Administration of Villa Sabrina nursing home in Terni

SECTION I - PREFACE

CONTENTS

The purpose of this Code of Ethics is to outline in a transparent and public manner the rights, duties, responsibilities and ethical principles that inspire the activity of VILLA Sabrina srl (hereinafter VS srl) with respect to all the subjects with whom it enters into relations for the achievement of its corporate purpose (Guests, suppliers, employees and/or collaborators, partners, institutions, etc.); it is, therefore, a directive whose rules of conduct must be kept in mind in the daily work and which presupposes, first and foremost, respect for the laws and regulations in force, also internal to VS srl. The Code of Ethics of VS srl:

• aims to set ethical "standards" of reference and behavioural norms to which the company's processes, decision-making and conduct must be oriented;

• requires consistent behaviour from the management and from all persons to whom it is addressed, i.e. actions that are not, even only in spirit, discordant with the company's ethical principles;

• contributes to the implementation of VS srl's social responsibility policy, since it is aware that the consideration of social and environmental concerns helps to minimise exposure to compliance and reputational risks, strengthening the sense of belonging in its interlocutors.

SECTION II - APPLICATION METHODS

Article 1: ADOPTION AND UPDATING

This Code of Ethics is to be read as a tool susceptible to subsequent amendments and additions according to the internal and external changes to the Company, as well as experience acquired over time to ensure full consistency between the guiding values adopted as fundamental principles and the conduct to be adopted according to the established in this Code of Ethics.

Article 2: ADDRESSEES

This Code of Ethics is binding for the partners, the Health Management and the employees, as well as for all those who, although external to VS srl, work directly or indirectly for it.

All the addressees indicated above are, therefore, obliged to observe and, as far as their competence is concerned, to have observed the principles contained in the Code of Ethics. Under no circumstances does the pretence of acting in the interest of VS srl justify the adoption of behaviour that is in contrast with what is set out in this document. The observance of the rules of the Code of Ethics must also be considered an essential part of the contractual obligations of the employees of VS VS srl under and for the provisions of art. 2104 and following of the Civil Code.

Article 3: CODE OF ETHICS AND ORGANISATION, MANAGEMENT AND CONTROL MODEL

The Organisation, Management and Control Model of VS srl complies with the prescriptions contained in this Code of Ethics, which is an integral part of it. In this respect, in fact - the Code of Ethics is voluntarily adopted by VS srl and expresses values and principles of conduct recognised as its own and which all the addressees are called upon to observe, constituting the first step in the implementation of the Code of Ethics.

In this respect, in fact

• the Code of Ethics has been voluntarily adopted by VS srl and expresses values and principles of conduct recognised as its own on which to call the observance of all addressees, constituting the first tool for the prevention of any offence;

• VS srl strives for a continuous operational improvement of internal procedures in order to make company management more effective and efficient by encouraging, where possible, the use of computer-based tools, in order to reduce repetitive and merely executive activities, to the benefit of those with higher professional content, guaranteeing the timeliness and punctuality in the processing of requests by all interlocutors and collaborators, with the punctual compliance with the rules to pursue the exclusive interest of the company and its shareholders.

Article 4: TRAINING ACTIVITIES

An information programme on the contents of the Code of Ethics is envisaged for employees and recruits through meetings and the sending of printed and supporting material.

SECTION III - MISSION, ETHICAL PRINCIPLES AND MANAGEMENT POLICY

VS srl pursues the aims of promoting and protecting health, in the implementation of the healthcare objectives envisaged by the national and regional health planning and the objectives defined by the WHO for all health and social health organisations:

• promote a high degree of satisfaction for Guests and their Families

• guarantee the lowest possible risk for the Guest, the operators and the environment;

• ensure the qualification of professionals through the development and implementation of collaboration and the exchange of knowledge between the professionals working in the facility;

• guarantee efficiency in the use of resources.

Article 5: VALUES

Starting from the corporate mission The Management intends to direct the entire organisation towards the pursuit of its vision in accordance with the following principles and fundamental values:

I: Innovation

Prevent risks and be creative in identifying opportunities for improvement.

Engage in training and professional development.

M: Mastery 

Knowing, Knowing how to do, Knowing how to be. Freedom and responsibility for professional and personal action, in compliance with laws, professional technical-scientific guidelines and company rules.

A: Authenticity 

Transparency in management and relationships.

Communicating, committing to the achievement of objectives consistent with the principles and corporate values.

G: Guft - Courage

Courage in thinking, acting, and communicating.

Being an active part of the organisation.

Express one's personality in what one does by working.

E: Ethics

Legality and honesty in behaviour, actions and relationships.

Listening and active participation while respecting confidentiality.

Article 6: INTEGRITY, HONESTY, FAIRNESS AND LOYALTY

Respect for the values of integrity, honesty, fairness and loyalty entails, among other things, committing oneself:

• to promote and require compliance with internal regulations and/or all laws by staff, collaborators, guests, suppliers, and any other third party with whom it has a legal relationship;

• strict compliance with current anti-money laundering legislation, undertaking, in any case, to refuse to carry out any suspicious operation in terms of fairness and transparency;

• to promote at all levels practices aimed at preventing local and transactional corruption practices;

• to ensure and promote internally the observance of all organisational rules and prescriptions to prevent the perpetration of offences (under Legislative Decree 231/01)

• to record every operation and transaction only if supported by appropriate documentation, to be able to proceed at any time with the performance of controls that certify its characteristics and motivations and identify who authorised, performed, recorded, and verified the operation itself; consequently, employees and/or collaborators must make any accounting entry accurately, promptly and completely, scrupulously complying with civil and tax laws as well as internal accounting procedures.

