Inspection on 10/04/07 for The Royal Elms

This inspection was carried out on 10th April 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Royal Elms 23/10/07

The Royal Elms 18/07/07

The Royal Elms 01/12/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Royal Elms The Royal Elms 23 Windsor Road Newton Heath Manchester M40 1QQ Lead Inspector Sue Jennings Unannounced Inspection 10th April 2007 10:00 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 Royal Elms DS0000067697.V335401.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 Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Royal Elms Address The Royal Elms 23 Windsor Road Newton Heath Manchester M40 1QQ 0161 681 9173 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) Rajanikanth Selvanandan Michelle Lawton Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home will only provide a service to a maximum of 26 people whose primary need for care arises from old age. The matters detailed in the attached schedule of requirements must be completed within the stated timescales. 1st December 2006 Date of last inspection Brief Description of the Service: The Royal Elms Care Home is a care home offering personal care for 26 elderly persons. The home does not offer nursing care. The accommodation is provided on two floors in a Victorian style building, which is serviced by a passenger lift to all levels. The home has a modern extension that provides accommodation for five of the 26 residents accommodated at the home. The entrance to the home is at ground level and the garden area is accessible to all residents. The home benefited from the provision of a large garden to the rear of the property. It is set among similar sized well-established residential properties. There are three lounges; one of the lounges is the smoking area. The home provides personal care for 26 people there are two double rooms and twenty two single rooms; six of the single rooms provide en-suite facilities. There is an enclosed parking area to the front of the property offering off road parking for approximately eight vehicles. The home is situated in the Newton Heath area of Manchester close to good public transport links to Manchester City Centre and Oldham. Fees for the home are £373.54 per week with additional charges for hairdressing, chiropody and continence aids. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 5.5 hours on Wednesday 11th April 2007. During the course of the site visit time was spent talking to the deputy manager, staff and the owner, 4 of the residents and a visitor to find out their views of the home. A number of the Commission for Social Care Inspection’s survey forms were sent to relatives by the home. None of the survey forms had been received at the time of the site visit. However, residents did refer to the forms in discussions. Time was spent examining records, documents, the residents and staff files. A tour of the building was also conducted. A number of the requirements from the previous inspection had been addressed and there was evidence that the home was working towards improving the service. The home nor the Commission for Social Care Inspection had received any complaints in relation to this home. What the service does well: What has improved since the last inspection? The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 6 A number of bedrooms had been redecorated since the last inspection. A new care plan format had been introduced. Staff files were in the process of being reviewed and updated. 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 Royal Elms DS0000067697.V335401.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 Royal Elms DS0000067697.V335401.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home carried out a pre-admission assessment of need and provided sufficient information for prospective residents to make an informed choice about admission to the home. EVIDENCE: Prospective residents were able to visit the home before making a decision to move in. It was acknowledged that this was not always possible. However, families were equally given the same opportunities. The home had a Statement of Purpose and Service User Guide, which informed families and prospective residents about the home. The home’s manager carried out a pre-admission was completing the assessment for each prospective resident. On examining a sample of these The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 9 assessments, they were found to be sufficiently informative about the needs of the resident. The home does not provide intermediate care. The Royal Elms DS0000067697.V335401.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): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents’ needs were both assessed and reviewed. However, poor medication administration practices had the potential to put residents at risk. EVIDENCE: There was evidence to show that the care plan format was under review and a number of care plans had been updated onto the new format. These included preferred times for getting up and going to bed, preferred style of dress for example trousers or skirt and dietary preferences. This showed that the home were listening to residents and involving them in the care planning process. The new care plans were easy to read and identified residents needs and the action required by staff to meet those needs. They also gave a timescale for The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 11 the tasks, which may put staff under pressure to perform hurried tasks. There was no evidence that residents were actively involved in developing their care plans. One relative commented that they had not been involved in the care planning process. There was evidence to show that reviews of care plans were being carried out and comments recorded. Daily report sheets were kept for each resident however, where a resident was taking a special diet or at risk of developing pressure areas the daily record did not fully reflect the action staff had taken to meet these needs. A sample of residents’ Medication Administration Records (MAR) was examined and this raised a number of questions. There were concerns that one resident’s long-standing medication had not been administered for over a week and no record of the usual medication being stopped by the GP. There was also no record of whether the GP had visited the resident. In general there were a number of gaps in recording on the Medication Administration Records (MAR) where medication had been given but not signed for. There were concerns that Pharmacist’s sticky labels were being used on the MAR sheets when new medication was dispensed midway through a month. Where amendments need to be made to MAR sheets the