Inspection on 18/05/05 for The Normanhurst Residential Care Home

This inspection was carried out on 18th May 2005.

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

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

Other inspections for this house

The Normanhurst Residential Care... 27/02/07

The Normanhurst Residential Care... 10/02/06

The Normanhurst Residential Care... 14/12/04

The Normanhurst Residential Care... 23/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Normanhurst De La Warr Parade Bexhill on Sea East Sussex TN40 1LB Lead Inspector Niki Palmer Unannounced 18 May 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Normanhurst Address De La Warr Parade Bexhill on Sea East Sussex TN40 1LB 01424 217577 01424 734650 Normanhurst@btinternet.com Mr David Lewis Mr Robert Hebbes Ms Claire MacMillan Care Home (CRH) 82 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of Old age, not falling within any other category registration, with number (OP) 82 of places The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That only older people will be accommodated. 2. The maximum number of residents to be accommodated is eighty two (82). 3. Residents should be aged sixty five (65) years or over on admission. Date of last inspection 14 December 2004 Brief Description of the Service: The Normanhurst Care Home is situated on Bexhill seafront and provides accommodation and personal care for up 82 older people. The home is close to local shops with rail and bus services within easy walking distance. Carers are on duty 24 hours a day. All rooms are centrally heated and most have en-suite facilities. Residents are welcome to bring their own furniture and other personal possessions. Each room has a telephone connected to the switchboard with a direct dial facility. This facility also acts as a call bell system in the event of a resident requiring assistance. In addition, all bathrooms and toilets have a call system. Televisions can be installed free of charge. There is a shop on site selling a range of goods. Staff will shop in Bexhill on behalf of reisdents on a daily basis. A range of activities are provided in the home however residents are encouraged to be independent and access local community activities whenever possible. The home aims to create a hotel-like warm, friendly atmosphere whereby residents feel safe. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at The Normanhurst Care Home will be referred to as ‘residents’. This unannounced inspection took place on a Wednesday between 10.00am and 4.00pm and was carried out by two inspectors. The inspection began with discussions with the deputy manager of the care home in respect of progress made since the last inspection, followed by the examination of five care records. In order to gather evidence on how the home is performing, individual discussions took place with 15 residents, whilst others commented on their care during lunchtime, the inspectors having been invited to join them for a meal. In addition, five care staff were spoken with during the visit, including one of the registered providers. A detailed inspection of the premises and its facilities took place. 68 residents were accommodated at the time of the inspection. What the service does well: What has improved since the last inspection? The home has worked hard to improve the activities offered to residents. A monthly newsletter is now published advertising a variety of outings to nearby places, and other in-house activities such as knitting and needlework, Bingo, quizzes, musical entertainment, and a planned fete for the summer. The home has recently begun to repaint and modernise the outside of the building and plans are in place for a new ramp and automatic doors. Some of the carpets have been replaced and new shelving put up. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 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 Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 and 6 Adequate information is available to prospective residents. The admission procedure does not identify how individual needs can be met by the home. EVIDENCE: The home has a Statement of Purpose in place last updated in 2002, which was seen on the day of inspection. The vast majority of the residents spoken with stated that they had been provided with detailed written information regarding the facilities of the home prior to them moving in, and in addition had individual terms and conditions of their contract; copies of which were seen in their care plans. There did not appear however, to be a Service Users Guide in place. It is required that one is produced to include the home’s Statement of Purpose, the details of the last inspection report and a copy of the home’s complaints procedure. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 9 All residents stated that they had visited the home in advance of their admission in order to support them with their decision to move. Many had visited on an informal basis, usually alongside one of their relatives to ‘get a feel of the place’, whilst others had used the ‘hotel’ on a regular short-term holiday/respite break. All of those spoken with said that The Normanhurst creates a ‘hotel-like’ atmosphere, which supported their decision to move to the home on a permanent basis. Although the home has worked hard to improve it’s pre-admission assessment document, of the four seen there is still some scope for improvement. All were found to be brief in nature, and did not include details of the level of support needs that individuals required. For example, a brief statement was recorded for one resident who had had reduced mobility, yet there was no assessment of his need; for example how he mobilised, the support he may require i.e. walking frame/wheelchair/walking stick/ground floor level room; and what steps should be taken by the home to ensure that his independence is maintained. In two of the other pre-admission assessments seen, only the medical history, next of kin and General Practitioner had been recorded, without any assessment of their need. Intermediate care is not provided. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9 and 10 Care plans do not provide staff with clear guidance in respect of the assessed needs of residents. EVIDENCE: Five individual plans of care were seen on the day of inspection. It was pleasing to note that considerable work had been carried out by care staff in compiling detailed personal profiles and that all care plans had been shared with and signed by the individual. However, they do not provide staff with details of the level of care needs that the person may require. For example, one individual had been registered as blind. Her social care assessment stated that she liked to be independent and go out alone, but the risk assessment failed to identify any potential risks and the actions that are to be taken by the home to maintain her safety. In addition, all of the care plans seen contained a falls risk assessment, however did not provide any evidence of the preventative measures to be taken in accordance with recent clinical guidelines produced by the National Institute of Clinical Excellence for the prevention of falls. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 11 Medication storage and records were examined and found to be in order. Controlled drugs are stored in an appropriate metal cupboard, and records indicate that the home’s procedures are good. Risk assessments were seen for those residents who self medicate. All staff spoken with confirmed that they had received medication training. All residents have their own bedroom; double rooms are available for couples to share. All of the residents spoken with were very complimentary of the staff and the support that is provided at the care home. Comments included ‘carers are all very good’, ‘very kind, and ‘cheerful and helpful’. All residents are addressed as either Mr or Mrs by all care staff, which was observed throughout the duration of the inspection. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 Daily activities and excursions are managed well by the care home. The arrangements in place for the provision of food are satisfactory. EVIDENCE: The arrangements in place for daily life and social activities have improved considerably. An activities coordinator is employed on a part-time basis and has made arrangements for a summer fete, a trip to Arundel Wildfowl and Wetland Centre and an outing to Eastbourne for lunch. In addition regular events in the care home include; keep fit, bingo, knitting and sewing. All events and activities are advertised in the home’s monthly newsletter, which also gives details of residents’ forthcoming birthdays and a word search. All residents spoken with were very complimentary of the activities provided. A daily menu is on display in the reception area of the care home. A meat, fish and vegetarian option were available for lunch on the day of inspection, whilst smaller snacks are offered at tea time. Due to the size of the care home and number of residents that it caters for, mealtimes take place over two sittings. Residents confirmed that they have the choice of either first or second lunch. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 13 Half of the residents spoken with expressed some dissatisfaction with the choice, quality and content of meals provided, which has been an ongoing concern over the two previous inspections. The lunch eaten was found to be well presented, hot and flavoursome. A recommendation has been made for the residents, chef and manager of the home to meet on a monthly basis to discuss and plan the menus. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home’s complaints procedure does not provide residents with details of how their complaint will be dealt with. EVIDENCE: Through discussion with staff and residents, it appears that the majority of ‘minor’ concerns are usually raised informally and directly with the manager. All residents are provided with written details of how to make a complaint about the care home, however it currently states that all concerns should be raised through the Commission for Social Care Inspection. A clear procedure needs to be devised to specify how the care home will respond to any concerns that arise and ensure that all complaints will be responded to within a maximum of 28 days. The home has an Adult Protection and whistle-blowing policy in place, although has yet to provide training to all staff in the recognition and reporting of abuse as required in the previous inspection report. Staff spoken with stated that Adult Protection procedures were discussed with them during their induction period, but that they would feel more confident if formal training was provided. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,25 and 26 The Normanhurst provides residents with a safe, comfortable and wellmaintained place to live. EVIDENCE: The Normanhurst presents very much like a hotel. All residents spoken with spoke positively of their rooms and other accommodation, particularly those with sea views. All of the bedrooms seen were found to be of a good standard. The front of the building is currently being repainted, and in addition will be having the entrance made more accessible to residents with a gradual ramp and automatic doors. On the day of inspection, minor works were being carried out around the home; new shelving was being put up and some rooms were being redecorated. New carpets are gradually being replaced around the home, and the dining area is due to be repainted, carpeted and furnished with new dining chairs, tables and curtains in due course. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 16 Many of the residents were complimentary of the laundry service available, which was found to be suitably equipped on the day of inspection. All communal areas and corridors were maintained to a good standard, however it was noted that one of the sash window restrictors on the second floor corridor was not working. The environment was found to be clean throughout and is maintained by house keeping staff. Gloves and aprons are currently stored in the main office on the ground floor, not around the home in bathrooms for example. This was discussed in detail with the deputy manager and a requirement made that suitable equipment to ensure good infection control practice is available throughout the home. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 29 Staffing levels are adequate to meet the needs of residents, however the home’s recruitment procedures and practices have the potential to jeopardise the safety of residents. EVIDENCE: Residents confirmed that there are usually sufficient numbers of staff on duty to meet their needs. On the day of inspection five carers were on duty to attend to the needs of residents, whilst three care staff were working in the dining area to serve lunches. It was concerning to note that one of the carers was 16 years old, and was providing personal care to residents. This was addressed immediately with the deputy manager and registered provider of the home. Two housekeeping staff were also on duty. Staffing rotas evidenced that there are three waking night staff on duty to provide care to residents and one additional person to carry out the laundry duties. 17 day and 10 night carers are employed at the care home, only two of which currently hold an NVQ level 2 in care, however 10 are working towards this at a local college. One of the carers spoken with during the inspection confirmed that she is enjoying working towards her NVQ level 2 and is able to utilise her knowledge and skills into practice with the support of the deputy and registered manager. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 18 Four recruitment files were seen on the day of inspection. Three were found to contain two satisfactory references, proof of identification and a current police and POVA check, however one of the recently employed house keeping staff’s file did not have adequate information in place, required for the CRB check. This was discussed with the registered provider and a requirement made that she is only to carry out her duties under supervision until a POVA first check has been received and CRB applied for. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32 and 38 The manager is supported well by the staff in providing clear leadership throughout the home. EVIDENCE: The registered manager has been in post for almost two years and is currently working towards NVQ level 4 in management and Registered Manager’s Award. All five of the care staff and residents spoken with stated that she is approachable and supportive. Rotas examined confirmed that sufficient time is set-aside in order for her to carry out her management responsibilities. There is evidence that the home is managed in a way that ensures as far as is reasonably practicable the health, safety and welfare of residents and staff. Hot water temperatures are regulated and checked on a weekly basis by a designated person. Records evidence that the fire alarms are tested every Thursday. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 20 Named appointed first aider signs are on display in the main office area, a recommendation has been made that other signs are placed throughout the care home for the benefit of residents. Prior to the inspection, a concern was raised by a family member to the Commission for Social Care Inspection regarding a mobile telephone mast (Hutchison 3G UK Limited) which has been installed on the top of the care home since September 2002. A requirement has been made for the home to collate up to date clinical research and evidence from the Department of Health regarding the possible risks that telephone masts may pose to health. This information should be made available to all existing and new residents and be included within the home’s Statement of Purpose in order to help residents make an informed decision of where to live. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 2 3 3 x x x x x 2 The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 22 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 OP1 Regulation 5(1) Requirement Timescale for action 17/08/05 2. OP3 & OP4 14(1) 12(1) 3. OP7 15(1) 12(1) 4. OP7 13(4) That a Service Users Guide is devised to include the homes Statement of Purpose, details of the last inspection report and a copy of the home’s complaints procedure. That the pre-admission 17/08/05 assessment document is improved upon to demonstrate how the home can meet individuals assessed needs [THIS IS OUTSTANDING FROM THE PREVIOUS 2 INSPECTIONS]. It is required that all care plans 17/08/05 set out in detail the action to be taken by care staff to ensure that all aspects of health, personal and social care needs of residents is met [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION]. That care plans meet all clinical 17/08/05 guidelines produced by professional bodies concerned with the care of older people and includes a detailed risk assessment reflecting perceived risks to individuals [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION]. Version 1.30 The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Page 23 5. OP16 22 17(2) & Schedule 4. 6. OP18 12(1)(a) 13(6) 7. 8. OP25 OP26 13(4)(a) (c) 16(2)(j) 9. 10. OP27 OP29 18(1)(a) 18(2) 19(1) & Schedule 2 12(1)(a) 13(3)(4) (a) 11. OP38 That the home establish a complaints procedure for considering complaints made to the registered person which specifies how complaints may be made, who will deal with them and that they will be responded to within a maximum of 28 days. It is required that all staff be trained in the recognition and reporting of abuse [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION]. That the sash window restrictor on the corridor of the second floor is mended/replaced. That suitable equipment is available throughout the home to ensure good infection control practice. Staff providing personal care to residents must be aged at least 18 years or over. That new staff are only confirmed in post following completion of a satisfactory police and POVA check. That current evidence regarding the possible risks associated with the sitings of mobile phone masts is gathered and provided to all existing and new residents. This information must be included within the homes Statement of Purpose. 17/08/05 17/08/05 With imediate effect. With immediate effect. With immediate effect. With immediate effect. 17/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations That regular monthly meetings take place between the manager, chef and residents to discuss and plan meals. H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 24 The Normanhurst 2. 3. OP28 OP38 That 50 of care staff achieve NVQ level 2 by December 2005. That appointed first aider signs are displayed throughout the home for the benefit of residents. The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Normanhurst H59-H10 S21254 The Normanhurst V227210 180505 Stage 4.doc Version 1.30 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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