Inspection on 29/12/05 for The Gables Nursing Home

This inspection was carried out on 29th December 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

The Gables Nursing Home 07/01/10

The Gables Nursing Home 20/11/07

The Gables Nursing Home 27/07/06

The Gables Nursing Home 28/07/05

The Gables Nursing Home 08/12/04

The Gables Nursing Home 10/08/04

The Gables Nursing Home 19/06/03

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Gables The Gables Nursing Home 123 Wendover Road Aylesbury Buckinghamshire HP21 9LW Lead Inspector Sue Smith Unannounced Inspection 29th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000019226.V276425.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. DS0000019226.V276425.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Gables Address The Gables Nursing Home 123 Wendover Road Aylesbury Buckinghamshire HP21 9LW 01296423077 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) Mr A.S. Dhot Mrs S.K. Dhot Mrs Minerva Patti Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places DS0000019226.V276425.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. General Nursing Care Date of last inspection 28th July 2005 Brief Description of the Service: The Gables Nursing Home is an older building with character, retaining some of its original features. The Home is situated on a main road close to local amenities. The Home provides Nursing care for 22 Service users. The staff team consists of a skill mix of qualified Nurses and Carers with a Manager who is a suitably qualified Nurse. The Home has access to a large well-kept garden, which is situated approximately five minutes away at Mandeville Grange, also owned by the proprietors. Due to the Close proximity of these two Homes the Manger is registered to manage both Homes. DS0000019226.V276425.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by Regulatory Inspectors Sue Smith and Guy Horwood over 2.5hrs. The Deputy Manager was available throughout the inspection. During the Inspection a variety of documents were assessed which included pre-admission assessments, Careplans, medication, policies, activities, menus, complaints, adult protection and training, In addition a full environmental tour took place, which has highlighted several issues that need to be addressed in the future plans for the home. What the service does well: Provides a full pre-admission assessment to ensure the home is able to meet the needs of potential Service Users prior to admission. Has individual Careplans in place, which identify social as well as care and medical needs. These were maintained to a high standard. Robust medication procedures are in place with all medication administered by suitably qualified Nurses. Policies with additional guidelines are in place to support staff to care for the Service User coming to the end of the lifecycle. Additional policies are in place to support staff to implement actions on the death of a Service User. Service Users are supported to maintain links with families and friends with no restrictions in place on visiting. All complaints are appropriately investigated with documentation open to inspection. All complaints are actioned in line with the homes policy. A programme of training is in place, which supports the professional development of the staff team. A suitably skilled Manager who is supported by a competent Deputy Manager undertakes the management of the home. DS0000019226.V276425.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: A high proportion of the issued raised are due to the findings of the environmental tour. There are several areas throughout the home that would benefit from an update in decoration and refurbishment. As mentioned in this report the inspectors realise the impact such development of the home would have financially and as a result have asked for a business plan which is reflective of the next 24 months to address these issues. This plan can then be used when assessing the environmental standards for the home during future inspections. An immediate requirement was received for work that had not been completed following a requirement of the last inspection for the Sluice room lock to be fixed. DS0000019226.V276425.R01.S.doc Version 5.1 Page 7 The door to Room 10 requires further repair work to be undertaken to ensure it does close. 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. DS0000019226.V276425.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000019226.V276425.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. A thorough pre-admission assessment is undertaken for all prospective Service Users thus ensuring the home is able to meet the needs of Service Users prior to agreeing admission. EVIDENCE: All Service Users are visited prior to admission to assess suitability. Supporting documentation of these assessments was evident in the individual Careplans. As a high proportion of admissions takes place directly from hospital it is unlikely the Service User would visit the home prior to admission, in these cases the families or significant others are invited to the home to decide whether it would be suitable. Trial periods are offered with ongoing assessment of needs taking place, any issues of concern are addressed during this time with additional care and support put in place as required, should the admission be seen as unsuitable during this time then additional support would be offered until such time as DS0000019226.V276425.R01.S.doc Version 5.1 Page 10 alternative accommodation can be found. The ongoing assessment process was evident during this inspection with one recent admission requiring a change of room due to incompatibility with the existing Service Users needs. The family of this Service User were appreciative of the open dialogue with the Deputy Manager and the support offered. DS0000019226.V276425.