Article 7: FAIRNESS, OBJECTIVITY AND PROTECTION OF PERSONS/GUESTS

Respect for the values of fairness and objectivity implies that VS srl is committed to

• to avoid any form of discrimination, detrimental to personal dignity, in particular, that based on race, nationality, gender, age, disability, sexual orientation, political or trade union opinions, philosophical views or

religious beliefs, guaranteeing equality and impartiality in access to the services provided;

• not to tolerate sexual harassment and physical or psychological harassment, in whatever form and context they occur

• to listen to the requests of colleagues, guests and suppliers without any preconceptions or behaviour aimed exclusively at defending their own position and work;

• to avoid, in the performance of their duties, taking decisions or carrying out activities contrary to or in conflict with the interests of the company or in any case not compatible with the observance of official duties;

• to show sensitivity and respect towards others by refraining from any behaviour that could be considered offensive.

Article 8: TRANSPARENCY AND CONFIDENTIALITY

Compliance with the principles of transparency and confidentiality implies that VS srl is committed to

• disseminate truthful, complete, transparent and comprehensible information, to enable the addressees to take conscious decisions, regarding the relations to be entertained with VS srl itself or which see the same involved;

• update, disclose and enforce the rules concerning the management, processing and communication of confidential information to third parties, to the observance of which it calls upon the addressees

• protect the confidentiality of the data and information that VS srl's employees and/or collaborators may have in their possession. The members of the administrative and control bodies, the employees and the collaborators must be fully aware that it is forbidden for them to carry out buying and selling operations or other transactions, even through third parties, or to advise the carrying out of such operations, by exploiting information that they may have come to know as a result of the activity carried out;

• consider confidentiality as the cornerstone of the exercise of the company's activity, which is fundamental for the reputation of VS srl and the trust placed in it by the customers. It is therefore expressly forbidden to communicate, share or make improper use of confidential data, information or news concerning the Guests or third parties in general, with whom VS srl has, or is about to have, relations. Personal data must be managed in a strictly controlled form in absolute compliance with the laws in force and with the correctness and professional ethics of the health operators, and can only be disclosed to those who have an actual need to know them for the exercise of their specific functions. Every person who has relations with VS srl must avoid the undue communication or dissemination of such data and/or information. The employees and/or collaborators of VS srl are obliged to adhere strictly to this principle, even after the termination of the working relationship or collaboration, in any case.

It is also prohibited

• in communications addressed to shareholders or employees/suppliers/family members, to state facts that are untrue in such a way as to mislead the recipients on the aforementioned situation, causing damage to the image or assets of the shareholders or creditors, with the intention of deceiving them and to obtain an unfair profit for oneself or others

• in the reports, with the awareness of the falsity and the intention of deceiving the recipients of the communications, certifying falsehoods or concealing information concerning the situation of VS srl, in such a way as to mislead the recipients of the communications on the aforementioned situation, in order to obtain an unjust profit for oneself or others

• conceal documents or, with other suitable means, prevent or in any case obstruct the performance of the control or audit activities legally attributed to shareholders.

Article 9: RESPONSIBILITY

Respect for the value of responsibility implies that the activities of VS srl are carried out

• being inspired by the principles of sound and prudent management, to be a solid, reliable, and transparent company, open to innovations, interpreter of the ever-changing needs of Guests and their Families, attentive to the needs of its members, interested in the best development and use of human resources, and in the most efficient company organisation

• guaranteeing structural, technological and organisational conditions that safeguard the health and safety of workers, whether employees or not;

• pursuing the company's interests in compliance with laws and regulations, basing its conduct on the principles of loyalty and fairness;

• protecting the company's reputation and assets;

• recognising the importance of respecting the environment and assessing, by the Addressees, the environmental impact of their decisions in order to minimise any negative effects, seeking compatibility between economic initiative and environmental needs, not only in compliance with current legislation but also taking into account the best experiences on the subject.

ARTICLE 10: QUALITY IMPROVEMENT

VS srl pursues a policy aimed at improving the quality of the services provided.

In order to maintain, develop and increase knowledge and skills, VS srl promotes the involvement of personnel in training and/or instruction activities.

The standards of quality provided and perceived are periodically verified, also by third parties, through direct monitoring actions and by a careful evaluation of the level of user satisfaction by all operators.

Article 11: MANAGEMENT OF RELATIONS IN CONNECTION WITH CRIMINAL OFFENCES IN THE FIELD OF SAFETY AT WORK

WORKPLACE SAFETY

VS srl clearly sets out and makes known, in this formal document, the fundamental principles and criteria on the basis of which decisions are taken, of all types and at all levels, with regard to health and safety at work.

These principles and criteria can be identified as follows:

• taking care of one's own and the guests' health and safety by observing the instructions given by the employer, managers and supervisors, for the purposes of collective and individual protection;

• assess risks that cannot be avoided;

• combat risks at source;

• adapting work to the individual, particularly in terms of the design of workplaces, choice of equipment and working methods, in order to mitigate monotonous and repetitive work and reduce the effects of such work on health;

• use work equipment and safety devices correctly and immediately report any deficiencies and/or dangerous situations;

• take into account the degree of technical development;

• replace what is dangerous with what is not dangerous or is less dangerous;

• planning prevention, aiming at a coherent whole that integrates technology, work organisation, working conditions, social relations and the influence of factors in the working environment;

• participate in the education and training programmes organised by VS srl;

• undergo the health checks provided for by the regulations in force and/or ordered by the doctor.

These principles are used by VS srl to take the necessary measures for the protection of the safety and health of workers, including the prevention of occupational risks, information and training, as well as the provision of the necessary organisation and means.

VS srl, both at the top and operational levels, must adhere to these principles, in particular when decisions are to be taken or choices are to be made and, subsequently, when they are to be implemented.

Article 12: MANAGEMENT OF BUSINESS ACTIVITIES IN RELATION TO ENVIRONMENTAL CRIMES

VS srl wishes to comply with fundamental principles and criteria in respect of environmental protection.

