Inspection on 15/08/07 for Town Thorns

This inspection was carried out on 15th August 2007.

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 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

Town Thorns 22/01/07

Town Thorns 23/02/06

Town Thorns 16/09/05

Town Thorns 15/03/05

Town Thorns 09/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Town Thorns Brinklow Road Easenhall Rugby Warwickshire CV23 0JE Lead Inspector Mrs Suzette Farrelly Key Unannounced Inspection 15th August 2007 09:30 X10029.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 Town Thorns DS0000004324.V338947.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 and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Town Thorns Address Brinklow Road Easenhall Rugby Warwickshire CV23 0JE 01788 833311 01788 833379 helen.owen@ben.org.uk 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) BEN - Motor & Allied Trades Benevolent Fund Ms Helen Mary Owen Care Home 66 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (42), of places Physical disability (14) Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (with nursing) and accommodation for residents of both sexes whose primary needs on admission to the home are within the following conditions: Old age not falling within any other categories, OP, 42; Physical disability, PD, 14; Dementia - over 65 years of age, DE(E), 10. The maximum number of residents to be accommodated is 66. 2. Date of last inspection 22nd January 2007 Brief Description of the Service: Town Thorns is a purpose-built care home and stands in more than 20 acres of grounds. It is designed as a continuing care centre to provide full nursing, residential care and sheltered housing accommodation primarily to people who are connected with the motor and allied trade. The home is divided into four units: Nursing Care, Dementia Care, Residential Care and Younger Adults with Physical Disabilities Units. Town Thorns is situated near the village of Brinklow close to Rugby. The home has facilities for residents to engage in social activities within the home and in the community. The manager has advised on January 22nd 2007 that the current fees for a place in the home are as follows: Full Nursing Care from £665.00 - £700.00 and Residential Care £410.00. The cost of hairdresser, chiropody, toiletries, newspapers, magazines and personal items are not included in the fees. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is based on outcomes for residents and their views of the service provided. This process considers the service’s capacity to meet the needs of the residents and ensure a safe and suitable environment for them to live in. This report is based on the findings of this key inspection including the unannounced visit carried out on Monday, 13th August 2007 and Wednesday 15th August 2007. During a key inspection examination through discussion, observation and looking at records is undertaken to establish that the service is continuing to offer and support safe and positive outcomes for residents. Discussion took place with fifteen residents about their experience of the home. They were able to express their opinion of the service they received; four residents found it difficult to express their thoughts and feelings because of medical conditions or dementia. General conversation was held with other residents about their experiences. Observation of working practices and staff interaction with the people living in the home was undertaken. Records and documents were examined and an opportunity was taken to tour the premises. No relatives were spoken to, nine staff members; the two assistant managers were spoken with. Feedback was given to the two assistant managers at the end of the visit. Seven residents were case tracked across the four separate units. This involves discussion with the resident about their experience of care and living at this service, examination of records, discussion with staff and assessing the facilities available to meet their needs. At the time of writing this report, 13 residents and 5 relatives had responded to our survey. An audit of residents’ surveys show satisfaction with the service provided. For example: ‘ They [staff] always sort my problems for me’ ‘I prefer my hot dinner in the evening. This has been arranged by introducing a cook-chill service’ ‘I am going on holiday soon’ ‘I received enough information’ Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 6 An audit of relatives’ comment cards also showed general satisfaction with the service provided. Comments included; ‘As my mother’s physical condition and mental health has deteriorated care plans have been skilfully adapted and carried out’ ‘Encourage a better quality of life for the person in care’ ‘Has lots of activities’ ‘Really personal, loving, professional care – couldn’t be better’ ‘Matron has an open door policy’ The manager returned the Annual Quality Assurance Assessment (AQAA). Information contained within this document has been used as part of the inspection to judge the experience and care of the residents. I would like to thank residents, staff and relatives for their hospitality and cooperation during the inspection visit. What the service does well: The admission process is robust and residents spoken to said that they had chosen to live at Town Thorns. Information is given to prospective residents and their representatives prior to admission to assist them in making the decision to use this service or not. Staff training is good and all staff have an induction and ongoing training in a variety of areas related to their particular role ensure that suitable care is given. The service has a good quality assurance system in place and practices such as medication administration, care planning, meals and laundry are checked on a regular basis. Feedback is given to residents and staff and changes are made where appropriate. The relationship between the staff and residents is good on all the units. Good communication was observed and residents spoken to said that staff are ‘kind and caring’; ‘always have time for you’; ‘Give you choice and support you’; and ‘ Are fun and always