Inspection on 03/07/07 for Trinity House Care Centre

This inspection was carried out on 3rd July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Trinity House Care Centre 12/01/09

Trinity House Care Centre 03/10/06

Trinity House Care Centre 31/01/06

Trinity House Care Centre 12/10/05

Trinity House Care Centre 29/03/05

Trinity House Care Centre 09/11/04

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Breme

Ravenhurst

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Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Trinity House Care Centre Mace Street Cradley Heath West Midlands B64 6HP Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 3rd July 2007 09:45 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 Trinity House Care Centre DS0000004830.V335183.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. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trinity House Care Centre Address Mace Street Cradley Heath West Midlands B64 6HP 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) 01384 634350 01384 412138 trinityhouse@schealthcare.co.uk None Southern Cross Care Homes No 2 Limited vacant post Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user who may be aged 60 years and over. Once the service user reaches 65 years or the placement is terminated, the condition will be removed and reverted to the original registration. One service user identified in the variation report of the 12 August 2004 may be accommodated at the home in the category DE. This will remain until such time that the service users placement is terminated. One service user (female) identified in the variation report dated 4.4.2005 may be 61 years and over. This will remain until such time that the service users placement is terminated. 28th February 2007 2. 3. Date of last inspection Brief Description of the Service: Trinity House Care Centre is situated in a residential area of Cradley Heath, which it close to the shops and local amenities. The home has three storeys and accommodates service users on all three floors. There are 31 single bedrooms and 2 double bedrooms all of which have en suite facilities. There are two lounges within the home situated on the first and ground floor. A large conservatory adjoins the lounge and is used as a dining room. The grounds are well maintained and there is a small car park to the rear of the property. The home is well maintained and is pleasantly decorated. Fees vary between £334 and £719* and are dependant on the needs of the service user and the type of room that will be occupied. Items that are not covered by the fee include hairdressing, toiletries, chiropody and newspapers. * Please note fees will include the free nursing care contribution when applicable. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection undertaken without any prior notice by one Inspector. The inspection was carried out between 9.45 and 17.30. The inspection included a tour of the building, talking to service users, relatives and staff, a review of records including information forwarded by the Manager before the inspection and survey comment cards that were completed by service users and their relatives. Care records were reviewed as part of the “case tracking” of three service users and five staff files were also reviewed. Jane Shelley has been managing the home since early May 2007. Twelve of the previous fourteen requirements have been addressed, or removed as they no longer applicable; no new requirements were made as a result of this inspection. What the service does well: What has improved since the last inspection? The draughty windows and faulty window catches have been replaced ensuring that bedrooms are much warmer and more comfortable for residents. Hot water temperatures are regularly checked and when they are outside safe guidelines staff take appropriate actions to address this and safeguard residents form the risk of scalding. A check of the water system to protect against the risk of infections has also been undertaken. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 6 There has been a comprehensive review and improvement of all care documentation. A review of the risk of pressure sores has also been undertaken to minimise the risk of pressure sores within the home. This review has resulted in a considerable amount of new equipment including electric profiling beds and pressure mattresses purchased for residents. Senior Managers have continued to undertake checks on all care records to ensure that they provide sufficient and appropraite information to safeguard the homes residents from the risk of pressure sores. The recruitment and selection of staff is robust and safeguards residents at the home. When staff are employed they receive regular supervision to assist their development and review their practice. Since the previous inspection the home have given terms and conditions of residency for all residents, this enables residents to have written information about what is and is not included by their fee and confirmation of the room that they will have. 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. Trinity House Care Centre DS0000004830.V335183.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 Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2,3 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be assured that their needs will be assessed in full, prior to their admission to the home and that the home will be able to meet their needs. EVIDENCE: People who come to live at the home have their needs assessed prior to coming to live at the home. Prospective residents are visited by a senior nurse either at their home or hospital during which they will discuss their needs, to give assurance that staff know what their needs are and will be able to meet them. Contracts have been in place for privately funded residents and placing contracts for residents who are funded by primary care trusts and social services for some time. Since the previous inspection the home have given terms and conditions of residency to all residents, this enables residents to Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 9 have written information about what is and is not included in their fee and confirmation of the room that they will have. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home have an individual plan of their care that identifies their needs, although this is not always updated as their needs change which means that all needs will not be consistently met. Medication practices within the home are good and safeguard residents from harm. EVIDENCE: People who live at the home have a plan of their care which give staff instructions on what care they require. Care plans are generally updated monthly and whenever possible staff try to involve the resident or their representative in its review. There are appropraite care risk assessments in place to highlight when residents are at risk of pressure sores, poor nutrition, falls and their moving and handling needs and abilities. Where risks are highlighted, appropriate care plans are put in place to show how the risk is to Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 11 be managed and therefore reduced, and when appropraite what equipment is required to be used. Staff ensure that residents are seen when needed by other health professionals such as: GPs, Tissue Viability Nurses, Dieticians, Chiropodists and Opticians. Recent visits by a Tissue Viability Nurse and Dietician had been recorded in one residents care records. It was disapointing that while a record of the advice that the residents needed to sit on a “gel cushion” had been recorded and that they needed nutritional supplements, this had not been transferred into their plan of care. Recent concerns have been highlighted in relation to a resident who developed severe pressure sores. It has been determined that their specialist mattress had been removed and it was alleged given to a new resident, within three days they developed serious pressure damage to their skin. As a result of these concerns there has been a total review of how the risk of pressure sores can be reduced within the home, a considerable amount of new equipment including electric profiling beds and pressure mattresses has been purchased for residents. Senior Managers have undertaken and continue to undertake checks on all care records to ensure that they provide sufficient and appropriate information to safeguard the homes residents from the risk of pressure sores. The home has appropriate and safe systems for the ordering and storage of medicines. All medicines are administered by qualified nurses who are undertaking further assessments to ensure that their practice is safe. Good and positive interactions between residents and staff was observed both during this and previous visits to the home. Residents say “ the staff are so good”. Information provided by the home before the inspection also confirmed that staff treat residents with respect and uphold their privacy, dignity, independence, choice, and rights. This was also reflected in the positive feedback from residents, relatives and visitors who were surveyed by the Commission for Social Care Inspection prior to the inpection. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13, 14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home enjoy a range of activities to suit their interests; family and friends are encouraged to visit as they wish. Food at the home is excellent, varied, tasty and appetising. EVIDENCE: The home has an activities organiser who helps to provide and coordinate activities for residents. Residents enjoy regular games of bingo with other popular events being the visits from school children from the local primary school who come to read to the residents. The mobile library visits monthly enabling residents to choose their own library books, there are also monthly church services, weekly movement to music and regular visits from entertainers who do “singalong” sessions for the residents. The residents have also had recent jewellery and clothes parties to enable residents and their visitors to buy items if they wish to. Celebrations are held for each residents’s birthday with one resident having a birthday on the day of the visit, other Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 13 events such as anniversaries are also celebrated. Staff purchase items such as toiletries for residents but it was suggested that staff should take residents out whenever possible to choose and purchase items themselves. Residents and visitors all praised the quality and the choice of meals available to them. Everyone agreed that the food is “excellent”. One relative said he was able to spend the majority of the day with his wife and was able to have his meals with her, which he appreciated. Meal times were observed and it was pleasing to see that residents were given the choice to go to the dining table to eat their meals. Dining tables were set with appropriate cutlery and condiments. Snacks are laid out daily for residents to help themselves to when they want. The home is able to provide meals for people with specialised needs such as diabetes. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of consistent management has resulted in people being unsure who to complain to and a lack of confidence that concerns will be addressed and residents will be safeguarded. EVIDENCE: The home has a complaints policy that meets with the requirements of the legislation. The complaints procedure is prominently on display in the reception area and is in also included in the information pack that is given to people when they move into the home. The Commission for Social Care Inspection has received three complaints about the home since April 2007. It is disapointing that complainants identified that they had already highlighted their concerns at the home but felt appropraite actions had not been undertaken. There were two concerns concerning the breakdown of the lifts and another about the failure to take appropriate actions when a resident had become unwell. These concerns have since been addressed. Since her appointment the new Home Manager has ensured that she is available to listen to residents and their relatives and everyone spoken to confirmed that she was approachable and that she addressed any concerns that they had. The manager also holds a weekly surgery when visitors and Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 15 relatives know that they can come in to talk to her. There are also regular staff, resident/ relatives meetings. The home has had one adult protection referral which is still ongoing and related to one resident who developed severe pressure sores as highlighted within the Health and Personal care section of this report. The home does have a “Whistle Blowing policy” but it is disapointing staff did not question the decision to remove the pressure mattress from the residents bed who later developed the pressure sores. Staff do attend training in Abuse and POVA and this is constantly updated. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, warm and well maintained making it a pleasant and homely place for residents to live. EVIDENCE: The home is clean, comfortable and well maintained. The home had had a flood the day before the visit as a result of recent excessive rainfall. It was good to see that the Manager had acted quickly to summon help and there had only been minimal disturbance with systems in place to address the damage quickly. Requirements made at the previous inspection to replace ill fitting windows resulting in bedrooms being cold and draughty have been addressed although seals in some still required resealing as rainwater had managed to get through some. Action has been taken to improve lighting throughout the home making it more pleasant and safer for people with poor eyesight both to read and also move around the home. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 17 The home has a range of aids and adaptations to assist dependent people such as grab rails, assisted baths, hoists and wheelchairs. As highlighted previously in this report there has been a considerable investment in the provision of pressure relieving equipment and electric profiling beds to assist residents’ comfort and safety. The courtyard garden, which can be accessed via the conservatory, is paved to enable service users in wheelchairs access to it. The garden has been improved further since the previous visit with more flowers and hanging baskets. The management make that point that “Trinity house is definitely a HOME not an institution. There are no visiting hours as we have an open house policy”. The home is clean and has appropriate infection control procedures in place to minimise the risk of cross infection to people who live in the home. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels generally meet residents’ needs but residents do have to wait for attention particularly during the morning. Recruitment and selection procedures are robust and safeguard the service users. Staff training opportunities are good. EVIDENCE: Care staff levels have been increased by one carer for afternoon and night shifts. There was some concern that the nurse call was not answered within 3 and half minutes and as a result went into emergency mode (this occurs when the bell is not answered by staff within 3 and half minutes) on 8 occasions during the morning and prior to lunch during the inspection. This needs investigating as it means that frequently residents have to wait in excess of 3 and half minutes for attention. Residents in the lounge also had to ask staff on several occasions if they could go to the toilet. Additional kitchen, laundry and domestic staff are also available seven days a week. The home also has an Activity Organiser who works 16 hours a week over four days. The home currently has 3 of its 18 care staff (25 ) with a minimum of National Vocational level 2 qualification (NVQ) or equivalent. The home is Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 19 working towards the requirement that they have at least 50 of care staff with NVQ 2 with a further 8 care staff currently working towards this qualification. Recruitment and selection procedures at the home are robust and protect the service users with all required checks in place before the new employee commences work. New staff receive induction training and it’s as pleasing to see all staff have an appraisal and have regular staff supervision sessions. Recent training has included fire safety, moving and handling, protection of vulnerable adults and food hygiene, pressure sores and their prevention. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of experienced and consistent management has compromised the well being of the homes residents. The home needs strong and effective leadership to ensure that appropriate systems to monitor practice and compliance with policies and procedures are implemented to safeguard service users. EVIDENCE: The home has had several managers in the last eighteen months most of whom have been “interim” or “Acting” managers. Senior Southern Cross managers have supported the managers although a lack of a permanent manager in the home has resulted in a lack of leadership within the home. Staff and relatives continue to raise concern about the lack of a long term Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 21 Manager. Staff and relatives did speak highly of improvements made by the current manager who has been in post since early May 2007. The home needs the stability of a permanent manager to enable it to go forward and give confidence that residents will be listened to and that staff have required skills and are appropriately trained to provide quality care. Southern Cross homes have an identified Quality plan for the home although this is reliant on the home having an effective and competent manager. Quality audits are undertaken six monthly with corrective actions identified, with a copy of the audit sent to both the Regional Manager and Regional Director. The home undertake monthly audits of pressure sores, service users weights, accident statistics, vacancies and recruitment, the kitchen and a review of all regulation 37 notifications that have been sent to the Commission for Social Care Inspection (CSCI), although information gained as part of the adult protection identified that this information was not complete. Residents’ surveys are undertaken at least annually with identified plans of action identified. Required visits on behalf of the registered company are undertaken. The registered company has been proactively identifying ways that requirements of Commission for Social Care Inspection will be met. The home has good systems in place for dealing with service users monies. There is a clear audit trail of all monies received and of all transactions that have taken place. Supervision is being undertaken regularly for all care staff. Staff have all recently had an appraisal. Procedures to protect service users include regular and required checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points, wheelchairs and hot water. Records identify that staff regularly attend mandatory training in fire safety, moving and handling, food hygiene, first aid, health and safety, infection control and protection of vulnerable adults. The Manager has an overview matrix of staff training to enable her to easily identify staff requiring updates in statutory training. Maintenance records and contracts were reviewed and were found to be up to date. The lift(s) have been out of action for some time but discussions with the new manager highlighted that this has now been resolved Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 3 x 3 x x x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x 3 3 x 3 Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP28 Regulation 18 Requirement The home must have at least 50 of its care staff qualified to a minimum of NVQ level 2. Previous timescale of the 30/06/06 Timescale of 31/03/07 Not met An application for a registered manager for the home must be forwarded to CSCI Timescales of 31/01/07 and 31/03/07 Not met Timescale for action 31/12/07 2. OP31 9 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 Refer to Standard OP38 Good Practice Recommendations The storage and distribution temperature of hot water should be recorded. Trinity House Care Centre DS0000004830.V335183.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Office Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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