These principles and criteria can be identified as follows:

• not to carry out waste collection, transport, recovery, disposal, trade and intermediation activities without the prescribed authorisation;

• not to cause the pollution of soil, subsoil, surface water or groundwater by exceeding the risk threshold concentrations and, if necessary, provide for remediation;

• when preparing or requesting a waste analysis certificate, provide the correct information on the nature, composition and chemical/physical characteristics of the waste itself; not illegally engage in waste trafficking;

• not to exceed the air quality emission limit values set out in current authorisations, prescriptions and legislation;

• not to import, export, transport, possess, use for profit, purchase, sell, display or hold for sale or commercial purposes specimens of wild flora and fauna listed in the EC Regulation no. 338/97 in the absence of or in breach of the required certificates or permits; not to offer for sale or otherwise dispose of the aforementioned specimens without the prescribed documentation;

• outside the permitted cases, not to destroy a habitat within a protected site or in any case not to deteriorate it compromising its state of conservation;

• outside the permitted cases, not to destroy, take or possess specimens belonging to a protected wild plant species.

Article 13: CLINICAL RISK MANAGEMENT

Villa Sabrina srl promotes the "Culture of Safety" by orienting behaviour towards the prevention of risks related to the activities performed through sharing/training meetings on the risks/hazards identified through the FMEA_FMECA analysis of the service delivery processes. DIR is responsible for verifying the operations of personnel in line with what has been defined for the mitigation/prevention of risks related to nursing care.

Starting from the risk analysis, the necessary actions have been identified to prevent the occurrence of any undesirable events of a clinical, environmental or occupational nature. AMM has defined responsibilities (see All QM organigram) for the integrated management of environmental risk (RSPP), operator risk (DOCTOR) and patient risk (DIR). All the personnel concerned have been adequately trained in the application of the procedures, instructions, etc. relating to risk management and actively participate in periodic and systematic control events.

To monitor healthcare processes and take any preventive safety measures, audits are carried out annually by the Medical Director. The purpose of the audit is to verify

• the correct filling in of the health documentation;

• the adequacy of the health documentation;

• compliance with procedures and instructions, from the point of view of patient safety;

• compliance with the guidelines and protocols adopted within the organisation;

• the correct management of clinical risk;

• the correct management of near misses, adverse, and sentinel events, if any.

• the correct application of the actions detected during the application of the FMEA methodology;

• the effectiveness of clinical and care services in compliance with guidelines and ministerial recommendations;

• adherence to the guidelines and protocols used.

The audits are highlighted through the final compilation of an audit report by the Medical Director.

The planning of the audits is reported in the Internal Audit Programme form. The indicators that emerge will be analysed during the management review.

SECTION IV - RELATIONS WITH PERSONS WITHIN THE COMPANY AND RULES OF CONDUCT

Article 14: RELATIONS WITH PERSONNEL

VS srl recognises personnel as a fundamental and indispensable factor for the company's development and considers it important to establish and maintain relations with employees and collaborators based on mutual trust.

VS srl is therefore committed to developing the attitudes and potential of its personnel in the performance of their duties so that the abilities and legitimate aspirations of individuals find full realisation in the achievement of company objectives.

In particular, at the time of recruitment, candidates are assessed according to whether they match the required profiles; personnel are hired solely on the basis of regular employment contracts since no form of irregular employment is tolerated.

At the start of the employment relationship, staff receive clear and specific information on regulatory and remuneration aspects, and throughout the employment relationship, the employees or collaborators receive indications that enable them to understand the nature of their assignment and enable them to carry it out properly, per his/her qualification.

It is VS srl's commitment to take care of the training of all its employees and to encourage their participation in refresher courses and training programmes so that the skills and legitimate aspirations of the individual are realised in conjunction with the achievement of the company's objectives.

It follows that VS srl, through the competent functions, selects, hires, remunerates and manages personnel on the basis of criteria of merit and competence.

Article 15: OBLIGATIONS OF PERSONNEL

The professionalism and commitment of the personnel represent a specific obligation, as they are essential prerequisites for the achievement of the Company's objectives. Employees and collaborators cannot be exempted from observing the provisions of this Code of Ethics.

In particular, they undertake to work with diligence and loyalty according to the following rules of conduct:

It is forbidden:

• to use scientific or other means of persuasion whose contents are misleading or untrue;

• providing unnecessary services or declaring services that have not actually been provided;

• duplicate billing for the same service or fail to issue credit notes if they have been invoiced, even by error, for non-existent or non-financial services;

• to make use, for their own purposes, of the projects, systems, procedures, methodologies, reports or other invention or activity developed by VS srl and for which the latter holds individual property rights;

• to engage in personal activities that could lead to conflicts of interest, even potential ones, with the company or that could interfere with the ability to make impartial decisions in the best interests of the Company;

• to accept, even indirectly, money, gifts, goods, services or favours in connection with any relationship with any third party with whom VS srl has an existing agreement, in order to influence their decisions, with a view to more favourable treatment or undue benefits or for any other purpose.

Staff must also abide by the following rules:

• the personnel, in the performance of their duties, must not engage in conduct that could create, even potentially, situations of conflict with the interests of VS srl;

• the employees, in the performance of their duties, must be appropriate in their clothing and behaviour, respectful towards Guests and their families, suppliers, colleagues and superiors; employees are not allowed to call Guests and their family members, suppliers, colleagues and superiors by name during their work, and to have confidential attitudes that are not justified and not in line with company policy;

• any requests for or offers of money, gifts, or favours of any kind, received by Personnel, as established in the previous point, must be promptly brought to the attention of the director;

• the information acquired in the performance of the activities assigned must remain strictly confidential and appropriately protected in compliance with the provisions of the regulations in force, and may not be used, communicated or disclosed to third parties;

• skills and professionalism must be enriched with the experience and cooperation of colleagues thus creating an atmosphere in which all colleagues feel welcome and encouraged to achieve their professional goals;

• the activity of each employee and collaborator must be characterised by maximum collaboration in order to achieve the satisfaction of all parties;

• the decisions taken must be based on principles of sound and cautious management, through the careful evaluation of potential risks, in the knowledge that their choices contribute to the achievement of positive business results;

• each person is required to work diligently to protect the company's assets, using with scrupulousness and resources entrusted to him/her, avoiding improper uses that may cause damage or a reduction of efficiency, or be, in any case, in conflict with the interests of the Company.

