Inspection on 30/11/06 for The Heathers

This inspection was carried out on 30th November 2006.

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

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

Other inspections for this house

The Heathers 10/07/07

The Heathers 15/11/05

The Heathers 13/04/05

The Heathers 29/11/04

The Heathers 07/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Heathers 50 Beccles Road Bradwell Gt Yarmouth Norfolk NR31 8DQ Lead Inspector Mrs Susan Golphin Unannounced Inspection 30th November 2006 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 The Heathers DS0000015646.V322763.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 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. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Heathers Address 50 Beccles Road Bradwell Gt Yarmouth Norfolk NR31 8DQ 01493 652944 F/P01493 652944 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) Mrs Shereen Arunthathi Jesudason Miss Carol Ann Preston Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. From time to time a maximum of two (2) service users between the age of 50 and 65 years may be admitted to the home. Forty-five (45) service users may be accommodated of either sex who are aged over 65 years. The total number not to exceed 45. Date of last inspection 15th November 2005 Brief Description of the Service: The Heathers is a single storey extended property situated in the village of Bradwell, on the outskirts of Great Yarmouth. 45 older people can be accommodated in 21 double rooms (11 en-suite) and 3 single rooms (1 ensuite). Most of the bedrooms open out on to a patio area and gardens which is mainly laid to lawn with small flower beds and attractive containers arranged on the patios. In addition there are three communal rooms including a dining room which service users and their families can access. There is ample off street parking space to the front of the premises. The fees range from £325 to £510 per week. There are additional charges for personal toilet requisites, newspapers, hairdressing and chiropody services. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups that assess how well a provider delivers the service to people. This key inspection has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This report gives a brief overview of the service and the current judgments for each outcome group. In addition to the key inspection the management and staff and residents agreed to take part in the trial use of an observational tool which can be used to observe and record the well being of residents and their contact with other residents, staff and visitors to the home throughout a two hour period. The trial was carried out on 27 November 2006 between 11am and 1pm by the lead inspector. Feedback on the exercise was given to the management and staff on the day. The inspector thanks all those who agreed to take part in the exercise. What the service does well: The home continues to offer a good level of care to older people with complex care and nursing needs. Four comment cards from GP’s and one from other health care professionals stated that they were satisfied with the care service. Seven comment cards from relatives also expressed satisfaction with the service and care input to their relatives. Six comment cards from residents also stated that they were satisfied with the service overall, some minor comments were made regarding individual needs and wishes and they have been passed directly to the management for their attention. During the discussions with four residents they said that the staff are helpful and kind, one said that she has been a resident for a long time and wouldn’t want to live anywhere else. During the discussions with staff it was said that they thought the general standard of care and service has improved in the last year. That the addition of new stand aid equipment to help people to move has made tremendous difference to the way they work. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3 Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four residents were interviewed on the day ( as part of the thematic probe exercise) Also looked at the records for three other residents ( who were part of the SOFI observation exercise. Three of the residents said that they had been given information about the home and had visited beforehand, and they had been able to make a decision about the home based on the information and with the help of social workers and family. One person who has been resident since September 2006 said that she made the decision to live at the home once they had seen the home itself and read the information brochure. Another resident said that she had been able to make a decision about staying in the home with the help of her family, but could not recall seeing any information at the time. The residents seen on the day said that they had made the right decision at the time. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 9 Only one resident was aware of the annual increases in the fee. The administrator issues letters to residents or their representative or financial advisor re changes in costs /fees. Copies lie on file with the contract. None of the residents could recall what the contract actually said or whether they had signed them( only one could recall signing the contract and that was not recently.) All the residents seen and those able to express a clear view about their care said that an assessment of their needs was completed and that they were asked about their care and their immediate needs. From the discussions with residents throughout the day some of the decisions about accepting a place in the home were clearly made with help and pressure from family and in one situation reluctantly because there was no alternative care option. Copies of the service users guide are made available to all prospective residents and to commissioners of the service. Only one resident said they have the information with them. Residents files contained copy contracts and assessments of need signed by the service user or their representative. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10. Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for the group of residents involved in the Sofi observation and the thematic probe questionnaire were made available on the day. The assessment of need for each person is in place. Reviews are held regularly or as personal health care needs dictate. The reviews and any changes to the plans are agreed and signed by the resident or their representatives in one case it states that the resident has verbally agreed to the plan as they are unable to sign. The staff were observed attending to the care and nursing needs of the residents throughout the day in a kindly and attentive way. Residents confirmed that the staff assist them where needed and are kind and helpful. The comment cards returned to CSCI by relatives also expressed an overall satisfaction with the service, with an example of improved well being and appetite. Two patients admitted recently from hospital both have pressure area wounds that are responding to treatment and are being managed by the The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 11 nursing staff Three other patients have wounds which need dressing on a regular basis and two patients who are peg fed. The nurses manage the wound care of the patients and are supported and advised on wound care for residents by visiting district nursing staff. Residents GP’s offer clinical guidance and advice on treatment, nutrition and tissue viability. Wound care practice is audited by the manager on a weekly basis. The management and auditing of the medication process is carried out by the nursing staff and the manager. Continence management is discreet, but there has been a minor problem recently in one area of the home and the staff are looking at ways in which the personal continence management for one resident can be monitored more closely. A separate maintenance plan for the area is being used daily. Staff are also being reminded to work in resident’s rooms with the doors closed so that the management of incontinence materials and soiled linens is contained and sealed in laundry carriers when being transported through the home. During the observation exercise carried out prior to the inspection one member of staff was observed using mild infantile language and tone when addressing a resident. It was noted that the gesture was warmly received and responded to; however, the manager was made aware of the minor event and all staff will be reminded to address residents in a dignified way and using their chosen name. ( see recommendation) Intimate and personal care such as toileting and aiding mobility were observed as being appropriately offered and supported and carried out in a confident and competent way. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are regular activities taking place each afternoon through the week. There is a designated member of staff allocated to organise the group activities that include musical and craft sessions. One resident talked enthusiastically about the trips out in the summer and is also looking forward to the Christmas visit to the local pantomime. Resident’s can also attend activities in the wider community. There is a local club called Centre 81, where residents can attend if they wish. Visitors to the home are welcomed and encouraged and residents can see people in their own rooms or the communal rooms in private. In addition to the social and club activities there are weekly visits by the hairdresser(s) and periodic visits by the chiropodist. One resident commented positively about being able to ‘keep’ her own hairdresser, chiropodist, and GP. Resident’s are encouraged to be involved in their own care and its management, two people confirmed that they live their day to day lives as The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 13 they wish even though their mobility is limited and are dependent on the staff for all their met needs. Staff seen on the day have a clear understanding of the homes’ whistleblowing policy and are comfortable acting as advocates for residents as may be necessary. There are summer and winter menus that change weekly. There are two main courses offered at lunchtime when the main meal of the day is served. Residents confirmed that they are offered a good and varied diet and the inspector was able to observe the catering staff asking residents about their choice of meals and dishes. One resident expressed a desire for more fish meals rather than meat, and the housekeeper has agreed to spend time with the resident and devise a more individual menu for her. Staff were observed assisting people to eat and drink in an appropriate way. During the observation exercise two resident’s drinks were removed by a member of staff without any of the fluid having been consumed during the two hour observation period and without consultation with the resident concerned. The manager will remind staff about monitoring the intake of fluids to ensure both hot and cold drinks are readily available and offered throughout the day. ( see recommendation) The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,17,18 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has dealt with two minor complaints this year and one complaint was referred to the CSCI. The management have addressed the issues raised in the concern, and have reviewed some practice and procedures as a direct outcome of the investigation. From the comment cards returned to the CSCI prior to the inspection. One or two residents said that they were not familiar with the homes’ own complaints procedure, but knew who to talk to if they had any worries. The complaints policy has been updated this year and re issued. It is displayed on one of the central notice boards. During the discussions residents said that they would talk to their key worker or the office manager if they had a problem or any concerns. Others said that their families would deal with any matters relating to their care if they were not happy. All seven of the comment cards received from relatives stated that they were aware of the complaints procedure but had not had to use it. A general complaints file is maintained and any complaints relating to individual residents is maintained in their care plan. It is recommended that the complaints file contains cross reference details of all complaints that are kept in clients file for confidential reasons for audit purposes, and easy access. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 15 Staff regularly attend POVA training sessions and in the discussions with them on the day of the inspection were able to say how they would respond to any suspicions or allegations of abuse. CRB checks on all the staff have been completed and are stored safely and confidentially by the registered provider. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards19,26 Quality in this outcome area is ( good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The general standards of the home with regard to furnishings and fittings continues to improve with a good level of maintenance and input. Residents rooms are appropriately furnished and equipped. There are long term plans in place to improve the en-suite facilities in some of the older style rooms, this work will commence after the main extension has been completed. There are two small and one large communal sitting rooms and a good sized dining room which residents can use as they wish. As previously mentioned in the report, there is an ongoing incontinence problem which is being worked through with those concerned and practical ways sought to minimise the level of incidents. The staff are also to be The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 17 reminded to follow the homes own guidelines and agreed practice on managing used continence materials and soiled linens. A new extension is under construction to the rear of the premises. The building work is being is being managed externally and with minimum disruption to the residents. The manager attended infection control training on 20th November 2006 to update on any new protocols. The community infection control nurse visits the home annually to monitor the homes own policy and procedure. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is accommodating 39 older people of which 26 have nursing needs and 13 have care needs. The dependency level of 27 of the service users is high and the staff group confirmed that whilst the needs of the service users are not complex they all need constant attention with personal and intimate care, and at crucial times of the day such as early morning and evening or assistance with meals. Residents seen on the day said that the staff are attentive and helpful and respond quite quickly to calls. Only one resident commented that there is sometimes a delay in a response from staff especially at night, but in the main their attention was good. There is now a deputy nurse care manager in post to work in conjunction with the registered manager. The registered provider is on site each day and there is also a fulltime office manager to deal with day to day administration. The staffing rotas show that there are two qualified nurses on duty each day between 8am and 5pm and one nurse between 5pm and 10pm and from 10pm until 8am. The nursing staff are supported by seven care staff each morning The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 19 and five care staff through the afternoon and evening and three carers on duty at night. 54 of the care staff hold an NVQ2 or above qualification including the manager who has satisfactorily completed the NVQ4 this year. Mandatory training is in place and between two and eight staff have been able to access training sessions this year ranging from wound care; palliative care; managing challenging behaviour; protecting vulnerable adults; principles of care; medicine administration . All new staff complete the induction process skills for care. During the inspection it was agreed that the induction process will be linked to the formal supervision and appraisal process for the staff group, with the first appraisal / supervision session coming at the end of the induction period. ( see recommendation) There is a robust recruitment and selection process in place in the home. Four staff files were seen on the day and were well maintained and in good order. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35, 36 38 Quality in this outcome area is (adequate ). This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust management group with the registered provider attending the home every day. The staff confirmed that the management group are accessible and supportive. The deputy nurse care manager has been in post since May 2006 and is to be responsible for the supervision and appraisal of the staff. The deputy manager has completed observational assessments on all the care staff as part of the supervision procedure. Staff seen on the day confirmed that they have discussions with the managers about their work or problems in general but these tend to be on an informal basis and are not recorded. It was agreed that this process should be formally The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 21 implemented as a matter of some urgency and the first sessions with staff completed by March 31st 2007.( see requirements). A small sample of resident’s financial records were seen at the inspection. Each persons monies are maintained separately and securely. The records showed clear debit and credit balance and monies held corresponded with the record entry. Two signatures are obtained for any expenditure on behalf of a resident and receipts for any purchases are obtained. A sample of maintenance and safety records were examined during the course of the day. The records are up to date and well maintained. The records for heating, lighting, equipment, including hoists and aids are in place and up to date. A full fire risk assessment is being carried out on the premises by an external fire prevention and safety agency on 12 December 2006. Earlier in the year a complaint was made by a resident’s family who said that the home and residents rooms are cold at night. The heating system has been reviewed and efforts made to ensure the home remains at an ambient temperature. As a consequence of the complaint the management have purchased additional portable heaters to be used to supplement the main system. One resident has a separate heater of their own. The inspector has asked that each time there is a need to use the equipment in a residents room that a full risk assessment is carried out and maintained in the residents care plan, and reviewed and updated each month. ( see requirement). A quality assurance survey has been completed this year. Residents and their relatives were asked for their views on the service .The overall outcome is good and service users and families are satisfied with the service and service delivery. The results have not been published formally but discussion about the outcomes and any action taken should be displayed or the information shared with those who took part in the survey exercise. The quality audit survey is to be extended to staff and other health care professionals in 2007 and it was agreed that the results and any outcomes should be published in the homes news letter. ( see recommendation The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 2 The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 31/03/07 1. OP36 18 2 OP38 13 The registered providers must implement formal supervision for each member of staff. Repeated requirement The registered providers must undertake written risk assessments on any portable equipment or heating appliance when in use by residents. 31/12/06 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 OP10 OP15 OP16 Good Practice Recommendations It is recommended that staff are reminded of the homes own policy to address all residents with their given and chosen name and title at all times. It is recommended that all staff are reminded to monitor and check that residents are drinking and being offered fluids at regular intervals and also at mealtimes. It is recommended that all complaints are logged chronologically in a designated file and that complaint DS0000015646.V322763.R01.S.doc Version 5.2 Page 24 The Heathers 4 OP30 5 OP33 details kept in residents files can be cross referenced and easily accessed for audit purposes. It is recommended that on completion of their induction to skills for care programme all new staff receive a first appraisal /supervision session to ensure that their training and development needs can be assessed and planned for. It is recommended that the management include health care professionals, commissioners of the service and staff in the annual quality assurance review, so that their views of the service can be incorporated in the results and published in the homes news letter. The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 The Heathers DS0000015646.V322763.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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