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, 11. An individual plan of care is in place for all Service Users, which is reflective of current needs and personal preferences, ensuring all care is implemented professionally and in a manner suitable to the individual. Robust medication procedures are in place, ensuring the protection of Service Users. A death and dying policy and guidance is in place, ensuring all Service Users are treated with dignity and respect at the time of their death. EVIDENCE: All Service Users have an individual Careplan, which is reflective of current care and Nursing needs. The responsible Nurse regularly monitors these files. The Careplan included an assessment of mobility and supporting risk assessments, Pressure Wound assessments and actions, individual plans of care, which included health and social needs. Daily note entries were found to be informative and up-to-date. Careplans were reflective of review with further implementations added as required. DS0000019226.V276425.R01.S.doc Version 5.1 Page 12 Medication procedures were found to be robust with additional information held on file. There were a no gaps in MAR (Medication Administration Records), however the home is reminded to record refused medication on the MAR sheets. The Home has thorough policies and supporting procedures and guidance for staff when dealing with the death or dying process of a Service User. These place emphasis on respecting the wishes of the Service User and families and ensuring the dignity of the Service User is maintained. Additional policies are in place for dealing with a sudden death, which are in line with current guidance. DS0000019226.V276425.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, 15. Activities and social experiences are offered at the home with the support of an Activities Co-ordinator thus ensuring the social and recreational needs of Service Users are met. There are no restrictions on visiting times thus ensuring Service Users are able to maintain relationships and links with the local community. Menus are nutritiously balanced to ensure the needs of Service Users are met, however the main meals offered are repetitive and lack variety, which could become boring and unappealing to Service Users. EVIDENCE: The Home has an activities co-ordinator who works most mornings during the week. The group and 1:1 activities offered are appealing to the Service Users at the home. It was noticed that there was a shortage of planned activities taking place during the afternoon, one explanation for this is that Service Users prefer to sit and relax in the afternoons, however some form of activity management needs to be put in place for those few Service Users who would like some form of stimulation in the afternoon/evenings, especially during the winter months when access to outside facilities is limited. A recommendation DS0000019226.V276425.R01.S.doc Version 5.1 Page 14 is made to further explore activity management to include options for afternoons/evenings. The Home is providing meals, which are both nutritious and tasty, however on inspection of the menu it was noted these are a monthly rotating menu which provides limited variety in its main meal options, four of the seven main meals are repeated on all four weeks, there is a risk these could become boring and non-appetising to the Service Users, the Inspector recommends these be quality audited to ensure meals are varied and appealing. On saying this there is an abundance of food offered throughout the day with tasty home baking and refreshments. DS0000019226.V276425.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, 18. The Home has a comprehensive complaints procedure, with records of complaints and investigations open to inspection. The complaints procedure is made available to all Service Users and significant others, which ensures all relevant persons, are able to make a formal complaint appropriately. The Home has a Protection of Vulnerable Adults from Abuse Policy, however this needs updating to ensure the protection of Service Users. EVIDENCE: The home records all complaints with supporting investigation documentation open to inspection. There have been no complaints received at the home or directly to the Commission since the last inspection. The Home does have a Protection of Vulnerable Adults from Abuse Policy; this will need reviewing to ensure it is reflective of the Buckinghamshire interagency policy and its reporting systems. A requirement is made for this work to be carried out. It is also recommended the home makes application for a copy of the inter-agency policy for reference. DS0000019226.V276425.