SECTION V - RELATIONS WITH PERSONS OUTSIDE THE COMPANY AND RULES OF BEHAVIOUR

Article 16: RELATIONS WITH USERS

VS srl's activity is aimed at Guests to whom it is committed to guaranteeing

• Reduced waiting times to access services;

• Competence of care and health personnel appropriate to the services to be performed;

• Adequate human relations and humanisation;

• High degree of helpfulness, courtesy and promptness of the operators in responding to specific needs during the stay;

• Clarity of information provided;

• Orderliness and cleanliness of the environment.

Organisation's orientation towards meeting the Guest's needs

The above-mentioned activity is implemented through the:

• systematic measurement of the degree of Guest satisfaction, in order to activate the improvement actions that may result;

• structuring the best ways of dealing with the Guest, within the framework of the principles of protection, participation and communication;

• improvement of the organisation's ability to inform guests about services (access and use) and the guarantees offered;

• constant accountability of staff in responding to the Guest's individual needs.

Complaint management

Anyone wishing to make a complaint about an inefficiency must fill in the appropriate forms in the waiting room.

Article 17: RELATIONS WITH PUBLIC ADMINISTRATION

VS srl guarantees full transparency and completeness of information in its relations with the Public Administration and identifies and defines the channels of communication with all interlocutors (by way of example only: Ministries, Regions, the Guarantor Authority for the protection of personal data, the Inland Revenue, etc.) both at local, national and international level.

Article 18: RELATIONS WITH SUPPLIERS

The persons in charge of the process of acquiring goods and/or services

• shall comply with the principles of impartiality and independence in the exercise of the tasks and functions entrusted to them;

• must keep themselves free from personal obligations towards suppliers and consultants;

• must take into account, for particular types of goods/services, in addition to the normal selection criteria the concrete existence of adequate corporate quality systems;

• must not accept goods or services from external or internal parties in exchange for obtaining confidential information or the initiation of actions or behaviour aimed at favouring such subjects, even if there are no direct repercussions for VS srl;

• the purchasing process must reconcile both the search for maximum advantage and loyalty and impartiality.

VS srl takes care that the only criteria for choosing suppliers and consultants are related to quality and technical competence. The behaviour adopted is always characterised by professional respect for the confidentiality of information acquired during the course of the activity, as well as the current legislation on the protection of personal data.

VS srl is committed to developing fair and transparent relations with its suppliers. In particular, the following are ensured

• criteria and systems of constant monitoring of the quality of the services and goods/services provided;

• supply contracts marked by fairness, especially with reference to payment terms and the onerousness of administrative formalities.

Suppliers are sensitised to carry out their activities by following standards of conduct consistent with those indicated in the Code of Ethics. In particular, they must ensure that they take their business seriously and respect the rights of their employees, invest in quality and manage environmental and social impacts responsibly.

Article 19: RELATIONS WITH INSTITUTIONS AND ASSOCIATIONS

VS srl:

• may agree to requests for contributions from non-profit bodies and associations with regular articles of incorporation and articles of association, which are of high cultural or charitable value and which involve a significant number of citizens;

• any sponsorship activities may relate to the themes of medicine and scientific research, social research, the environment, sport, entertainment and art, and are only intended for events that offer a guarantee of quality.

• In any case, when choosing the proposals to adhere to, VS srl is careful to prevent and avoid any possible conflict of personal or corporate interests.

Article 20: RELATIONS WITH MASS MEDIA

The promotion of VS srl respects the ethical values set out in this Code of Ethics, repudiating the use of vulgar or offensive messages. VS srl takes care of the information published on its website and used as a channel of institutional communication, so as to make it a complete, effective tool in line with market expectations.

Article 21: RELATIONS WITH COMPETITION

No employee may be involved in initiatives or contacts with competitors that may appear to violate regulations protecting competition and the market.

Article 22: RELATIONS WITH POLITICAL AND TRADE UNION ORGANISATIONS

Relations with representatives of trade union organisations are reserved for the functions of VS srl authorised to do so.

Article 23: CONFLICTS OF INTEREST

Prevention of conflicts of interest

The Addressees of this Code of Ethics, in the performance of their duties, must not engage in conduct that could create, even if only potentially, situations of conflict with the interests of VS srl or its users, such as, for example, the pursuit, by the same Addressees, of objectives different from those agreed with VS srl and from those that have been assigned to them on the basis of the role and assignment received.

If situations of conflict with the interests of VS srl or with the users should arise, even if only potentially, the Addressees must immediately inform the Management and must refrain from any conduct that may be attributable to the reported situation.

More generally, the collaborators (employed and/or freelance), and, in general, all those who operate in the name and on behalf of VS srl must avoid any possible situation of conflict of interest that may arise from:

• taking part in decisions concerning affairs from which a personal interest could arise;

• accepting agreements from which personal advantage may arise;

• performing acts, entering into agreements and, in general, behaving in any way that could, directly or indirectly cause VS srl damage, even in terms of image and/or credibility on the market;

• conflict with the interests of VS srl, by influencing the decision-making autonomy of another person in charge of defining business relations with or for the same.

SECTION VI - MODALITIES OF IMPLEMENTATION

Article 24: DISCLOSURE AND SIGNALING

The Code of Ethics and its updates are brought to the attention of all Addressees (internal and external) through publication on the company Intranet and website, as well as appropriate communication and dissemination activities so that the values and principles contained therein are known and applied, and to avoid that individual initiative may generate behaviour inconsistent with the profile that VS srl pursues by adopting this document.

A hard copy of the Code of Ethics is given to each employee or collaborator upon appointment, employment or the start of the relationship.