smiling’. The home is well maintained and clean, free from smells, well organised and pleasant. The residents’ areas were spacious and homely and individual bedrooms were nicely decorated and personalised to the their taste. The food is of good quality and residents are given a choice at each mealtime. The kitchen has recently changed the menus after discussion with the Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 7 residents to ensure that their choices are included on the menus. Those requiring special diets are catered for. Each unit has a dining area, and residents can also chose to eat either on their unit or in the restaurant on the 1st floor. This area is nicely decorated and waitress table service is available. The service has a physiotherapy department headed by a qualified physiotherapist. Various treatments and activities take place to help residents improve movement and maintain skills. One resident said ‘the physiotherapist is really good and has helped me to get moving again’ There is a hydrotherapy pool that is used as part of physiotherapy and the residents on the younger adults unit also go swimming in the local sports centre. There is a fully equipped arts and crafts room, which is used daily by residents throughout the service. This department also supplies items to the units to enable activities to take place there too. Individual care is given in a sensitive and caring manner and residents and relatives were complementary about the care and attitude of staff. What has improved since the last inspection? What they could do better: Due to the diverse type of care required for each unit, the service needs to assess the care planning process to ensure that it suits the residents and individual areas and contains enough space to write the care required. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 8 The Registered Manager stated that a variety of improvements are to be assessed and implemented such as: 1. Different formats for the admission information including a DVD and talking tapes. 2. Establish more regular meetings for nursing and dementia care residents including their relatives or representatives to enable views, concerns and suggestions from these groups to be expressed 3. To encourage more residents to become involved in the running of the centre in relation to Daily Activities. 4. On discussion with those residents on YPD who utilised the personal allowance books they identified that they would prefer to keep their monies in the present format. In conjunction with the Finance Director at Ben Head Office we are identifying an in house system that can evidence their income/expenditure to enhance the residents knowledge of their individual financial situation. 5. We are planning to instigate a redecoration programme that will bring long term residents, into the schedule for redecoration of their rooms at regular intervals, where redecoration has not been carried out for some time. We are aware that our plans may have to be altered to reflect need. 6. To fit free swing door closures on Residential care. 7. To trial a new training day to cover mandatory training on specific days for both day and night staff. 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. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (OP) and 2 (YA) Quality in this outcome area is good Assessments are carried out before admission and the resident is informed that their needs can be met. This, other information and time is given to help the resident decide if they wish to use this service. All residents are issued with a contract so they know what can be expected from the service and what is expected from them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 11 Seven residents were case tracked, two from the nursing unit, and one from the residential unit, two from the dementia unit and two from the younger adults unit. The same paper work is used in the pre-admission of the residents in all the units. The information on these forms is brief and in two files examined there was not enough information to ensure that suitable care plans could be developed prior to admission. Pre-admission information for a resident recently admitted to the Dementia Care Unit showed improvement in the quality of the information gathered prior to admission. This assisted the development of good care plans prior to admission and it demonstrated that the resident’s needs could be meet. All residents are informed before admission verbally and in writing that their needs can be met and the admission date. In the case of an emergency admission, the service will admit under the understanding that after an agreed period of assessment a final decision will be made if the service can meet the needs and if the resident wishes to remain. An up to date Statement of Purpose and Resident Guide is available, which contains information about the facilities and the service provided on the different units. This is given to all residents who can use this when deciding if they wish to move into Town Thorns. All residents are given a month to decide if they wish to remain at this service after admission, this can be extended in some circumstances. One resident said that they had not yet made up their mind, but feel they would remain, as it was a ‘nice place’ and the staff ‘were good’. A relative who completed our survey wrote that prior to admission ‘A very thorough presentation and tour [was] carried out by the Matron Manager’ A resident spoken to said that they had made the decision to live at Town Thorns and would recommend it to others as a good place to live and be cared for. Twelve survey forms were returned to us. Ten services users stated that they received enough information about Town Thorns prior to admission; two said no they did not. Of these two one was an emergency admission. It was noted that ten residents said that they had a contract and two could not remember. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 12 The Registered Manager stated in the Annual Quality Assurance Assessment that they plan to improve the admission process through the following: To update pre-admission forms to fully address requirements of Mental Capacity Act and top develop quality assurance forms to assess how residents have experienced their admission to the Centre. Instigate review on all residents after one month by named nurse/keyworker including the Quality Assurance form of admission. Copy of this to be given to Acting Assistant Matron . For local authority funded residents this will be completed prior to the Local Authority 4 weekly review. All prospective residents will have the opportunity to see the new DVD, which features Town Thorns. Also to identify other formats for the Resident Guide, such as a resident reading the information or a taped version. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9, and 10 (OP) and 6, 9, 16, 18, 19, and 20 (YA) Quality in this outcome area is good. Residents are involved where possible in the development of their care and receive support in a way that suits them. Medication administration ensures the safety of all residents and those who wish to self medicate are supported to do so maintaining their independence. This judgement has been made using available evidence including a visit to this service. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 14 EVIDENCE: Time was spent on all four units within Town Thorns. Seven residents were case tracked, as previously mentioned and a selection of residents from all units were spoken to and staff observed in their interactions with the residents. The same care-planning format is used for all the units despite their very different functions. There are 20 different areas within the care-planning format and staff complete all these whether there is a problem or not. This made it more difficult to determine where care was required. However, the information regarding care was good containing the information necessary for the staff to have clear guidance of actions and care to be given. Daily records showed that this care is given and where changes would be necessary. Staff spoken to said that the care planning format was not very good and that there was insufficient space to write all the care required so they had to use multiple sheets, which could cause confusion. This was discussed with the assistant matrons, and the Registered Manager had stated in the AQAA that improvement in filing was to take place. All care profiles are checked on a regular basis and a letter is sent to the key worker/named carer regarding areas that have not been completed appropriately. These are then revisited to ensure that all the information required is available. This information was examined and the process discussed with the unit manager allocated to this task. She stated that this had improved the process and staff were now completing the paperwork more thoroughly. Risk assessments for falls, mobility, nutrition and the risk of developing pressure ulcers (skin breakage due to pressure) were seen in all residents’ case tracked. Care plans were available where a risk had been identified stating clearly the needs required and actions to be taken by staff. Forms assessing the need for bed rails were also available clearly indicating why these were needed and indicating that this had been discussed with the resident or their representative and agreed. When visiting the private rooms of these residents equipment necessary to assist with their care and to minimise recognised risks were seen. Staff spoken to were aware of each individual’s needs and how to use the equipment. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 15 Records of residents’ weights were available including the Body Mass Index, which indicates if the individual is underweight, of an acceptable weight or overweight. Care plans where required were written. In one case where the resident was below the acceptable weight, action had been taken resulting in gradual weight gain. All care plans are evaluated monthly and the key worker/ named carer sign the care plans to demonstrate this. Changes to care are recorded and signed. On the younger adults unit one resident who had very limited communication had a ‘Communication Passport’ in their room with information about how they communicate. The Speech and Language Therapist produced this along with the home. A care plan stating this was available in this resident’s profile. This did not give a clear indication how the ‘Communication Passport’ could be used, therefore for new staff or agency staff it may not be obvious and communication with this resident could suffer. The regular staff were very aware of how to communicate with this resident and it was observed that there was a comfortable relationship between the staff and the resident. Clear information about this resident’s aspirations and their abilities were recorded. There were also care plans related to aromatherapy and exercise. The unit manager explained how they had seen the benefit of these activities. Another resident in the younger adults unit has discussed their cultural needs and made it clear what food they like and had declined the need to practice their religion. When discussed with the resident they said that if they decide to permanently stay they would reconsider this. Another resident talked about going to college in September to study art and crafts. They also paints pictures for a commission, this is support by staff. On the Dementia Care Unit a resident had a care plan for ‘Challenging Behaviour’. This would benefit from clearer information about ‘Diversional Activities’ stating what works. The staff had completed a period of observation to find out if there were situations that triggered the challenging behaviour. The evaluation stated there was no particular time or situation that caused the behaviours except at meal times. It was agreed that this resident would usually not eat in the dining area unless they requested to do so. A resident on the Nursing Unit who is artificially fed (PEG feed) had care plans in place stating all care required in relation to the feeds to be given and care of the PEG site (where the tube enters the stomach). A letter from the North Warwickshire Dietetic Department giving information