Care Home: Ashley Lodge Nursing Home

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CARE HOMES FOR OLDER PEOPLE Ashley Lodge Nursing Home 12/13 Carlton Road Ealing London W5 2AW Lead Inspector Mrs Rekha Bhardwa 3 and 4 rd th Unannounced Inspection February 2009 11:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashley Lodge Nursing Home DS0000010938.V374173.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. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley Lodge Nursing Home Address 12/13 Carlton Road Ealing London W5 2AW Telephone number Fax number Email address Provider Web address Name of Responsible Individual(s)/company (if applicable) Name of Manager (if applicable) Type of registration No. of places registered (if applicable) 020 8998 9071 020 8810 4398 info@ashleylodge.com Mr and Mrs Kassam (County Point Limited) Mrs Nabat Tajdin Kassam Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (36) of places Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP 2. Physical disability - Code PD The maximum number of service users who can be accommodated is: 36 27th February 2007 Date of last inspection Brief Description of the Service: Established in 1972, Ashley Lodge Nursing Home is a family run business that has been operating under its current management for almost 20 years. According to its philosophy of care, the Home exists to provide a happy and homely atmosphere and a secure environment for its residents who can no longer be cared for in their own homes, having regard for their physical, social and psychological requirements at all times and ensuring that service provisions are encompassed within a flexible, safe, calm and culturally sensitive environment. The Home is made up of two large, attractive detached houses situated in a tree-lined residential area of Ealing. It is located close to Ealing Broadway and West Ealing stations, is accessible by several bus routes and is within walking distance of Ealing Broadway Shopping Centre. Ashley Lodge provides nursing care for thirty-six residents, with twenty-eight single rooms and four double rooms over two floors. The floors are connected by two stairways and a passenger lift. Two adjoining lounge areas, a conservatory and quiet room provide seating. There is no separate dining area. The Home has a well-maintained landscaped garden and patio to the rear of the property and off street car parking for six cars to the front. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 5 The Home provides twenty-four hour nursing care. It is managed by a registered nurse with over 35 years of nursing experience and is run by a team of nurses, health care assistants and support staff including cooks, kitchen assistants and laundry and domestic staff. All members of staff are suitably trained to perform their tasks to a professional standard. Residents also have access to visiting physiotherapy, chiropody, speech therapy and optical and dentistry services. Current fees range from £575 to £700 per week, dependent on assessed needs. Additional charges are made for sundries such as toiletries and newspapers. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 12 hours was spent on the inspection process. We carried out a tour of the home, and service user plans, medication records, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. 10 residents, 2 visitors and 7 staff were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, healthcare professionals and staff have also been used to inform this report. What the service does well: The Manager has the skills and experience to manage the home and home is being effectively managed. Prospective residents are fully assessed prior to admission to ensure the home can meet their needs. Staff care for residents in a gentle, courteous and professional manner, respecting their privacy and dignity. Teamwork amongst the staff is good. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home. Information regarding advocacy services is available but needs to be clearly displayed. The food provision is good and offers variety and choice to meet residents’ personal preferences. Systems are in place for the management of complaints and safeguarding adult issues, and these processes are followed effectively. The home is being well maintained and there is evidence of renewal and redecoration taking place. The home is being appropriately staffed to meet the needs of the residents. Staff receive induction training and training in topics relevant to the needs of the residents. Recruitment procedures are in place and are followed. Systems for quality assurance are in place to provide ongoing review and feedback. Overall health & safety is being well managed at the home. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 8 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 Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. The home does not provide intermediate care. This judgement has been made using available evidence including a visit to this service. Residents are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. EVIDENCE: Pre-admission assessments were available in each of the service user plans viewed. These were thorough and gave a clear picture of each residents needs. Copies of Social Services and Primary Care Trust assessments were also seen in both files. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans are well completed and maintained up to date, thus giving a good picture of the residents needs and how these are to be met. Further work is required to ensure that the care plans are individualised for each resident. Medications are being well managed at the home, thus safeguarding residents. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. Information regarding end of life care wishes is limited, however the Manager is aware of the need to discuss this with residents and their families, to ensure their wishes are identified and met. EVIDENCE: Samples of service user plans were viewed. Overall those viewed were well completed and up to date. Some of the information the care plans was general and needed to be personalised. This was discussed with the Manager. Monthly reviews had taken place plus additional reviews when a residents condition had Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 11 changed. In a few instances parts of a care plan had been completed in pencil. The need to ensure that all entries are made in ink in order that there is a permanent record was discussed. Where new needs had been identified, care plans had been formulated to address this. There was evidence that residents and their families had been involved in the formulation and review of the service user plans. Risk assessments for falls had been completed. Assessments