The Code of Ethics is the subject of specific information campaigns to the general public or other interested parties, including through press and mail or in the manner deemed most appropriate from time to time.

The Addressees of this Code of Ethics are obliged to report any instructions received that conflict with the law, employment contracts, internal regulations and this Code of Ethics.

Failure to comply with the reporting obligation is expressly sanctioned.

The contact details at which to report are as follows

• e-mail address: t.sabrina@libero.it

• registered and administrative office of VS srl, Strada Pareti 34, postcode 05030, Otricoli (TR), Italy.

Article 25: VIOLATIONS OF THE CODE OF ETHICS AND SANCTIONS

The Sanctions System, within the limits and according to the requirements set out therein, is aimed at

• Subordinate employees;

• Members.

With reference to employees, the disciplinary sanctions provided for in the respective labour contract are applied, in compliance with the procedures laid down in Law No. 300 of 1970 - the so-called Workers' Statute.

The disciplinary measures that can be imposed on them are:

• Verbal reprimand;

• Written warning;

• Fine not exceeding the amount of 4 hours' pay;

• Suspension from work and pay for a period not exceeding 10 days.

1.1 THE SERVICE CHARTER

Fourth

The "Service Charter" is the document with which each service provider declares what services it intends to provide, how it will provide them, the quality standards it intends to guarantee and undertakes to respect certain qualitative and quantitative levels, with the intention of monitoring and improving the quality of its service.

The introduction of the Service Charter as an instrument of protection for citizens originated with the Directive of the President of the Council of Ministers of 27 January 1994 "Principles on the provision of public services".

Our Service Charter contains all the necessary information to allow users to know what services the Residence offers, how to use them and the commitments made by the structure for the continuous improvement and satisfaction of our Guests.

1.2 VALUES AND PRINCIPLES FOCUSING ON THE PERSON

In a welcoming and comfortable environment, time and resources are dedicated by the entire staff to help the non-self-sufficient Guest combat loneliness and isolation due to old age and to overcome the discomfort that certain psychophysical limitations can create in the management of daily life, guaranteeing a state of physical, mental and social well-being.

PROFESSIONALISM

The professionalism of our staff is characterised by experience, competence, preparation, seriousness, constant commitment and thoroughness in their actions.

RESPONSIBILITY

For us, it is the accountability of acts, events and situations in which everyone has a decisive role. The obligations that derive from the position each one occupies, the tasks, and the assignments undertaken.

RESPECT

As awareness of the rights, merits and values of others.

EQUALITY

Every Citizen has equal rights with regard to access to Health Services; in the provision of the service, no distinction may be made on grounds of sex, race, language, religion, political opinions and forms of physical and mental disability.

IMPARTIALITY

The Residence is inspired by criteria of impartiality and justice; every Citizen is expected to behave in a manner that respects his/her dignity.

PARTICIPATION

The User has the right to access the information concerning him/her that is in the possession of the provider in accordance with the procedures governed by Law No 241 of 7 August 1990. Users may submit briefs, documents and observations and make suggestions for improving the service. Providers periodically acquire the User's evaluation of the Quality of the Service rendered.

EFFICIENCY AND EFFECTIVENESS

The activity of the Villa Sabrina RP is aimed at satisfying the health needs of patients as well as continuously improving the quality of the services offered and the care provided.

1. MISSION

"... the company's purpose is to manage a nursing home for the elderly, in compliance with the provisions of Resolution 647/1999 of the Regional Council of Umbria and any different and subsequent regulations" Villa Sabrina aims to offer social and health care to the elderly, both self-sufficient and not, seeking to reconcile the excellence of technical, professional, care and health services with the maintenance of a family atmosphere in which the guest does not lack human relations and the warmth of a real family.

4

2 THE STRUCTURE

2.1 PRESENTATION

Villa Sabrina is a nursing home authorised by the Region of Umbria with resolution no. 11379 of 12/12/2003, accredited with the Region of Umbria and in agreement with local health authorities and municipalities in Umbria and Lazio, with 24 beds for non-self-sufficient guests.

The innate desire to provide quality services and the special attention that has always been paid to the needs of the elderly population has led to a particular commitment to assisting the frailest elderly, who also suffer from senile dementia and Alzheimer's disease.

FACILITY AND GARDEN

The facility is arranged on three floors connected by a lift equipped with alarm bells and automatic return to the floor. It is organised into 12 double rooms equipped with 1 or 2 joint beds with safety bars on the sides, polyurethane foam anti-decubitus mattresses, headboards with soft or direct lighting and alarm bells. The guest may bring personal items to which they are affectively attached. All bathrooms are equipped with lifts and aids and have audible and visual alarms.

There is a large urbanised area outside the building with illuminated parking spaces for visitors and special spaces for the disabled.

A green garden and adjacent woodland contribute to the feeling of tranquillity that anyone entering the facility perceives. The construction of a vegetable garden/garden at human height allows the elderly, even those suffering from Alzheimer's disease, to recover their memories of old trades and makes them active and involved in daily activities.

SNOEZELEN ROOMS

The facility has developed a professional approach to dementia with both pharmacological and non-pharmacological therapies with the creation of a Snoezelen Room and Bathroom. The application of multisensory therapy in the Snoezelen Rooms represents a complete pathway of non-pharmacological care.

The main aim of non-pharmacological therapies is the reduction of certain behavioural disorders with a consequent reduction in the pharmacological load and thus in the quality of life; patients undergoing such treatment have demonstrated an improvement in behavioural disorders, in particular apathy, eating disorders, wandering, logorrhoea and agitation.

A research conducted by the University of Dundee found practical applications of the SNOEZELEN therapeutic and educational approach, noting specific benefits for different types of users: people with cognitive disabilities, psychiatric problems, post-traumatic stress disorders, acute and chronic pain control, and in cases of stroke and head injury outcomes.