information from the label should be copied in ink directly onto the MAR sheet to provide a permanent record. The entry should be signed by the writer and checked by another member of staff before the medication is administered to residents. There were also concerns about the way in which medication was being administered. One member of staff dispensed the medication into a pot and signed the MAR sheet whilst another member of staff administered the medication to the resident. This is poor practice, the person who administers the medication must sign that they have given the medication to the resident. The current medication practices and lack of adequate recording has the potential to put residents at risk. There were serious concerns with regard to the wrong hoist being used for transferring a resident. The resident said that she was in a great deal of pain and that when using the hoist her feet get ‘stuck and bang on the rails because I am too tall, my feet are really sore now’. Discussions with staff confirmed that they thought the hoist was too small. The proprietor and deputy manager were advised to contact the residents General Practitioner/District Nurses to request an urgent moving and handling assessment to reduce the risk injury to the resident. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 12 The owner covers some care shifts and demonstrated an awareness of equality and diversity taking into account the right of the all female residents in choosing whether they have a male or female carer. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A range of activities was available for the more able residents and the home enabled residents to choose their own daily routines, and have a varied diet. EVIDENCE: The home provided a limited range of activities to residents. In most cases, these were on a small scale including informal activities such as card games, dominos, quizzes that mainly happened in the afternoons. There was no evidence of any activities taking place on the afternoon of the site visit. One resident said, “There is not much going on here and I get bored, I like to get out and about”. It was reported that one of the care staff had taken on the role of activity organiser and there were records on care plans where residents had participated in activities. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 14 It was noted more able residents were included in the activities but there did not appear to be any arrangements made for those residents who were unable to play board games or take part in quizzes. It was suggested that the home research what activities are available for people with dementia. The home has a four-week plan of menus that are reviewed and updated every three months. There was no evidence that residents had been involved in planning menus. Residents spoken to said that the meals were “very good. One resident said, “We have plenty to eat the food is always very good”. Another resident said, “We always have a good choice”. The main meal on the day of the site visit was corned beef hash or bacon, boiled potatoes with butter and green beans, with jam and cream puffs for sweet and for tea, a selection of sandwiches or cheese on toast. The cook said, “I know what the residents likes and dislikes are”. Residents spoken to said that there were “no rules we can get up whenever we like and go to be when we like, I sometimes go for a lie down after lunch”. Another resident said, “I get up early I have an alarm clock but the others get up at different times”. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents felt able to raise their views and to be listened to. Policies and procedures relating to the protection of residents from harm needed improving. EVIDENCE: The deputy manager and proprietor said that there was an ongoing complaint however they were unable to locate the home’s complaint logbook. It was therefore not possible to assess if complaints were being dealt with in line with the complaints procedure or to assess if timescales, outcomes and actions were being properly logged. Residents were aware of the complaint procedure and one resident said, “ I know how to make a complaint there is a list on my bedroom door”. Another said, “Yes it is hung behind the door in my bedroom too”. There was no evidence that the home had a copy of the Manchester Multi Agency Policy and procedure for the Protection of Vulnerable Adults. The proprietor was advised to contact the local authority and obtain a copy of this document. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 16 Staff spoken to were aware of the procedures to be taken in the event of an allegation of abuse being made. Staff spoken to said they had undertaken Protection of Vulnerable Adults training, however this training had not been recorded on individual staff members training records. It was suggested that the proprietor consider developing a flow chart outlining the action to be taken by staff in the event of an allegation of abuse being made. This would be a useful tool for staff in the manager’s absence. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 17 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): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are safe and the homes environment was well maintained both internally and externally. However, the standard of hygiene in some areas was poor, which compromised the residents’ health and wellbeing. EVIDENCE: The home did not have a documented programme of redecoration and maintenance. The owner has applied for a capital grant from the local authority. This grant was available to homeowners to enable them to improve the quality of the environment for residents. The owner said that he did intend to redecorate and replace carpets and furniture however he did not wish to start refurbishing the home until a decision was made with regard to the allocation of funds from the capital grant application. The decision will be The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 18 made in June 2007 and even if no funds are available a redecoration programme will be developed and work start at that time. At previous visits to the home as part of the inspection process it had been noted that the bold strip design of the carpeting raised some concerns as it was felt that the carpet design could present as a hazard for those residents with limited vision or those with dementia who could confuse the strips for steps. This issue was raised with the new owner who gave a commitment to replace the carpet as part of the redecoration programme. The home had a maintenance person who was responsible for undertaking routine maintenance and the manager carried out a general tour of the building each week. There was a book where anything requiring repair was recorded by staff. A tour of the building was carried out and evidence was found that the home held a stock of disposable aprons, gloves and paper towels to manage infection control effectively. The home had a clinical waste contract in place. A sample of residents bedrooms were seen and it was noted that in two bedrooms the walls near the door were soiled and there had been no attempt made to remove the staining. This did not respect the dignity of the person living in the room and posed a potential risk to the health and wellbeing of residents. The owner should make sure that all areas of the home are kept clean and free from hazards to residents. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff were sufficient to meet the needs of the residents accommodated. The system for recording staff training needs to be improved to evidence that staff have the skills to meet the residents’ needs. EVIDENCE: The residents spoken with described the staff as “hard working” and “very caring”. Residents were seen to be at ease with staff and the general rapport between the staff and residents was seen as very positive. One resident pointed to a member of staff and said, “She is excellent”. There was little evidence of training on staff files and the home did not have a training and development plan. Priority should be been given to training and supervision. Training results in staff being more informed about the different health conditions that effect older people and about practices of care, which promotes the well-being of residents. There was some evidence that formal supervision for some members of staff had taken place. The owner said that a full audit of all staff files was underway The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 20 to ensure that the records maintained reflected the training that staff had undertaken. It was noted that the care staff were responsible for preparing the evening meal although it was not clear if they had received training in basic food hygiene. All staff responsible for preparing or cooking food must receive basic food hygiene training. The cook had achieved the NVQ level II in catering 2 years ago but had not received any further training in relation to food hygiene. One member of staff spoken to had achieved NVQ levels II and III in care and level II in cleaning and was keen to continue training. The retention of staff was in general good at the home with many of the staff having a long service history. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was seen to promote the health, safety and welfare of the residents and staff. However the systems and procedures in place, to safeguard and protect residents’ financial interests required improvement. EVIDENCE: The manager of the home was on sick leave at the time of the site visit. The deputy manager and owner assisted with the visit. Certificates regarding the servicing of health and safety equipment were seen and found to be in order. The gas safety certificate was due for renewal. The The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 22 inspection of the fixed gas appliances was under contract and the owner said he would contact the provider to arrange an inspection. There was a quality monitoring system whereby the home sent out questionnaires to relatives. This was in need of further development to draw together a report where the findings of all surveys could be made available to residents and families. The home did not act as appointee for any of the residents. Some resident’s personal allowances were kept in the safe and all transactions were recorded. Receipts for purchases were maintained on individual financial record sheets. The owner was unable to open the safe during the site visit as the dial had jammed therefore receipts could not be checked against monies in the safe. The owner was waiting for an ex-member of staff to contact him with the safe code number. There were some concerns raised that an ex-member of staff should have the current code to the safe that held residents money. It was recommended that a locksmith be contacted as soon as possible to open the safe and reset the code. The Royal Elms DS0000067697.V335401.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 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 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP8 Regulation 12(1)(a) Requirement The home must arrange for moving and handling assessments and the provision of appropriate equipment for residents. The home must improve the medication system to make sure that staff; • Are completing MAR sheets when medication has been removed from the blister pack and administered. • Not using pharmacist printed sticky labels on MAR sheets. Administering the medication must be the person signing the MAR sheet. Record any changes to medication following a doctor’s visit on the MAR sheets. Timescale for action 25/05/07 2. OP9 13(2) 25/05/07 • • The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 25 3. OP26 13(3) 16(2)(j) 4 OP30 18 The home must be kept clean and satisfactory standards of hygiene maintained. Where any part of the home is soiled this must be cleaned immediately to prevent the risk of infection. The provider must produce staff training and development plan that is kept up to date and reviewed on a regular basis in order to be able to evidence the staff have the skills to meet residents needs. 25/05/07 28/05/07 5 OP38 18 All staff responsible for preparing 25/05/07 or cooking food must receive training in basic food hygiene to ensure that they have the necessary skills to undertake their role. 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 OP15 OP14 OP19 Good Practice Recommendations It is recommended that minutes be kept of meetings held between the cook and residents when planning menus etc It is recommended that the home research activities designed for people with dementia so that all residents can be involved in the programme of activities. It is recommended that a programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept. It is strongly recommended that the consideration be given to replacing the carpet in the dining room and lounge. 4. OP20 The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 26 6. OP33 The registered person should further develop a process of quality assurance/monitoring, based on seeking feedback from residents and other interested parties, in order to produce a report of the outcomes. The Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU 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 Royal Elms DS0000067697.V335401.R01.S.doc Version 5.2 Page 28 - 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!