caring for people with dementia, but felt that further specialist training in this area would enhance their skills and enable them to further meet the needs of service users. Some staff had not received specialist dementia training. From discussions with the home’s administrator it was suggested that the acting manager would undertake a dementia training course to enable her to train, or to update the home’s staff in dementia care. The home was seen to contain aids and equipment appropriate to the care needs it aimed to meet. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 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 standard(s) 7, 8,and 9. Service users’ health and personal care needs were well met within the home. Staff had a good awareness of how to protect the privacy and dignity of service users. The home’s medication procedures ensured the protection and wellbeing of service users. EVIDENCE: Three service users’ care files were inspected and found to contain care plans that were clear and sets out service users’ health, personal and social care needs. Care plans provided sufficient detail and information to enable staff to meet the assessed needs of service users. Service users and one relative spoken with were positive about the care and the respect for privacy and dignity shown by staff. During the inspection the district nurse spoke about how well the home had addressed recent pressure sores resulting in no service user currently being treated. The home provided equipment necessary for the promotion of tissue viability and prevention of pressure sores. The district nurse was in the home to treat a service user with a trauma wound. There was no evidence to suggest that service users’ were being weighed. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 12 The home’s medication policies and procedures were inspected and were being well maintained. Staff had received the appropriate training and maintained good links with a community pharmacist. At the time of the inspection there were no service users’ retaining responsibility for their own medication. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 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 standard(s) 12 and 15. The home did not satisfy service users’ social and recreational needs on a planned basis. The home supplied sufficient quantities of fresh food, prepared by an experienced cook, and provided a well balanced diet that met individual needs. EVIDENCE: From observations made on the day of the inspection and care plans sampled, there was little evidence that service users’ were involved in any planned activities. From discussions with staff and one service user it was confirmed that some activities were initiated by staff on an ad hoc basis and did not occur on a regular basis. The Acting Manager stated that there was very little response when activities had been planned. The home did not employ an activities co-ordinator. (see requirement on P23). The home’s cook provided the evidence in relation to menu’s, food ordering, storage and regular checks carried out on kitchen equipment and cooked food. Menu’s showed a good range of meals that were repeated fortnightly taking into account seasonal foods. Service users’ spoken with were positive about the food and alternatives if required. The main meal of the day was well balanced and enjoyed by the service users spoken with. Staff were seen to assist service users’ when required. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 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 standard(s) 16 and 18. Arrangements for dealing with complaints, together with the appropriate policies and procedures, help the protection of service users. EVIDENCE: The Commission for Social Care Inspection (CSCI) had received two complaints since the last inspection. One complaint referred to the home not having sufficient staff working at a weekend referred to by the complainant as the time she was collecting her mother, and found that she had not been dressed properly and her hair was in a mess. Records requested by CSCI relating to staff rotas, showed that one member of staff had called in sick for the afternoon shift reducing the number of staff on duty. It had not been possible to immediately cover this position until later in the afternoon when another member of staff was due in. The home’s complaints policy was available to relatives and visitors, with further details displayed on the home’s notice board. The second complaint later developed into a Pova issue following an assault involving two male service users. Both were sharing a bedroom at the time and an assault resulted during the night. The wife of one of the male residents made a complaint that she had not agreed to her husband sharing a room, although it was later found that she had lodged with the home, a document agreeing to her husband sharing the home’s double room. The POVA issue was investigated and found that it was not possible to prove who was to blame. The police reported that no further action was to be taken. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 15 Regarding this incident, the home’s policy and procedures relating to the protection of vulnerable adults had been reviewed and updated. The home was in receipt of the recently revised Essex Guidelines on the Protection of Vulnerable Adults. From discussions with staff it was felt that they would benefit from refresher training in Adult Protection. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 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 standard(s) 19, 22, 25 and 26. The home provides a well-maintained environment that is accessible to service users, homely, and meets individual needs. Specialist equipment is provided to maximise service users’ independence. The home did not have appropriate hot water systems in place to ensure the safety of service users. EVIDENCE: During the inspection the areas viewed were clean and tidy, the location and the layout of the home is suitable for its stated purpose. Service users’ bedrooms were well maintained and decorated to an acceptable standard. The view from one bedroom on the ground floor was obstructed by the storage of old furniture and a mattress. This was pointed out to the member of staff accompanying the inspector. Records relating to the maintenance of the premises were in place and maintenance is normally carried out on a monthly basis. The Acting manager submits requests for any major work to be carried out to the company administrator. Records in relation to water temperatures had not been completed for 2005, random temperatures taken during the Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 17 inspection of baths and hand basins, were above the recommended safety levels of 43 degrees centigrade. The premises complied with the requirements of the local fire service. It was noted that new disability equipment had been purchased for one of the bathrooms and environmental adaptations in place to meet the needs of service users. Following the home’s last inspection a requirement to have an assessment of the premises by a suitably qualified person was still outstanding. The Acting Manager confirmed that this had now been addressed with a visit imminent. The home’s laundry facilities remain the same as the last inspection, with planning permission being sought to have a new laundry room outside the main building. Staff spoken to, confirmed that the current situation means that drying and ironing clothes can be difficult because of the lack of space. The home’s original plan of incorporating a new laundry area and walk in shower, using an existing room, had been cancelled due to difficulties with planning restrictions. Washing machines have a specified programme to meet disinfection standards and the home has policies and procedures covering infection control with a risk assessment in place. The home was clean and tidy. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. Staffing levels and skills are appropriate to meet the basic needs of service users, however, there was little scope to provide individual quality time through the home’s key-worker system. Recruitment practices were robust and protected service users. EVIDENCE: The dependency levels of service users’ had been re-assessed following discussions and a requirement made at the home’s last inspection. Since this inspection staffing levels in the home have fallen. From discussions with the Acting Manager and records seen, the home has two full-time vacancies. At present the Acting Managers hours and agency staff are being used to ensure adequate cover is maintained, both during the day and through the night. One member of staff spoken with thought the present staffing situation did not allow the home’s key-working system to be effective in supporting individual service users. Staff spoken with discussed their NVQ training but this standard was not fully inspected this time. The files of three members of staff were sampled and inspected. All contained the required checks (including references and CRB/POVA check). Identification documents had been obtained (e.g. birth certificate, passport, drivers licence, etc.). Contracts of employment were in place. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, and 37 . Care and management responsibilities were not sufficiently balanced to ensure formal supervision sessions were taking place and training needs were being met. The home’s records, for the protection of service users’, were generally well maintained with the exception of records in relation to the home’s hot water outlets. (See Outcome for Standard 25). Records were kept in a secure manner. EVIDENCE: The home’s management structure has changed since the last inspection with the current Acting Manager no longer being supported by the General Manager, who left in March 2005. The current position is that the company has advertised the vacant manager post with some response, but no applications received for the post. Staff spoken with commented on the dedication of the Acting Manager and her hands-on approach to managing the home. She is currently undertaking the NVQ Level 4 in Management and Care and is due to Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 20 take a trainer’s course in dementia. Although not experienced in management she has a wealth of experience in care work. The views of service users’, their families and professionals supporting the home had been completed. The findings have been collated and the process is at the stage of developing an action plan for the home, based on the information gathered. Practical supervision by the Acting Manager had taken place through her hands-on approach and staff meeting’s, however, formal supervisions were not taking place for all members of staff, particularly night workers on a regular basis, ie six times annually. From information gathered from staff, supervisions had been conducted through questionnaires that were returned to the Acting Manager. A new staff supervision form had been developed for future formal supervisions. Records required by regulation for the protection of service users’ inspected included a sample of: • Staff rotas. • Staff recruitment records. • Medication records. • Service user assessments. • Care plans and daily care records. Records were generally well maintained, up to date and kept in a secure manner. Records relating specifically to the health, safety and welfare of service users’ were not inspected except for records pertaining to baths and hand-basin water temperatures as reported under Standard 25. (See requirement). Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 2 x x 2 2 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 2 x x 2 2 x Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 22 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 OP4 Regulation 18 (1)(a) Requirement The registered person must ensure that all staff are trained in specialist areas in order to meet the needs of service users. This specifically refers to the need to ensure that staff training in dementia is completed(Previous timescale of 28/02/05 not met). The registerd person must ensure that the weights of service users are undertaken with records of gain or loss maintained, and appropriate action taken. The registered person must ensure that all parts of the home to which service users have access are free from hazards. This relates to the hot water temperatures of baths and hand wash basins. The registered person must ensure that there are measures in place to ensure against the spread of infection. This specifically relates to the need to ensure hand washing facilities are available in the Laundry Room, and sluicing facilities are also available.(Previous Timescale for action 31/08/05 2. OP8 14 (1)(a) 31/07/05 3. OP25 13 (4)(a)(c) 30/06/05 4. OP26 13 (3) 31/07/05 Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 23 timescale of 31/03/05 not met. 5. OP31 8 The registered provider must ensure that there is a manager in post, who is qualified, and competent to run the home. An application for registration must be made to the Commission for Social Care Inspection (CSCI).(Previous timescale of 31/01/05 not met). The registered person must establish and maintain a system for reveiwing and improving the quality of care in the home.(Previous timescale of 31/03/05 not met). The registered person must ensure that all staff working in the home are appropriately supervised. The registered person must ensure that the records kept in the home for the protection of service users, are present, complete, and correct.(Previous timescale of 31/01/05 not met). The registered person must ensure that service users social and recreational needs, are assessed and carried out on a planned basis. 31/07/05 6. OP33 24 31/07/05 7. OP36 18 (2) 30/06/05 8. OP37 17 30/06/05 9. OP12 16 (m) 30/06/05 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 OP22 Good Practice Recommendations The registered person should ensure that the premises are assessed by a suitably qualified person and equipment provided accordingly. Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Tang Hall I56 S45521 Tang Hall V220759 UI 100505 Stage 4.doc Version 1.20 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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