2.2 THE STRUCTURE'S COMMITMENTS

With reference to the above-mentioned fundamental principles, the Residence undertakes to guarantee that no discriminatory behaviour is implemented by Employees, Collaborators and Consultants, which takes the form of unequal treatment in the provision of services;

In this way, a process of conscious decision and choice on the part of the patient is guaranteed, which is embodied in the so-called "informed consent", which is fundamental in the relationship between the Guest and the healthcare personnel. 

AND BEFORE

In order to ensure maximum transparency of information with the Guest, therefore, the Residence undertakes to

• guarantee the Guest, or his/her delegate in the cases provided for by law, the most complete and appropriate information on the diagnosis, prognosis, possible alternatives, prospects and foreseeable consequences/complications of the choices made;

• not use misleading and untruthful means of persuasion, scientific or otherwise;

• periodically check the reports received by the public relations office to analyse

any feedback and/or complaints from users.

The principles underpinning the activity of admitting, treating and caring for patients at the RP are based on ministerial regulations with respect to care activities and are summarised in the following points

• clinical governance of all cases by drawing up a customised Individual Care Plan (PAI), constantly updated in the light of the results obtained and emerging problems;

5

• active involvement in decision-making processes and sharing of the care pathway with the Guest or his/her family members/caregivers, right from the early stages of admission, with structured moments of listening and discussion

• constant monitoring of appropriateness, both in the selection of patients eligible for admission and in the decisions regarding the choice and continuation of care programmes;

• staff training through continuous updating of technical and organisational skills.

o

3. RELATIONS WITH THE PUBLIC

3.1 INFORMATION REQUESTS

For any kind of information, you can contact the Administrative Office

✓ on 0744.709073 from MONDAY to SATURDAY from 9:30 a.m. to 12:30 p.m. and from 3:00 p.m. to 6:00 p.m.

✓ send an email to t.sabrina@libero.it,

✓ contact us via the website.

3.2 ACCESS TO INPATIENT SERVICES

All citizens who, on the basis of the principle of free choice, opt for Villa Sabrina as the facility for their residency in private social-health care and/or in agreement with the local health authority (USL), have access to RP services.

At the time of the application for admission, the Management Contact Person collects the health and care data on the appropriate form (Mod.72.02 "Application for admission and eligibility") and explains to the applicant in a clear and exhaustive manner the points set out in Procedure PG 01 "Eligibility and admission procedure with service delivery, planning, management and control". Completion of the questionnaire and the fact sheet enables the facility team to plan the individual care plan and properly integrate the new resident.

The RGQ (nursing coordinator) defines, together with the Medical Director or the Facility Doctor, the eligibility of the request and, if eligible, the applicant will be placed on the waiting list.

Inclusion on the waiting list does not entail any cost or constraining commitment for either party, but allows the Administrative and Health Directorates to verify the eligibility criteria applied:

• persons over 65 years of age who are not self-sufficient with stabilised chronic pathologies;

• non-self-sufficient persons aged < 65 years with stabilised chronic pathologies with a care load appropriate to the organisation of PR

• persons who do not require specific 24-hour nursing care (with artificial respirators, transfusions or other hospital care)

• the absence of pathologies that prevent them from living in the community

• the absence of infectious diseases

• Italian-speaking patients or those who understand and speak it

If the request is eligible for admission, priority is given to:

• request history

• request with urgent accommodation and relief

• patients affiliated with the Umbria and Lazio Local Health Authority

• patient's general condition and residual functions will be evaluation criteria based on the care burden.

In the event of a call, the family member must sign the accommodation contract, as an agreement and assumption of responsibility by the Guest and his/her family member; if there is no bed the request will be archived pending re-evaluation at the first available place, according to the criteria of the same PG 01 procedure.

3.3 CLINICAL NEWS AND PRIVACY

The administration and healthcare management are at the disposal of the Guests' families for telephone or in-person interviews. In the exclusive interest of the Guests, staff are bound to strict confidentiality regarding all information concerning Guests and do not provide any information to family members or persons unless expressly authorised. When signing the accommodation contract, before

6

of admission to the Facility, adequate information is provided and consent to the processing of personal data is requested, in compliance with European Regulation 2016/679 (GDPR).

3.4 RELEASE OF COPIES OF HEALTH RECORDS AND ADMINISTRATIVE DOCUMENTS

Villa Sabrina has specific guidelines regarding access to documents, as governed by L.241/1990, which regulates the manner in which the User's personal documentation is released (individual care plan, diagnostic examinations, integrated social-health record, etc.).

A copy of the Guest's personal medical records may be delivered, at the explicit request of the Guest and/or of the guardian/support administrator with an appropriate health care proxy and/or of the legitimate heirs, to the management contact person. At the administration office, it is possible to pick up the form to be filled in to make a request, which, if there is no objection, allows a copy of the documentation to be issued within 7 working days. The cost of the copy is €50.00. The reception desk can also issue the interested parties with proof of stay and other administrative documentation.

3.5 GUEST SATISFACTION QUESTIONNAIRE

The perceived quality of the services and performances provided is assessed annually by analysing the Guest Satisfaction Questionnaires. The questionnaires are anonymous and are given in the paper form to caregivers or to the Guests themselves annually, when requested or at the end of a temporary stay. In the management review, the returned questionnaires are analysed and the results are published on the notice board in the corridor of the facility and on the website.

3.6 DISSERVICE OR APPRECIATION REPORT FORM

The Residence guarantees the possibility of filing a complaint following a disservice, act or behaviour that has denied or limited the use of services. Users may complain directly to the Management, communicating their observations verbally or in writing, on plain paper or using Form 83.02, which can be obtained at the reception desk. The Management undertakes to respond in writing to complaints received, which are not anonymous, within 3 days of receipt. Complaints are dealt with at the same time as they are reported, and the maximum time limit for processing them is 15 days if external bodies or suppliers are involved in resolving them.

