Inspection on 10/01/07 for The Hawthorns

This inspection was carried out on 10th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hawthorns 21/07/08

The Hawthorns 08/08/07

The Hawthorns 30/12/05

The Hawthorns 06/09/04

The Hawthorns 21/04/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Hawthorns (The) The Hawthorns Coulsdon Road Caterham Surrey CR3 5YA Lead Inspector Kenneth Dunn Unannounced Inspection 10th January 2007 10:00 Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 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 Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 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 Adults 18-65. 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. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorns (The) Address The Hawthorns Coulsdon Road Caterham Surrey CR3 5YA 01883 383713 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) Surrey and Borders Partnership NHS Trust To be confirmed Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2005 Brief Description of the Service: The Hawthorns is on the main site of Surrey and Boarders NHS Trust Headquarters. It is a self-contained building set within a group of homes. Each service user has their own bedroom. There is ample garden space to the rear of the property, which has a patio area; the rest of the garden is laid to lawn. The building is a modern bungalow style property providing accommodation for service users on the ground floor only, however there are some steps within the building. There are local shops and pubs within walking distance of the home, other community facilities, such as the library and swimming pool are reached by using the home’s own transport or local bus services. Many day care facilities are provided for service users on the Trust’s Headquarters’ site. A few service users attend activities within community facilities, such as local education services. The service users have a complex range of needs; including challenging behaviour Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes site visit by the CSCI as part of the key inspection process and carried out by Mr. K. Dunn. The site visit commenced at 09.30hrs and finished at 13.30hrs and included a tour of the premises, informal interviews with staff and service users, and a review of documents and care records. The inspector noted that some of the service users at the home have communication difficulties and judgements were made about them based on their mood, behaviour and information given by staff. The inspector would like to thank the acting manager, staff, service users; relatives, care manager and the health care professionals for their contribution to the inspection What the service does well: What has improved since the last inspection? Some work has been carried out by staff to enhance to general décor of the home. Staff recruitment has been given a priority, two new members of staff have been appointed and a potential third person has been identified and interviewed but had not been appointed. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide are good ensuring prospective service users have up to date information on which to make decisions about admission to the home. The arrangements for care planning are good ensuring prospective service users’ needs are assessed before admission to the home. EVIDENCE: The home had a statement of purpose and service user guide is written in plain English, nicely presented and easily accessible to the service users. The inspector was informed that the service users do not retain individual copies of the Statement of Purpose or the Service users guide; this was partly because some service users regularly destroy their copies or others simply do not and wish to have a copy. The inspector was informed that in order to ensure that the service users have the ability to read a copy of the statement of purpose or service users guide there is a copy kept available in the office at all times. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 9 The home had a policy on assessing the needs of service users and the acting manager stated “any prospective service users would be admitted to the home only after following a full assessment of their individual needs”. A review of records confirmed the home had a pre-assessment form including a proposed care plan which covered personal care, health needs and social support. The inspector noted evidence of joint care assessments with the service manager and individual care manager for each service user. The assessment was procedures followed at The Hawthorns are designed to of the safeguard the welfare of service users. There has however been no new service users admitted to The Hawthorns since the previous inspection, documentation seen indicated that the last admission was on the 16th of March 2001. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The arrangements for care planning are good ensuring the needs of service users are identified and met by the home. Decision making in the home is designed to ensure that the service users make decisions about their lives and assistance as needed. The systems for risk taking was robust and promoted the independence of service users. EVIDENCE: The acting manager stated the home had individual care plans and a review of records confirmed the home had person centred plans drawn up with the involvement of staff, relatives, and with limited involvement of the service users. A review of records confirmed care plans included management guidelines for service users likely to be demonstrate challenging behaviour. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 11 There is good evidence that person centred plans is regularly reviewed to reflect the changing needs of service users. Further evidence confirmed individual choices made by service users were recorded and reflected in the menu plans, activity schedules and care plans. The manager stated the home had a policy on risk taking and a review of records confirmed the home had risk assessments, which were dated and signed by staff. Further evidence confirmed risk assessments promoted independence in the areas of personal care and the use of the homes transport for community access. The manager commented staff have risk assessment training covered in LDAF (Learning Disability Award Framework) to minimise identified risk and hazards, and the home had general risk assessments pertaining to the environment to promote safety. It is indicated in a comment card completed by one of the service users care manager ‘‘staff demonstrate a clear understanding of the care needs of service users’’. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle arrangements at The Hawthorns are good ensuring service users participate in valued and fulfilling activities. The service users are part of the local community. The systems for appropriate relationships are in place ensuring service users maintain family links and friendships. Meals at the home are good and offer variety and choice. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 13 EVIDENCE: The home had a weekly activity programme for service users, which reflected valued and fulfilling activities. A review of records confirmed service users regularly attended day centres and undertake group activities and outings. The home has it’s own transport for community access and a review of records confirmed service users visited the local shops and leisure facilities. The manager stated the home had a visitor’s policy and visitor’s information was available in the service user guide. A review of records confirmed that some relatives visited the home and service users who can go home regularly to spend time with family and friends. Further evidence confirmed staff addressed service users by their preferred names and interacted with service users. Observations confirmed service users were engaged in preferred activities including, listening to music, TV and games. A review of menu plans indicated meals offered variety and choice with healthy eating options. Further evidence in the weekly activity planner confirmed service users help plan and prepare meals with service to meet their choices and preferences. The acting manager informed the inspector that all menus have dietician input to ensure it is adequate to meet the needs of service users. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for personal support are good ensuring service users receive personal support in the way they prefer and require. The systems for healthcare are well developed ensuring service users physical and emotional needs are met. The arrangements in place for the management of medication is designed to promote health, however the failure to audit the medication stored at the home has resulted in mistakes being made. EVIDENCE: The home has a schedule of activities reflected in the routine of the home with times for getting up, personal care and meals. Observations confirmed service users had good personal hygiene and were appropriately dressed to reflect their personal choice. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 15 The home had arrangements for health care with service users having access to a local GP (General Practitioner) and input from district nurse, psychiatrist and behavioural support team to meet the needs of service users. Further evidence confirmed service users have health action plans in place to highlight their present and possible future needs. Dental, chiropody and optical services are currently accessed through the trust. The inspector was informed that these arrangements would eventually be phased out and the service users would then receive treatment via the PCT (Primary Care Trust) or privately as required. The home had a policy on medications and a service level agreement with a local chemist to supply medications to the home. Further evidence confirmed the home kept a record of medications received by and returned to the pharmacy to prevent mishandling of medications. However a quantity of tranquilisers was found during the inspector audit which had been recorded and signed as being returned to the pharmacy in September 2006 but were in fact still on site. The inspector found two further errors again in the controlled drugs cabinet with records indicating that a different quantity was on site compared to the actual audit total. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complains system and there is evidence that the service users feel their views are listened to and acted upon. EVIDENCE: The service has a complaints policy, which is contained within the Service User guide and the employee’s handbook. There have been no complaints made directly to the CSCI and a review of the complaints log would indicate that there have been no complaints made to the manager since the previous inspection. A service user informed the inspector that she was more than happy with the home and did not need to make any complaints. One service users felt that if she had an issue with anyone she could go to the manager or her care manager and even friend’s out-with the home. Feedback received from relatives of some of the service users would indicate that generally they have no complaints and that their relative is well looked after. However two family members did feel that they were not fully aware of the complaints policies and processes if the need ever arose to make a complaint. A recommendation has been made to ensure that all relevant parties are aware of the complaint policy and have a copy of the policy of the document. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for the home’s premises need strengthening to ensure service users have a safe, comfortable and homely environment in which to live. EVIDENCE: The home’s premises are suitable for it stated purpose. On the day of the inspection the home was clean, well ventilated and apart from the toilets and the smoking area was free from mal odours. Observations confirmed the décor was still not satisfactory even with the efforts of the staff to meet a requirement from the previous inspection report. Some areas of the home had been redecorated but the majority of the home still requires maintaince and the decor updating. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 18 The upper area of the home was found to be in the most urgent need of refurbishment specifically the shower room, corridor and the toilet. The toilet was of particular concern, during the inspection even after cleaning it was still retained a very strong mal odour, the toilet cistern lid was broken and had been replaced by a peace of unsealed chip board, several tiles were broken or had holes in them that were then filled with a commercial filler. The flooring in all common areas was worn and in some areas the repairs were unsightly and could also become potential trip hazards themselves. Generally the lighting is very poor throughout the home and this was particularly pronounced in the dining room where the medication cabinet is fitted and could be partially to blame for two of the medication errors found. The kitchen and laundry areas are functional but again would benefit from redecoration. The net result was that the service could not be considered homely comfortable or safe. The home had a policy on infection control hand washing facilities prominently sited and observations confirmed staff practised infection control measures by washing their hands regularly. Following discussions with the manager a requirement has been made for a written development and refurbishment plan to be drawn with timescales to safeguard the interest of service users. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 19 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Recruitment and vetting practices are good and the service is committed to safeguarding the welfare of service users. Training and development needs are well developed ensuring the service users individual and joint needs are met by appropriately trained staff. EVIDENCE: The home operates a robust policy for the recruitment and retention of staff. In compliance with the policy all of the staff recruitment files are stored in a locked cabinet to promote confidentiality. A review of records confirmed staff have completed application forms, written references, statement of terms and conditions, job descriptions, health questionnaires, training records, personal details and CRB (Criminal Record Bureau) disclosure information to safeguard the welfare of service users. The inspector noted staff recruitment files were generally in good order however the information about recruitment was not easily accessible for auditing due to the practice of documents being placed randomly within the file. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 20 The manager stated the home had induction and foundation training and the trust had a dedicated training budget. A review of induction records confirmed staff training was linked to service users’ needs and covered statement of purpose, document and records, policies and procedures, and legislation. The service is still very heavily reliant on regular bank and agency staff that offer some degree of continuity to the service users. The manager stated that the trust had embarked on a major recruitment drive in an attempt to fill the vacancies and that the service had recently employed two new members of staff and during the inspection the manager was informed of a potential third staff member identified by the trust human resources department to work at the home. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 21 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management approach in the home provides an open, positive and inclusive atmosphere. The home is currently without a registered manager but is manager by a senior member of the care team in an-acting up capacity. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. EVIDENCE: Since the last inspection the registered manager has left the service and as a result a senior member of the care team is acting up and is currently managing the home on day-to-day bases. The trust has made previsions to ensure that the acting manager is effectively supported by her line manager within Surrey and Boarders NHS Trust. The acting manager indicated she was being actively supported the managers role by her line manager. The local Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 22 management of the home appears to be effective, and the home is generally operating well. The acting manager stated that she is now attempting to progress the staff team and to move them forward and to further develop the home, to ensure that when a new manager is appointed the home will remain service user focused. The RI must ensure that a new manager is appointed by the trust as soon as possible and that the appointed person applies for registration with the CSCI as soon as they are in post. The home has an effective quality audit monitoring system in place. The home under takes regular monthly regulation 26 notification visit and the report is well documented. The records observed on the day of the site visit were found to be well documented and kept up to date. This included certificates for the testing of Legionella, gas, electrical and a number of other areas tested. Insurance cover for the home is in place. However it the errors found during the medication audit and the failure of the trust to comply with the environmental requirements from the previous inspection would indicate that the general management of the home is not robust and requires to be strengthened. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 2 3 X X 2 X Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation 23(2)(b) Requirement Timescale for action 10/03/07 2 YA20 3 YA24 It is required that an immediate programme of refurbishment of communal areas is undertaken. Previous date for completion 31/03/06 13(2) The RI must ensure that the Schedules3.3 policies and procedures for the (I&k) safe handling of medication are fully implemented. 16(1), A development and 23(1&2) refurbishment plan to improve the environment of the home must be drawn with timescales to safeguard the interest of service users. 10(1), 12(2,3&5) 9(2)(b&I) The RI must ensure that the home is effectively managed. The RI must ensure that a manager is appointed to the vacant post, and that they make an application to be registered by the CSCI. 01/02/07 10/03/07 4 5 YA38 YA37 10/03/07 10/03/07 Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 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 Refer to Standard YA22 YA34 Good Practice Recommendations The RI should ensure that all relevant parties are aware of the complaint policy and have a copy of the policy. It is recommended that an audit of all staff files be carried out to ensure that all relevant items are correctly and securely stored. Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate Oxford Business Park Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Hawthorns (The) DS0000013667.V316671.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!