of the interaction between Cranberry juice and warfrin was available. This explained that Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 16 Cranberry juice can enhance the effects of warfrin and if used then the blood clotting times must be carefully monitored. There was no care plan to instruct staff of this and the signs and symptoms that they should be aware of in the case of low blood clotting times. It was established that the staff are aware of this and that regular blood tests are conducted to ensure that these stay within safe limits. Care given to residents is good and meets their needs, it also minimise risks and ensures individuality and encourages residents to maintained as much independence as possible. The care planning format does not always reflect this in enough detail and relies on staff having good memories and sharing information verbally. Care plans for areas such as sexuality, mental health, behavioural and communication would benefit from more information to ensure that staff action in a consistent way. Four relatives were actively involved and had attended reviews and signed the Care Plan Agreement form. Three of the residents’ case tracked had agreed with their care. One resident spoken with said that they had spent time with the carer discussing their needs and that the plans of care had been agreed. Comments made by residents during the visit were: ‘Really good care, I would recommend this home’ ‘Staff are very good’ ‘I can decide on my care and I tell staff if I need anything, which they always give me’ ‘All my needs are looked after’ ‘I helped to develop my care plans’ All residents have access to community services such as GPs, district nurses, opticians, dentists and chiropodists. Clear records are maintained in each resident’s records about visits, the reason for the visit and outcomes. This is good practice. There is a physiotherapist employed by the service that gives treatment and offers assistance and advice to the units. The department is equipped with equipment to assist residents in mobility and movement. One resident was Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 17 seen receiving exercise for their arms to increase muscle tone. The physiotherapist also uses the hydrotherapy pool for residents, which they enjoy. Medication was checked on all four units, this has improved since the last inspection and no anomalies were found. Each unit manager checks all medication at the end and beginning of each four-week cycle to check the amount of medication left against the amount of medication administered. This check is also carried out in the second week of the administration cycle. The Medication Administration records were clear and where one or two tablets were to be administered the amount actually given was recorded. Some residents self medicate and appropriate form were available and completed. The process for ensuring that the resident continues to self medicate appropriately is good. New forms have been developed and the unit manager was about to implement these. Four resident medications were checked on each unit and found to be correct. On one unit the unit manager, during the check had found a mistake and discussed what action she was going to take to discover what had happened and how to prevent further mistakes occurring. All staff who administer medication are either qualified nurses or trained carers. The service ensure that all staff have received training and are tested before administering medication to make sure that this is carried out safely. All issued related to the inspection that took place in January 2007 have been addressed. Residents are treat with respect and their dignity is maintained. Staff knock on doors prior to entering and always spoke in a respectful manner. One relative stated that they wished to purchase insurance for the belonging kept at the home, however the insures were unwilling to do this as there was no lock to the door, they had requested that this was dealt with, this has not yet been done. It is important that residents are able to lock their rooms if they wish. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 18 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents have a choice of activities, how they spend their day and whom they see; this will increase their sense of well-being and independence. The meals are nutritious and well balanced and residents have a choice at all meal times. This judgement has been made using available evidence including a visit to this service. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 19 EVIDENCE: All four units were visited including the arts and craft rooms. Residents are given the opportunity to attend various activities throughout the day in the arts and crafts rooms. Activities also take place on the units. The Dementia Care Unit had a variety of activities including individual and group activities. Those activities seen were discussing photographs, looking at magazines and books, and playing table tennis, which created a lot a laughter and fun. Some residents on the nursing unit chose to attend an arts and crafts morning, while there they made hand puppets. One resident said that this was good exercise for her hand, which was weak. On the younger adults unit residents chose what they did which varied, some attended the arts and crafts room to complete art projects, others remained on the unit to pursue individual activities. One resident has regular aromatherapy. Records showed that a number of residents regularly play bingo and attend a weekly exercise group organised by the ‘physiotherapy department’. Other activities provided include, weekly indoor bowls and a poetry afternoon. Painting, crafts and games including dominoes, cards, scrabble, quiz, crossword, and chess are also made available on a regular basis. The service organises visiting entertainers on occasions and regular church services take place. The service has a chapel available for use. Transport for community arranged events are provided by the home and residents are asked to make a donation towards the cost. Visits out are arranged. The home has a number of volunteers that assist in providing therapy, to drive the transport and run the league of friends shop. Residents were observed to spend time in the privacy of their own rooms or join other residents in communal areas for company, meals or activities. The service has an open visiting policy that is in keeping with the wishes of the residents. Residents said they are able to have visitors and maintain contact with family members. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 20 The hairdresser visits weekly and provides services at the home in the Hairdressing Room on the 1st Floor. The cost of hairdressing is not included in the fees and range from £5.50 - £18.50 depending on what is required. Lifestyle diaries are being developed and involve the resident and their relatives in producing a story about the residents life. This highlights important events for the resident, and includes pictures and photographs. The ‘scrapbook style’ gives the resident the choice to make it as long as they want. Residents spoken to said that they have access to personal spending money, as they required it and they knew how to do this. The receptionist holds records of income and outgoing payments for the resident. Records of incoming and outgoing money were clear containing information of incoming and outgoing monies. All residents on the younger adults unit have been asked if they would like individual Banking Accounts, they have declined. The service will ensure that all new residents are asked this prior to admission. The service has improved in the assistance given to residents who wish to shop for personal items such as clothing. Trips are taken with staff who are in their own clothes to assist the resident in their shopping. All bedrooms are single occupancy to provide privacy for residents. Residents choose when to get up in the morning and retire to bed. On the day of the inspection, residents were well groomed and cared for. For example nails cut and clean, hair combed and clean and the men had been shaved if that was their choice. Each unit has an individual kitchen, which was clean, organised and stocked with items for breakfast and snacks. Each unit had a working dishwasher and fridge. Temperatures of the fridges are recorded daily. The main kitchen is clean and well managed. Store cupboards were stocked with a wide range of food including fresh fruit and vegetables. The cook talked about the arrangements for cleaning the kitchen and said there was a cleaning schedule in place that is signed and this is used to make sure all areas of the kitchen are routinely cleaned. Menus were displayed in the kitchen and showed a varied and nutritious diet. The menus had a variety of choice for each mealtime. The kitchen staff are aware of those residents who require special diets and are able to supply Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 21 these. Residents spoken to said the food was good and confirmed they were always offered alternatives. The cook had recently changed the menus after consultation with the residents so that their choices could be included. Lunch was eaten with the residents on the Dementia Care Unit. Lunch arrived from the kitchen in a hot trolley where it is served by the staff from the kitchenette. The meal was shepherds pie, vegetables and potatoes or gammon and chips. The meal was well presented, hot and enjoyable. Two residents spoken to during the meal stated that they had enjoyed their dinner and this was backed by all the food being eaten. The dining area is part of the lounge area; some residents chose to eat their meal at the tables and other to remain where they were. Staff accommodated these choices. Staff assisted residents who could not feed themselves or were reluctant or forgot to eat. This was done sensitively; staff spoke to the resident while feeding them giving encouragement and making light conversation. The assistance was at a speed that met the resident’s need. Observations showed that residents were able to make choices about the meals they wish to eat. There was a calm atmosphere during the meal. One resident on the dementia unit had lost weight in the earlier part of this year and there was evidence that the staff had encouraged them to eat and monitored their intake resulting in recent weight gain. After meals, care staff wash the dishes using the dishwasher, in the kitchenettes on each of the units. Residents are offered drinks throughout the day, and snacks are also available. The cook stated that at teatime, supper is also sent to each unit. Changes have been introduced so that residents now have the main meal of the day at lunchtime instead of in the evening. One resident on the younger adults unit prefers to have their meal in the evening this has been arranged. Comments made by residents during the visit include Don’t like spicy food. . Food is good and I have a choice each day”. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 22 Food is satisfactory, but find the helping far too big”. “I like the meals and am always full. They make really nice puddings. Residents can choose how and where to spend their time and do not have any restrictions imposed on them. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 23 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 (OP) and 22 and 23 (YA) Quality in this outcome area is good. Residents, relatives and friends can be confident that their concerns and complaints are listened to, taken seriously and acted upon. All residents are protected from abuse as staff are suitably trained to recognise abuse and act accordingly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a good complaints policy and procedure. A resident complaints policy is available on the notice board in each unit and residents are given a copy on admission to the service. The service has also adapted the complaints procedure for the younger adults unit, which is contained in their book ‘All about me’. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 24 Thirty services users responded to the service’s satisfaction survey and 22 residents stated that the response to complaints was either good or excellent and a small minority said that the response was poor. The service has arranged additional training for staff in their response to complaints made. The service has received ten complaints since March 2007, clear records of the complaint, the investigation and responses were available demonstrating that the service had taken the complaints seriously and acted appropriately. Twelve residents and four relatives responded to our survey, 11 residents said that the staff listen to what they say and that they know who to talk to if they have any concerns or complaints. Resident comments ‘I would tell my key worker, named carer or the unit manager’ ‘I would talk to the unit manager or manager of this home’ ‘I have made one complaint about the night staff, and this was dealt with well and solved the problem’ One resident said that they had only been at Town Thorns for two weeks and did not know everyone yet; his relative stated that the resident had some confusion. One relative responded that they did not know who to talk to; all other relatives stated that they would know who to talk to in the even that they had a complaint. Five staff spoken to were aware of what to do in the event that a resident had a complaint. Complaint forms are available to record the information from the resident and/or their representative. The service has started to have regular resident meetings to discuss issues in the service and how improvements can be made. These are recorded and a copy is available on each unit. The unit manager uses this information as part of the improvement plans, such as activities, meal times, furniture setting and staffing activities. All care staff have now received training in the protection of Vulnerable Adults and have an understanding of what is abuse and what actions they should take. Four staff spoken to are fully aware of their role in the protection of those Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 25 they care for. There have been no Adult protection issues since the last inspection. Policies and procedures related to recognising abuse and what to do in the event of an allegation or actual event are available; these are also in line with Local Authority Guidance. There is also a ’Whistle Blowing Policy’ that states the responsibility of staff to report incidents of abuse. Four staff spoken to were full aware of their role and gave a clear and concise description of their actions. Staff were also aware of the seriousness of residents who hurt other residents and their role in the protection of both residents. Clear plans of actions were seen where a resident could become aggressive and hit out at other residents. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 26 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26 (OP) and 24, 26 and 30 (YA) Quality in this outcome area is good. Residents live in a well-maintained, pleasant, homely environment, which meets their needs. They have individual private bedrooms that are comfortable and have their own possessions around them. The service is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 27 EVIDENCE: Town Thorns is situated in the heart of the Warwickshire countryside and overlooks fields and wooded areas. It is purpose-built with the original building being used for functions, staff accommodation and accommodation for relatives to stay. Planned visiting which may require a stay is charged at £20 per night including breakfast. No charges are made for unplanned visits such as a resident becoming ill or dying. The gardens and grounds cover an area of 20 acres and are well maintained, attractive and accessible with designated walking areas. The service has recently had work carried out around the pond area creating a wooden type pier with fencing to ensure safety. There are some secure gardens designed specifically for residents in the dementia care unit to reduce the risk of losing their way. Four units are available, two on the ground floor (The nursing unit and younger adults unit), the dementia care unit is on the lower ground floor and the residential unit on the first floor, which also accommodates sheltered housing. The home is decorated and maintained to a good standard. The home has two large function rooms with Bars where parties are held and alcohol served. The registered manager is a registered licensee and able to service alcohol. The Hotel Service Manager explained that various parties are held examples are Christmas, special Birthday and functions open to the public such as fetes. The younger adults area has recently been redecorated and the walls outside the residents’ rooms have been painted with pictures that the individual chose to express their interests, personality and hobbies. The environment is well maintained. All areas of the home are clean, bright and airy and free from any unpleasant smells. There are 58 single bedrooms 54 of which have en-suite facilities and four double bedrooms with en-suite facilities. None of the residents were sharing a room. Each unit has assisted bathrooms to meet the needs of the residents. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 28 Seven residents were happy for their rooms to be viewed, which were large enough for the use of wheelchairs and lifting equipment to be used if required. Their rooms were personalised, and in one resident’s room the relative had purchased the furniture at the same time as the room being fully decorated to the resident’s taste. Residents spoken to said they were satisfied with their accommodation and were very comfortable. Most bedrooms have a locked drawer in which to hold medication, (if the resident wished to self medicate on completion of the necessary risk assessment), or money if they chose to manage their finances. On the younger adult unit, there is a shared kitchenette, where residents can make snacks and light meals for themselves. The kitchen has low working surfaces that meet the needs of people who use wheelchairs. One resident said that they use this area most mornings for making their breakfast. The dining and lounge area on this unit are clean and spacious and has patio doors opening up on a