4 LIFE IN THE FACILITY

The activities in the Villa Sabrina RP are organised in accordance with the needs and the Entertainment, Occupational Therapy and Mobility Plan; timetables are subject to change according to care needs:

ACTIVITIES BY HOURS

Waking up and hygiene 06:00 a.m. According to the personal needs of the Guest

Breakfast 07:00 a.m. to 9:00 a.m.

Morning activities and hydration 10:00 a.m. to 11:30 a.m.

Lunch 12:00 p.m. to 1:30 p.m.

Afternoon rest Depending on the personal needs of the Guest

Snack 3:00 p.m. to 4:00 p.m.

Animation 4:00 p.m. to 5:30 p.m.

Dinner 6:00 p.m. to 8:00 p.m.

Rest Depending on the personal needs of the Guest

7

4.1 HOW TO RECOGNISE STAFF

All PR staff wear a name tag on their uniform with the employee's name and job title.

The colour and shape of the uniforms allow the staff to be traced back to a professional group, the caregivers wear white trousers and polo shirts or white and lilac coats, the animator the lilac coat and nurses the white uniform with V-neck.

4.2 VISITING IN-PATIENT RELATIVES

In the post-COVID period, visitors can access the facility every day by appointment with the administration in order to allow for the turnover of relatives, the normal course of care activities and the rest of the guests; it is recommended to follow the indications given for visits due to COVID.

The timetable is flexible to allow:

• the acclimatisation of the new guest with more assiduous closeness in the first days of the caregiver;

• more visiting hours for the caregiver ;

• assistance for severely bedridden residents

• the proximity of the family member in the case of terminally ill or agonised residents.

4.3 TELEPHONE, TV, INTERNET

TELEPHONE: Each resident has the possibility of receiving or making telephone and/or

video calls using the facility's portable devices at no cost.

TV: In the communal halls and all rooms there are television sets, which can be equipped with earphones, for watching favourite programmes. In the main hall, the entire community can participate in watching television programmes of common likings, such as Sunday Mass.

INTERNET: connection is either by personal devices or through the facility's Wi-Fi.

4.4 MAIL, NEWSPAPERS AND MONEY

Incoming mail is delivered daily to recipients or their contact persons by the secretariat, which also forwards any outgoing mail. Books and magazines preferred by Guests are available in the facility. The facility chooses NOT to manage Guests' money but to anticipate any expenses and ask for documented reimbursement.

4.5 HAIRDRESSER, BARBER AND PODIATRIST

The service is available for a fee by appointment with freelance external collaborators who indicate the agreed rates charged for their services in the facility.

4.6 LAUNDRY SERVICE

The laundry service for hotel linen and personal clothing is carried out

in-house and at no additional cost. In the case of particularly delicate garments such as silk, the facility does not assume responsibility for washing, which remains the responsibility of the family members.

4.7 PERSONAL BELONGINGS

Upon entering the facility, a form is filled in to register all clothing and personal possessions in order to manage them as best as possible during the stay. It is advisable to avoid bringing valuables and money, if necessary they will be kept by the administration and made available for every need.

4.8 RELIGIOUS ASSISTANCE

Each Guest has his or her right to belief and religion, and the facility will try to do everything possible to create moments of spiritual assistance, if unable to personal meetings, it will make radio, internet and TV available to allow them to be enjoyed.

4.9 LOCAL VOLUNTARY ASSOCIATIONS

Villa Sabrina collaborates with ANCESCAO of Terni and with the local Social Centres for the elderly and with A.M.A.T.A. Umbria for support in the management of persons suffering from Alzheimer's disease and other forms of dementia.

8

5 RIGHTS AND DUTIES OF GUESTS

The participation of all staff, family members and Guests in the fulfilment of rights and duties in the facility is the basis for them to be able to fulfil their commitments in the provision of social and health care services to the best of their ability, to enjoy their rights and those of the community.

5.3 RULES FOR FAMILY MEMBERS FOR THE SAFETY OF GUESTS

*DO NOT MOVE GUESTS AUTONOMOUSLY: our Guests are fragile and often unable to be cooperative when moving, so if you move a Guest on your own you run the risk of hurting yourself and him too. Ask for support from staff who are trained to move safely.

*COLLABORATE WITH HEALTH STAFF WITHOUT REPLACING THEMSELVES: Our guests are

complex to deal with, if you feel that the care we are providing is not adequate, our healthcare staff are available for clarification and discussion. Do not intervene on your own (e.g. with supplements or medicines, with exercise or with medication) as these could be harmful to your loved one's health.

* BEWARE OF FOOD TAKEN FROM HOME: The Residence is not only a place where one is treated but also a place for socialising and sharing that encourages the development of interpersonal bonds...why not share something that reminds us of home, of our traditions? The "food hygiene 'legislation' prohibits the serving of home-made and non-packaged products; it is, therefore, forbidden to bring your loved one home-made food, if you want to bring something 

5.1 RIGHTS :

*to respect dignity and confidentiality

*to listen with kindness and competence

*to timely, clear, comprehensive, up-to-date and comprehensible information

*to know the purposes and modalities of appropriate healthcare provision and to trust in a relationship of trust with the team

*to be assisted by qualified personnel

*to know the conditions of stay and the costs of services

*to receive information within the limits permitted by respect for privacy and the user's wishes

*to complain and to know the outcome, to make proposals and suggestions in verbal and written form

*to express one's opinion on the services offered through the Satisfaction Questionnaire

5.2 DUTIES

*It is your duty to maintain a responsible attitude towards other patients, avoiding any behaviour that may cause disturbance (noise, bright lights, radio, loud TV, mobile phones, etc.).

*Maintain respectful and collaborative behaviour with all the personnel of the facility and with the Health Management.

*Adhering to therapeutic prescriptions and behavioural indications received, in order to guarantee the best possible outcome of treatment.

* Respecting the environment, equipment and furnishings within the facility.

*It is the duty of each patient to promptly inform healthcare professionals of his/her

intention to forego scheduled healthcare services and treatment, in order to avoid wasting resources.