for moving & handling had been carried out and the specific equipment in use for each resident had been documented. Continence and nutritional assessments had been carried out. Care plans had been formulated for any needs identified in the assessments. All residents are weighed monthly, and in some cases weekly weights have been implemented. Some marked changes in weight loss had been recorded for one resident and this had been followed up with a referral to the Dietician. The GP carries out a weekly visit to the home, plus attends at other times as required. There was evidence of input from the Tissue Viability Nurse, Chiropodist, Optician, Physiotherapist and other healthcare professionals. Medication management and records were sampled at the home. All receipts and disposals had been recorded. With one exception administration records were complete and where a medication had been omitted for some reason, the correct coding with an explanation for the omission had been used. Where a stock balance had been carried forward these had been recorded. A list of registered nurse signatures and initials was available. Allergy information had been clearly recorded. Instructions and recording of warfarin were clear with clear entries of varying doses. Fridge temperature records were within safe ranges. Dates of opening had been recorded on all liquid medications. Controlled Drug administration was being correctly recorded in the register and balances checked were correct. Appropriate single use lancing devices for blood glucose monitoring were in use. Staff were seen caring for and conversing with residents in a polite, gentle and professional manner. We observed the staff interacting well with residents and there was a good atmosphere throughout the home. Residents looked well cared for and were dressed to reflect individual preferences. Residents spoken with said that the staff are very kind and they were being well cared for at the home. Staff spoken with said that there is good teamwork and staff work well together. Residents can have their own telephone, either landline or mobile, and several rooms viewed had telephone facilities. The care plans for health deterioration and end of life care wishes contained limited information. The importance of providing residents and their families with the opportunity to discuss this topic was highlighted, and the Manager said that she would do so. It is acknowledged that this is a sensitive area of care, and if people do not wish to discuss it as yet then this can be recorded. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 12 Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an activities co-ordinator, however more work is needed to ensure activities are provided on an ongoing basis to meet the needs and interests of all the residents. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available in the Service User Guide, thus ensuring residents right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet residents individual needs and preferences. EVIDENCE: Since the last inspection the home has employed a new activities co-ordinator. An activities programme is displayed and there was some evidence of activities taking place. We viewed the activities records and it was clear that the activities provided were very repetitive and there was little variation in the activity provision. Information regarding resident’s individual hobbies and interests was brief. This area must be developed to ensure that from the information gained the activities programme can be further developed to Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 14 include outings and activities to suit all the residents. This was discussed with the Manager at the inspection. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home and kept up to date with their relatives’ condition. Residents can receive visitors in one of the communal rooms or in their bedrooms, as they so wish. The home has information regarding advocacy services in the Service User Guide. The need to ensure that this information is displayed and available was discussed. Following the inspection we were informed by the Responsible Individual that advocacy information had been requested from Age Concern in Ealing and that once this had been received into the home this would be displayed on the notice board. We viewed the kitchen. The area was clean and tidy and records were up to date. The home has a 4-week menu and choices are available at all meals. Foodstuffs in the kitchen were being appropriately stored and there was evidence of stock rotation. Fridge, freezer and cooking temperatures were being recorded. Residents spoken with said that they enjoy the food and are offered a choice, and documentation was available to evidence this. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place for the management of complaints and for adult protection concerns, thus safeguarding residents. EVIDENCE: The home has a clear complaints procedure. No complaints have been received by the home since the last inspection. Residents and representatives spoken with said that the Manager addresses any concerns raised promptly and is very open and approachable. The home has policies and procedures in place for the protection of vulnerable adults, and these dovetail with the Ealing Safeguarding Adults documentation. Staff spoken with said that they would report any concerns and were aware of Whistle Blowing procedures. Staff had received POVA training. There has been one referral made to the Ealing Safeguarding team since the last inspection. Ashley Lodge Nursing Home DS0000010938.V374173.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): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home is being well maintained, thus providing a clean and homely environment for residents to live in. Clear infection control procedures are in place and being adhered to, thus safeguarding residents. EVIDENCE: We carried out a tour of the home. Overall the home was being well maintained with evidence that renewal and redecoration was taking place throughout. Issues identified in relation to damaged armchairs and a damaged wall had been addressed by the second day of the inspection. Whilst there is evidence that redecoration and refurbishment is taking place at the home this needs to be incorporated into a plan. Some carpets in resident’s bedrooms were worn and had rucked and therefore were a potential trip hazard. The Manager completed risk assessments for these bedrooms and we were informed following the inspection that plans are in place to replace these Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 17 bedroom carpets. The gardens are well maintained and there has been a new patio area laid for the residents. The home was clean and tidy and smelled fresh throughout. We viewed the laundry room and the washing and drying machines are industrial and meet the homes needs in this area. Residents’ individual clothing is appropriately cared for and items viewed were labelled. Protective clothing to include gloves and aprons was available. There was evidence that staff had received training in infection control. Ashley Lodge Nursing Home DS0000010938.V374173.