pleasant well-maintained garden. It provides a welcoming place for people to enjoy their meals and relax in. At the last visit to this service the entrance to the bathroom, in the younger adults unit, was off a small corridor that leads to the sluice room. The approach to the bathroom provided limited access for wheelchair users and was unwelcoming. Alteration to this bathroom had commenced along with other decorating work and minor alterations. Adaptations and equipment are available to meet the assessed needs of the residents and include handrails fitted along the corridors, grab rails in the toilets, access ramps and a passenger lift for wheelchair users. There is a suitable call alarm system in place. Laundry facilities are organised, clean and hygienic. Soiled laundry is put into red bags and washed at the right hot water temperatures to ensure it was thoroughly clean and to control the risk of infection. Hand washing facilities and disposable gloves are available. The storage area for clean linen and clothes was tidy and clean. When asked about the laundry service residents said their clothes were usually returned promptly and they were satisfied. The laundry person discussed the washing procedures and care of residents clothes and was fully aware of managing cross infection. There were items of Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 29 clothing not named. Every two to three months the service puts all the clothes out in the main hall and ask residents and relatives to check if any belongs to them, they then ask relatives to look at what remains. If unclaimed they are given to charity shops. Staff were wearing protective clothing when carrying out personal care tasks, health care treatments or when handling soiled laundry reducing the risk of infection spread. Liquid soap and paper hand towels are available in the toilets and each floor had a sluice facility used by staff to clean commodes. Alcohol based hand scrub is available on the wall outside each residents room with the exception of the dementia care unit (for safety reasons), this is to reduce bacteria on their hands and is used by staff before entering and leaving the resident’s room. Infection control training is in place and staff are required to attend this training. Staff spoken to are fully aware of their role in preventing cross infection and maintaining a clean environment. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 30 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 (OP) and 32, 24 and 35 (YA) Quality in this outcome area is good. Residents’ needs are met by well-trained staff and supported by the safe practices of employment. The right skill mix and numbers of staff are available on a daily basis to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are enough staff on each unit of suitable training to meet the needs of the residents. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 31 Younger adults unit (15 residents) In the morning there is a nurse and four carers, in the afternoon and evening a nurse and three carers. At night, a nurse and a carer. Older people nursing care unit (18 residents) In the morning there is a nurse and six carers, in the afternoon and evening a nurse and four carers. At night, a nurse and two carers. Older people residential unit (21 residents) In the morning there is the unit manager and four carers, in the afternoon and evening, three carers. An additional carer is on duty on the residential care unit on the early and late shifts, this is to provide a care service for people living in the sheltered housing. Dementia care unit (8 residents) A unit manager and five carers cover the day and evening shift and two carers at night. Other staff on duty include: the physiotherapist, two laundry persons, chef and two kitchen assistants, activities coordinator, and two administrators. There are also four GAP students from abroad who work voluntary for a year at Town Thorns assisting with activities, physiotherapy, escorting residents and assisting with daily life. They are not involved in personal care. Other staff employed are three maintenance personnel, two grounds persons and three part-time drivers. The Hotel Facilities Manager stated that all home cleaning would go to subcontractors in the near future. Examination of two weeks staff rotas showed that the numbers of staff available met the assessed needs of residents and bank or agency staff were used to fill any gaps. The same agency carers are used where possible to ensure consistency and there are good procedures in place to check that training and employment checks have been carried out. Eight residents replied always when asked ‘ Are staff available when you need them’, four said always, one said usually and three said sometimes. One comment received stated Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 32 ‘I may have to wait a few minutes if they [staff] are dealing with someone else but they always let me know’ One resident spoken with said ‘I never have to wait long, sometimes in the morning when it is very busy, but they tell me how long. It’s OK they can’t be everywhere’ Thirteen staff have left in the last twelve months, this is an improvement from the past year and there is more stability in staff employment. Three residents spoken with said that the agency staff are much better and they are getting to know them and that staff are caring and considerate. A designated person is responsible for the planning and development of the staff training programme. Various in-house training is available and one member of staff was receiving Mental Capacity Act training on the day of the visit and certificates were seen on the units for staff who have just completed this training. The service now uses the Skills for Care Induction Standards for all new staff and six staff have commenced the LDAF training, designed for those who specifically care for and work with younger adults with learning disabilities. Unit managers are responsible for the formal supervision and appraisals of staff. This is still not taking place as often as it should. A National Vocational Qualification (NVQ) programme is in place and this is being reviewed with all staff to ensure that support to achieve an NVQ in care is in place. Twenty-four staff have achieved NVQ level 2 and/or above and the service is committed to this training for all staff. The recruitment files for three newly appointed staff were looked at were in good order. Checks had taken place prior to their coming to work in the home. Criminal Record Bureau checks had been complete and two written references obtained. The service has recently transferred the files into a new filing system and the application forms were incomplete. It is important that the files have all the completed information available. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 33 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 34 Standards 31, 33, 35 and 38 (OP) and 37, 39 and 40 (YA) Quality in this outcome area is good. Residents live in a home that is managed well where they are asked their opinion and participate in making decisions. The checks on equipment and the environment ensure that they are safe from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was on vacation at the time of the inspection, at the last visit she said that she had been at the home since July 2005. She has completed the National Vocational Qualification level IV in Management and completed training in Dementia Awareness. She is working towards completing the Chartered Institute of Management qualification. All staff are aware of their roles and whom they should report to. The lead clinical nurse, assistant matron and administrative staff support the manager in her work and report directly to her. There are three unit managers’ working days and one-unit manager on duty at night. The unit managers and assistant managers said that they felt supported by the registered manager to carry out their role and that they believed they supported the staff on the units. Staff and residents spoken to said that there was a more communication in the home and regular meetings are held to discuss issues. One relative who gave feedback said that the manager had an ‘open door policy’ and felt they could approach them at any time. There is a quality assurance system in place. This includes regular checking of practices throughout the service, surveying residents and their relatives and consulting with residents and staff through meetings. The residents with staff have developed a monthly ‘News Sheet’ giving information about the services, activities and interesting news. Staff are not supervised every two months as is required, the management are aware that this needs further examination. The home has now offered a Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 35 placement to social work students who have assisted in the assessment of social care aspects of the younger adults. Through information gathered during this visit and the information on the AQAA it is demonstrated that the registered manager and her assistant managers recognise where improvements are required and act upon this. The management discuss change with unit managers and staff before this happens. The management of residents’ personal monies was examined and discussed. The monies are held in a non- interest account and each resident has a separate accounting system showing the amount of money coming in and going out. Residents in the younger adults unit have been asked if they would like to set up individual bank accounts but they have declined. The manager is introducing a system where all residents will receive a statement each month of the money they have remaining, what has been deposited and what has been removed. Discussion took place with Facilities Manager who oversees the maintenance of all ancillary services. Records related to fire safety were discussed and seen these met the required standards. Door Guards have been fitted to fire doors that are required to be kept open at certain times. The service has a hydrant pump for use by the fire brigade this is checked yearly. The fire officer from Warwickshire visited on 2nd April 200 and was satisfied with the systems in place. The service has its own sewage plant; this is tested four times a year to ensure that the levels of bacteria are within acceptable limits. Other equipment is tested as required. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 36 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 X 2 X 3 3 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 3 23 3 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 37 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 OP29 Regulation 19 Requirement Employment records must contain all the information required such as, full application form, explanation of gaps in employment, suitable references from last employer and a statement by the person as to their mental and physical health. Timescale for action 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA2 OP7 Good Practice Recommendations Residents views on their assessed needs should be included on their assessment document. The care planning process should be assessed and modified to ensure that it meets the diverse needs of the residents on the different units. Evaluation of care given should be clearly written in the daily profile to indicate changes and why these changes in care provided has been made. DS0000004324.V338947.R01.S.doc Version 5.2 Page 38 3. OP7 Town Thorns 4. OP7 More information regarding sexuality, mental health, behavioural and communication should be recorded on the care plans to ensure a consistent approach to interactions and care. All doors should have a lock and residents offered a key where possible and if required. All information related to staff should be on file and available at all times. All staff should be supervised six times per year and practices monitored, records of this must be available. 5. 6. 7. OP24 OP27 OP38 Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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. Town Thorns DS0000004324.V338947.R01.S.doc Version 5.2 Page 40 - 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. 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