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Suitable sleeping accommodation is provided with evidence of personal possessions to make these more homely for Service Users, however some furnishings are in need of replacement to ensure a homely and safe environment is maintained for Service Users. The Home has designated cleaners who ensure the home is clean, hygienic and free from offensive odours. Sufficient numbers of toilets and bathrooms are available to ensure the needs of Service Users are met. The Home does need refurbishment and an update in decoration in some areas to ensure it continues to provide a homely and safe environment for Service Users. EVIDENCE: DS0000019226.V276425.R01.S.doc Version 5.1 Page 17 The home is an older building with an extension providing additional facilities. Service Users spoken with at the time of inspection were happy to be at the home and were complimentary of the standards of both the Nursing/Care team and the domestic team, they reported the standards of cleanliness in the home are maintained and they had no serious issues of concern with the environment. However on inspection the Inspectors have found areas that do require refurbishment, repair and decoration to ensure the home continues to maintain its standards. The Home is cleaned to a high standard by a dedicated domestic team, there were no offensive odours present on the day of inspection and infection control measures are in place. There are sufficient numbers of toilets in close proximity to Service Users bedrooms. These are generally well maintained, however one toilet requires a new seat, as the one presently used is broken. In addition a large T.V. has been stored in this area making access difficult, the inspectors understand this facility is presently not in use, however as it is included in the numbers of facilities provided attention needs to be made to making this area accessible. It was also noted during inspection that the shower chair in one bathroom has a wheel missing making this equipment unfit for purpose. In the bathroom opposite Room 10, the clinical waste bag (which was empty) had been left on the floor, clearly an oversight by staff but one that needs to be addressed with staff. In addition this bathroom does need urgent attention to it’s flooring which will need replacing. Additional maintenance and decoration is required in this bathroom as there is evident chipping to woodwork and staining to wallpaper close to the sink and toilet. The seat to the bath hoist in one bathroom is stained and will need a thorough clean to remove stains or replacing if this is not successful. There was noticeable repair to the windowsill having taken place in one of the sluice rooms, however this work has not been completed and requires tiling to take place. Several bedrooms were without working call bells or call bells were situated out of reach of Service Users or were not an available facility in the room. The inspectors noted broken glass in the lead light windows in the downstairs hallway; this will need attention to ensure it is safely maintained. As work has already been carried out to preserve the extensive original leadlight windows in the stairway the inspector suggests similar preservation work takes place to this glass. DS0000019226.V276425.R01.S.doc Version 5.1 Page 18 The door to Room 10 is still not closing to its stops and will require further maintenance work to ensure this door is operating safely. Risk assessments need to be undertaken in relation to the supplementary heating used in some bedrooms to ensure all risks associated with their use are minimised. In addition to the maintenance issues that have been identified the inspectors feel the home’s Proprietors and Managers need to assess the replacement of some of the furnishings and fittings used in the home, due to age and excessive use some of these appear shabby and worn, which detracts from the otherwise excellent service provided by this home. This includes some vanity units in bedrooms which are chipped and worn, curtains that need re-hanging or replacing, carpets with permanent stains replacing and beds used for frail Service Users replaced with adjustable beds. The Inspectors do realise the cost implications associated with all of the above observations and would not expect all of this work to be carried out immediately. In response to these observations a requirement for a business plan reflective of a timescale up to 24 months of how the home’s environment will be updated and improved will need to be submitted to the Commission within 4 months of this inspection date. The Inspector will require this plan to take into account the risks associated with some areas and a prioritising of work to take place for those causing the greater risks. This plan can then be taken into consideration during future inspections of the home. The above observation also has an impact on the assessing of Standard 38 and has been reflected in the evidence section of this standard. DS0000019226.V276425.R01.S.doc Version 5.1 Page 19 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, 30. Suitably trained staff in sufficient numbers is provided at the home to ensure the needs of Service Users is met. An ongoing programme of training is in place, which ensures a competent staff team meet the needs of Service Users. EVIDENCE: The home holds records of all training; individual training and supervision folders, which were open to inspection, support this. These folders hold copies of all training certificates obtained by staff and a list of training undertaken. The home is reminded to up-date these as training has taken place to ensure an accurate assessment of training can be undertaken. In the past 12 months staff have attended training in Infection Control, Fire Awareness, NVQ, C.O.S.H.H., Customer Care, Abuse, Oral Health, Wound Care, First Aid and Moving and Handling. In