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): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed and staffing levels are kept under review, thus ensuring that the needs of the residents can be met at all times. Systems for vetting and recruitment practices are in place, thus safeguarding residents. There is an ongoing training programme, providing staff with the skills to meet the needs of residents. EVIDENCE: At the time of inspection the home was well staffed to meet the needs of the residents. There were appropriate numbers of domestic and catering staff to meet the homes needs. The Manager reviews residents dependencies on an ongoing basis in order to ensure staffing is maintained at levels to meet residents needs at all times The AQAA document completed by the home indicated that 84 care staff are qualified to NVQ in care level 2 or the equivalent. Employment records for 2 members of staff were viewed. We noted that all the necessary information with the exception of a medical questionnaire were available. The medical questionnaire had been completed and was in place for both staff by the second day of the inspection. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 19 The home has in place the Skills for Care common induction Standards. There is an ongoing training programme, which provides training in topics relevant to the resident group. Staff spoken with confirmed that they have access to training internally and externally. Registered nurses confirmed that they had received training in relation to some clinical aspects of care. Ashley Lodge Nursing Home DS0000010938.V374173.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): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being effectively and well managed, thus enhancing the lives of the residents. Systems for quality assurance are in place, to provide an ongoing process of review and feedback. Systems for the management of health and safety throughout the home are in place, thus protecting residents, staff and visitors. Shortfalls should be easy to address. EVIDENCE: The Manager is a first level registered nurse with several years experience in nursing and managing the care home. She also periodically attends study days in topics relevant to the needs of the residents. The Manager is very ‘hands on’ and has a clear overview of the residents and their needs. Comments received on the CSCI comment cards from service users, staff and health and social Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 21 care professionals were very positive and it is clear that the home is being very well managed. We were informed by the staff that the Manager is very supportive and promotes team working within the home. Some comments received include ‘I feel that the home is organised very well and that the Manager is very caring towards the residents and staff’. There is a quality assurance system in place. An external audit of the home is also undertaken and an action plan formulated to address any shortfalls. The home has obtained the ISO 9001:2000 accreditation for their quality management system. Regular audits are carried out to include home audits; health & safety, medication and service user plan audits. Satisfaction questionnaires to residents, representatives and stakeholders are sent out annually and the information collated and results published. The home does not hold residents meetings but instead the Manager is available to see residents and their representatives on a on to one basis. We were informed that the home does not manage personal monies on behalf of residents. A sample of servicing and maintenance records were viewed and those viewed were up to date. The home employs a full time maintenance person. Fire drills were taking place for both day and night staff. We noted that the last fire risk assessment evaluation had been completed in 2006. Copies of the risk assessment for 2007 and 2008 could not be located at the time of the inspection. We were contacted by the Responsible Individual following the inspection and were informed that a company has been commissioned to carry out the assessment. Risk assessments for equipment and safe working practices were in place. The training matrix evidenced that staff had received health & safety training to include moving & handling, fire awareness, food safety, and first aid and infection control. Staff spoken with said that they receive training in all health & safety topics. Ashley Lodge Nursing Home DS0000010938.V374173.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 23 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 Responsible Individual(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The information contained within the service user plan documentation must be personalised to reflect the individual needs of the resident. All entries in the care plan must be in permanent ink to ensure that there is a permanent record. Full information regarding the wishes of residents and their families in respect of end of life care must be ascertained and recorded, so that these wishes can be respected. Where decisions have not yet been made, this must be clear in the residents care plan so that staff take appropriate action in the event of health deterioration. The activities provision within the home must be further developed to ensure that there is a range of activities on offer for all residents. These activities must meet the individual interests and preferences of the resident. Copies of the fire risk DS0000010938.V374173.R01.S.doc Timescale for action 03/04/09 2. OP11 12 03/04/09 3. OP12 12 01/05/09 4. OP38 23 03/04/09 Page 24 Ashley Lodge Nursing Home Version 5.2 assessment must be available at the premises for inspection, to ensure the safety of the residents and staff at the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Responsible Individual/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations The home should have in place a renewal and redecoration plan, which reflects the work completed and the dates of completion. Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection 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 Ashley Lodge Nursing Home DS0000010938.V374173.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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