Care Home: Knowle Hill

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What the care home does well People had their needs assessed before moving into the home. Each person had a written plan of care that detailed their needs and what action staff needed to take. The records showed that people`s health care needs were met. People told us they were treated with respect. Relatives spoken to confirmed this and our observations on the day were positive. There is an activities programme in place and staff told us people were encouraged to take part. Staff welcomed and encouraged contact with family and friends and relatives told us they were made welcomed when they visited. Many of the people using the service needed assistance to make choices. Staff told us they were able to assist with choices by having detailed information about the person and talking to relatives. People told us they were happy with the food provide, this was supported by relatives and staff. The home has a complaints procedure, which is displayed. Staff were able to tell us the steps they took on a daily basis to protect people from abuse and confirmed they had received training on the protection of vulnerable adults. The environment was safe and well maintained and there were procedures, equipment and the skill of the staff to promote good hygiene standards. Staff told us in the main there were enough staff on duty to meet peoples needs and that the staff worked well as a team. The recruitment procedures were safe and staff received the training they needed to help them to do their jobs. People using the service, staff and relatives told us the home was well run and that the management was approachable. People are able to comment on the way the service is run and there comments are used to develop the service. There are safe working practices, the health safety and welfare of people using the service and the staff is promoted and protected. What has improved since the last inspection? Records are kept of peoples weight and visits by the chiropodist are recorded in people`s files. Medication that has been discontinued is removed from the drug trolley and returned to the pharmacy. People told us they were more than satisfied with the food provided. What the care home could do better: Medication practice needs to be monitored more closely to make sure that procedures are followed at all times to reduce the risk of mistakes being made and to ensure that people receive their medication as prescribed. The manager was immediately made aware of the shortfalls in the medication system and took prompt action to resolve them. Records of complaints must be kept at the home and available for inspection. CARE HOMES FOR OLDER PEOPLE Knowle Hill Streetfields Halfway Sheffield South Yorkshire S20 4TB Lead Inspector Shirley Samuels Key Unannounced Inspection 29th January 2009 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Knowle Hill DS0000002978.V373067.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. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Knowle Hill Address Streetfields Halfway Sheffield South Yorkshire S20 4TB 0114 248 3594 0114 248 0018 diane.harrison@sheffcare.co.uk www.sheffcare.co.uk Sheffcare Limited 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) Mr Douglas Roderick John MacAskill Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2007 Brief Description of the Service: Knowle Hill is a purpose built home for older people. It is in a residential area of Sheffield with good access to public services, such as bus routes, shops and public houses. Accommodation is provided over three floors, accessed by a lift. All of the bedrooms are single. Each floor is provided with a communal lounge and dining room. Sufficient bathing facilities are provided. The gardens are landscaped and a small car park is available. Information about the service is provided to service users and their representatives in the form of a service user guide. Information is posted in the entrance to the home along with the inspection report. Information is also posted on each unit. The fees range from £327.00-£395.00. There are additional charges for Hairdressing, chiropody, toiletries, papers magazines and external activities. Further information about fees can be obtained from the service. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means people who use the service experience good quality outcomes. “We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken.” This was a key inspection carried out on this service by Shirley Samuels on Thursday the 29/01/09 from 9am-5:30 and 30/01/09 from 9:30-10:30. In the report we make reference to “us” and “we”, when we do this we are referring to the inspector and the Commission for Social Care Inspection. On the day of the visit we sought the views of eight people using the service, five staff, four visiting relatives and the manager who assisted with the inspection. This visit was a key inspection and the inspector checked all the key standards. Feedback was given to the manager at the end of the visit. During this visit we looked at the environment, and made observations of the staff’s manner and attitude towards people. We checked samples of documents that related to peoples support, care and safety. These included three assessments and care plans, three medication records, and three staff recruitment files. We looked at other information before visiting the home. This included the Annual quality assurance assessment (AQAA). This is a form completed by the manager of the service which tells us how they think the service is doing, what has improved and what further action they plan to take to develop the service. The inspector would like to thank everyone for their cooperation and welcome. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Records are kept of peoples weight and visits by the chiropodist are recorded in people’s files. Medication that has been discontinued is removed from the drug trolley and returned to the pharmacy. People told us they were more than satisfied with the food provided. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 7 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. Knowle Hill DS0000002978.V373067.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 Knowle Hill DS0000002978.V373067.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): 1,3 and 6 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. People receive the information they need and are assessed before they move into the home. EVIDENCE: In each of the bedrooms there is information about the home in the form of a service user guide. This makes sure that people have the information they need. People did not move into the home without having their needs assessed. This made sure that the staff had the information they needed to make a judgement about whether or not they could meet people’s needs. The home does not provide intermediate care. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. Each person had a care plan, their health care needs are met and their rights are upheld. There are some shortfalls in medication procedures. EVIDENCE: Each person has a care plan that details all their needs and the action required by staff. The action taken by staff is recorded in daily recordings. The recordings seen were of a good standard and commented on people’s, personal care, sleep pattern, activities, health professional visits, medication, mood, interaction with others, family contact and visits, food and fluid intake and other general observations. This makes sure that staff had the information they needed to meet people’s health, personal and social care needs. People using the service told us they were asked about their needs and were able to contribute to the development of the care plan. It was clear from the Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 11 records that the care plan was developed from the initial assessment and with further information added as staff got to know people more. We noted that a lot of the information in people’s care files and care plans was unnecessarily duplicated in different documents. This posed a risk of one document being updated and another one not, which could cause uncertainty. Care plans were monitored and reviewed and details of any changers was rerecorded. Risk assessments were in place these were reviewed alongside the care plan. Records were kept of appointments treatments and intervention of all health care professionals, Including the GP, dentist, optician, chiropodist, district nurse, aroma therapist and hospital appointments. This shows that people’s health care needs are met. The home has a medication policy. Staff responsible for administering medication had received training. The manager monitors the medication system and makes observations to make sure it is managed safely. Since the last inspection we have been notified of two medication errors. The manager submitted information about the action taken to reduce the risk of mistakes being made. A community pharmacist, who also monitors the procedures regarding medication, visits the home and makes recommendation were necessary. The records show that this visit was last carried out in July 2008. Medication was stored appropriately and safely. The home did not keep unnecessary stocks of medication. Controlled drugs were administered and recorded appropriately. On the day of the visit stocks of controlled medication was checked against the records and were correct. There was one example of a change to medication being made by a GP being recorded on the Medication administration record but not the prescription label. This meant that Medication was not being administered as detailed on the prescription label. There were two examples of prescription labels not being legible. There was one example of medication being recorded as being out of stock. There was one example of hand written instruction on the medication administration record, which did not include the dose of the medication. These shortfalls increase the risk of mistakes being made and could place people at risk. These shortfalls were brought to the attention of the manager when they were identified. She took immediate action to resolve all the above. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 12 People told us they were always treated with respect and dignity. The relatives spoken to supported this. Staff were able to tell us how on a daily basis they promoted people’s rights. By offering choices, making information available, having knowledge about people’s wishes and feelings and treating people as they would like their loved one to be treated. This shows that people’s rights are respected. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. Activities are provided, family and community contact is encouraged and people are provided with a balanced and pleasing diet. EVIDENCE: In the surveys some people told us they would like more activities to take place. The staff told us one to one time and individual activities could take place with additional staff. There was an activities programme in place and people told us they were able to choose whether or not to take part. People’s records of care recorded when people had taken part in activities organised by the home, visits by family and outings with the home staff or relatives. Contact with family and friends was encouraged and people using the service and relatives told us that visitors were always made welcome and offered a drink. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 14 People told us they were able to make choices about their daily life, who they spent their time with, what time they got up and went to bed, and what activities to take part in and generally how they spent their day. This shows people are able to have control over their lives. The menu shows that people are offered a varied and nutritious diet. People told us they were happy with the food provided. It was always hot there was always sufficient and a choice was always offered. Drinks and snacks were offered between meals. Care plans Included nutritional assessments and detailed any special dietary needs and peoples food likes and dislikes. The menu was displayed in a prominent palace and in large bold print to allow people to read it easily. Observations of breakfast and lunch on the day of the visit were positive. People who were reluctant to eat were encouraged. People who wanted smaller potions were not over faced. The meal was not rushed and people were offered assistance in a patient and dignified manner. This shows that people are provided with an appealing balanced diet in pleasing surroundings and have a good mealtime experience. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and people are protected from harm or abuse. EVIDENCE: Since the last inspection there have been no complaints made to us about the home. There has been one safeguarding referral made to the Sheffield social services. The manager told us that this is ongoing. The home does have a complaints procedure most of the people asked told us they knew how to make a complaint and they had someone to talk to if they were not happy. In each of the bedrooms information about how to make a complaint was detailed in the service user guide. This information included telling people they could contact us if they were not satisfied. We have recently moved and the address and contact details need to be amended. The records show that two complaints have been made to the home. The manager told us that both complaints had been fully investigated. Only one of the complaints had the information available for inspection. The information available for this complaint detailed, the complaint, the investigation and a response to the complainant. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 16 People told us they felt safe at the home and would talk to staff and visiting relatives if they were unhappy. Staff were able to tell us the steps they took on a daily basis to project people from harm. The records showed that staff had received training on protection of vulnerable adults and were able to tell us what constituted abuse, what action they would take if they had any concerns and what they expected to happen following any reports they made. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. The home is reasonably maintained clean and hygienic. EVIDENCE: There have been some refurbishment, decoration, and replacement of carpets and development of the outside space since the last inspection. In the main the home was reasonable decorated although dated in places. People told us they were happy with their bedrooms and routines for cleaning and changing linen. Communal areas were accessible and pleasant; they were furnished in a homely manner with comfortable seating, furnishings and entertainment equipment. This made sure that people lived in a comfortable environment. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 18 Staff told us they were provided with all the equipment they needed to promote good hygiene practices. Staff received infection control training and were able to tell us what steps they took to reduce the risk of infection. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. There are enough trained and qualified staff employed and the recruitment procedures protect people from harm. EVIDENCE: The rota showed there was enough staff employed to meet people’s needs. People using the service told us there was always staff around and when they needed assistance staff were always available and responded quickly to calls for assistance. Staff were deployed in a way which offered some consistency of care to people by having teams of staff responsible for each wing of the home. The manager told us they tried to maintain this but it was not always possible. Staff told us that more of the people using the service are living with dementia and feel the staffing level needs to be reviewed to reflect this and enable staff to spend more time with people and provide a better level of supervision. People told us “the staff are very good”, “they are always helpful and kind”, “and staff are usually available but sometimes need to wait a little”. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 20 Staff told us “more staff would allow more outings”, “Consistency of care would be better maintained if the same staff worked in the same areas of the home instead of moving around”. The home employed enough domestic and catering staff to ensure good standards of cleanliness and catering provision was maintained. The manager told us that 73 of the staff were trained to National Vocational Qualification (NVQ) level 2 in care. This means that staff have the knowledge and skills to meet the needs of the people and that people using the service are in safe hands. The home has a strict recruitment policy the records show that appropriate checks are made which includes, references, criminal records, health and identification checks. Staff spoke of working with a “buddy” for three weeks as part of the induction. This shows the homes recruitment procedures protect people from harm. Each file did not however contain a clear up to date photograph. The records show that staff receive regular training including advanced care, customer care, basic first aid, fire training, moving and handling, infection control and health and safety. New staff complete an induction, which meet the skills for care standards. Staff spoke positively about training and confirmed that they received regular supervision. This makes sure that staff are trained and competent to do their job. Some staff told us they would benefit from training on dementia care. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interest of the people and there are procedures in place to promote heath and safety. EVIDENCE: Since the last inspection the registered manager left to manage another service but has now returned. The home is well managed. Staff, people using the service and relatives spoke positively of the manager they said she was approachable and managed the service in the best interest of the people using the service. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 22 The organisation runs a forum for people using the service. Representatives from different homes meet with the organisations representatives to discuss the services what is going well and what could be done better. The records show that visits are made by a representative of the organisation to monitor the conduct of the service. This visit includes looking at comments from people using the service, complaints, staffing, building, catering, health and safety, recording systems and setting out any action plans. This shows that people are able to comment on the way the service is run and there is a system in place for monitoring the conduct of the home. The last record of a visit to the home was dated June 2008. The manager told us a recent visit was made however the record of this visit was not available. People told us they were happy with the arrangements for managing their money. Some people told us family took care of this. Records of income and expenditure along with receipt were kept. Secure storage is provided for money and valuables. This made sure that people financial interest was safeguarded. Staff were able to tell us how on a daily basis they promoted health and safety. Staff told us they had received training, on health and safety including moving and handling and fire training. Observations were made of safe moving and handling and manual support of people. Records showed the maintenance of equipment to ensure they were kept in good condition and safe for use. Maintenance checks included, lift, hoist, wheelchairs, water supply, gas supply, fire fighting equipment and emergency lighting. This makes sure that health safety and welfare of people and staff is promoted and protected. The records did show that the annual test of electric potable appliances and equipment was just out of date. The manager referred this to head office on the day of the visit. Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 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 3 Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement To make sure people receive their medication as prescribed by the GP and they are protected from risk of harm. • Medication must be administered as detailed on the prescription label. • Prescription labels must be legible. • There must be a procedure in place to make sure medication does not run out. • Hand written instruction on the medication administration record must include all the information on the prescription label. These requirements were brought to the attention of the manager when they were identified. She took immediate action to resolve all the above. Timescale for action 28/02/09 Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 25 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 OP16 Good Practice Recommendations Within the complaints procedure, the address and contact details for the commission for social care inspection needs to be amended. Records of complaints should include details of the complaint, the investigation, the outcome, response to the complainant and whether they were satisfied or not. This information should be available for inspection. Each staff file should contain an up to date clear photograph. To further meet people’s needs Staff comments about dementia care should be considered and training provided as required. Records of monitoring visits made by a representative of the organisation should be available for inspection. OP16 3 4 5 OP29 OP30 OP33 Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 26 Care Quality Commission Yorkshire & Humberside Region Citygate Gallogate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 61 61 61 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.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 Knowle Hill DS0000002978.V373067.R01.S.doc Version 5.2 Page 27 - 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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