addition the home offers English as a Second Language to its foreign workers facilitated by Aylesbury College. At this time the home has three members of staff working towards their NVQ 2, four have completed their NVQ 2, one has completed an NVQ 3 and one is working towards an NVQ 3. In addition one member of staff has recently DS0000019226.V276425.R01.S.doc Version 5.1 Page 20 become a part time employee as he is undergoing his Nursing Training. At this time the Home does not have any Adaptation Nurses employed. A plan of future training is in place to ensure the continued professional development of the staff team. Service User feedback obtained during the inspection was reflective of a skilled and supportive staff team. DS0000019226.V276425.R01.S.doc Version 5.1 Page 21 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, 32, 34, 38 The Homes Manager is competent in her role; the home is professionally managed ensuring it continues to meet the needs of its Service Users. The home has health and safety policies and procedures in place, however there were some issues of concern, which could cause unnecessary risk to Service Users. EVIDENCE: The Homes manager continues to work efficiently in her role, supported by an able and experienced Deputy Home Manager. The Management team continue to work hard to meet the needs of Service Users in a supportive and homely environment. The homes Management and Staff have created a relaxed and friendly environment which ensure the Service Users are treated with respect, this has to be attributed to the professional standards maintained by the DS0000019226.V276425.R01.S.doc Version 5.1 Page 22 Manager and Deputy who operate an open door policy to ensure they are available to discuss issues of concern. The home received an immediate requirement during this inspection to ensure the lock on the sluice room door is fixed. This was not implemented following a requirement made at the last inspection. In addition a Service User was observed repetitively trying to gain entry to the laundry, which had been left unlocked, the inspector and a visitor to the home (in the absence of staff) ensured this did not occur. This was discussed with the Deputy Manager during the inspection who agreed it was an oversight by staff. However due to the high risk of this area the Inspector feels a requirement to ensure this door is locked at all times when not in use is required. As noted in the environmental standards of this report there are a high number of areas of the home that could be classified as a hazard (or high risk) to Service Users, as mentioned broken panes in windows were observed, call bells were out of order, flooring to one bathroom needs replacing, chipped woodwork, unfinished repairs to window sill (needs tiling) and adjustable beds need purchasing for those Service Users who require nursing care and are bed bound. In addition furnishings and fittings in some bedrooms and communal areas are looking shabby and in need of replacement. The Inspectors realise this is a tall order and appreciates the financial implications on the home, therefore a requirement for a business plan of how these areas will be addressed in the next 12 to 24 months will need to be submitted to the Commission for reference when conducting further inspections. Although the home has received a standard not met for some of its environmental standards (which include some aspects of health and safety) the Inspector would hope the reader is not detracted from the high standard of nursing and care that is implemented by a committed and dedicated staff team. DS0000019226.V276425.R01.S.doc Version 5.1 Page 23 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 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 3 3 2 2 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 3 X X X 2 DS0000019226.V276425.R01.S.doc Version 5.1 Page 24 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 OP18 Regulation 13 (6) Requirement The home is required to update its protection of vulnerable adult policy to ensure it is in line with the reporting systems of the Buckinghamshire Inter-Agency policy. The door to room 10, requires further maintenance and repair to ensure it is operating efficiently. An immediate requirement was given to ensure the work required to fix the lock to the downstairs sluice facility is undertaken. A 24 month Business Plan is submitted to the Commission within 4 months of this inspection which reflects the improvements under standards 19-26 and standard 38, The door to the laundry room remains locked when not in use. Timescale for action 29/03/06 2 OP19 13 (4) c 28/02/06 3 13 (4) c 29/01/06 4 OP19OP26, OP 38 23 29/04/06 5 OP38 13 (4c) 29/12/06 DS0000019226.V276425.R01.S.doc Version 5.1 Page 25 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 3 Refer to Standard OP12 OP15 OP18 Good Practice Recommendations A recommendation is made to further explore activity management to include options for afternoons/evenings. The Inspector recommends Menus be quality audited to ensure they are varied and appealing. The home obtains a copy of the Buckinghamshire InterAgency for the Protection of Vulnerable Adults from Abuse to support them in updating their own reporting systems. DS0000019226.V276425.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000019226.V276425.R01.S.doc Version 5.1 Page 27 - 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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