*Smoking only where permitted, to preserve the health of the community

9

must only be packaged and you must leave the product label and/or receipt with the facility, which will be kept specifically for food tracking purposes.

*DO NOT GIVE FOOD TO GUESTS: Our Guests often have medical conditions that limit their diets or even their ability to swallow. Giving unauthorised food to a Guest may jeopardise their health, we, therefore, ask you to refrain from independently giving food to Guests without the prior authorisation of health personnel.

*HYGIENE IS OUR PRIORITY: The staff is obliged to ensure the hygiene of the Guests. Products commonly available on the market may be aggressive and contain allergens that may cause side effects. For this reason, we ask you not to personally take care of your loved one's hygiene, but to turn to the staff, who will intervene in the most appropriate ways and with the most suitable products to preserve his or her skin and safety.

*WASH YOUR HANDS: Hands are the first vehicle of germs and therefore hand hygiene is the first step against infections. Health does not always involve complicated things or targeted interventions, there are simple gestures, such as washing your hands, that ensure that you stay well while respecting yourself and others.

*IF YOU ARE SICK STAY AT HOME: If you are unwell or sickly, don't feel obliged to visit us, for everyone's well-being it is better if you stay at home for a few days.

* MAKE SURE THE DOORS AND GATES ARE CLOSED: People live here who need to be protected as they are unable to manage themselves. Living environments must guarantee their safety, so if you find a closed door, take care to close it after you pass by. Also, make sure that external gates close after your passage and do not make it easier for people to leave; this is not a gesture of rudeness, but a concern for those who are more fragile.

* BEWARE OF SAFETY SIGNS AND ESCAPE ROUTES: Safety signage identifies hazards, prohibitions and obligations as well as provides information, escape routes and access routes are gateways to quickly deal with any emergencies. Don't underestimate these messages and make sure you don't obstruct escape routes: they may help you avoid hazards and deal with emergencies.

*SAFETY REQUIRES THE COLLABORATION OF ALL: The company is committed to ensuring

safe environments for guests, visitors, employees and collaborators. Please, help us maintain a high focus on safety and report malfunctions, breakdowns, etc. Your cooperation is a valuable aid to us.

6 RECREATION

The Villa Sabrina RP provides socio-medical services to non-self-sufficient elderly people with stabilised chronic pathologies, who cannot be cared for at home. 

Guests are people over the age of 65 who need 24-hour assistance and help with self-care, rehabilitation and healthcare services, as well as incentives to carry out activities useful for maintaining and recovering their motor skills and/or mental faculties.

The services provided are of social-healthcare relevance intending to recover and maintain residual functional assets; treatments include medical, nursing, rehabilitation and hotel services, with guaranteed continuity of care and socialisation and entertainment activities.

The stay, if not necessarily definitive, is oriented towards the possibility of reintegration into the home environment.

6.1 INTERVENTIONS PROVIDED DURING HOSPITALISATION - HUMANITAS

On admission, the patient and his or her family members will be welcomed with professionalism and understanding, respecting the time needed to manage such a delicate moment as the change in the life of a frail patient and the separation from the family and one's habits.

In the new guest's insertion, his or her life history, needs and desires must always be borne in mind; these aspects are highlighted in personal files and the individual care plan. The facility tends to favour

10

personalisation of living environments by allowing the admissibility of one's objects within the facility.

In the health field, the regulations in force envisage that in residences for the elderly prevention, care and rehabilitation activities are carried out that do not require hospitalisation.

Guests benefit from qualified nursing and medical assistance, a hospitality service, board, lodging, heating, linen and cleaning; opportunities for recreational and cultural socialising; assistance in carrying out personal hygiene activities; a laundry and cloakroom service; and religious assistance, if desired.

In proportion to individual needs, mobilisation and recovery of psychophysical autonomy are provided. 

Guests have the freedom to get up in the morning according to personal needs, respecting the daily schedule as far as possible.

HEALTHCARE: THE HEART OF THE STRUCTURE

In the facility, we are faced with persons with varying degrees of non-self-sufficiency, conditions that often do not depend exclusively and automatically on age, but also on physical or psychic illnesses, accidents, or the socio-economic and relational context in the family. Therefore, when considering the care needs of a guest, one must necessarily consider the complexity of intrinsic situations, knowledge of which is indispensable for the care pathway.

The multidisciplinary assessment of the elderly person, especially of the elderly over 85 years old, is the basis of the diagnostic-therapeutic-assistance process, summarised in the drafting of the individual car plan. Occupational therapy, group exercise and music therapy are activities which, integrated within the PAI (individual care plan) of the Guest, contribute to the positive evolution of the Guest's psychophysical state.

When recovery is not as hoped for and the handicaps persist, the facility tries to adapt to personal needs, minimising the disorientation of those who find themselves deprived of their autonomy. It is precisely in such conditions that the staff must demonstrate experience and inventiveness in adapting tools and equipment, in finding expedients that allow the elderly person to compensate, at least in part, for their deficiencies and inabilities.

The facility makes use of an adjoining Physiokinesitherapy Centre for physiatric, physiotherapy and masso-physiotherapy consultancy.

THE INDIVIDUAL CARE PLAN (PAI)

General medical assistance is provided by the general practitioner (M.M.G.) and is normally carried out at the Residence infirmary. The Residence has a Health Care Manager and a Geriatric Consultant who have the task of monitoring the Guests' state of health, in collaboration with all the professional figures working in the Residence. Specialist examinations, when necessary, can be booked at NHS Outpatient Clinics or, in the case of private specialist examinations, can be carried out directly at the Residence.

The multi-professional team, coordinated by the Medical Director, draws up a customised project for all persons taken into their care: the PAI, using specific assessment scales (ADL, Norton, Braden, Conley, MMSE, MNA, etc.) as aids, which allow the work of the facility's personnel to be adapted to the specific needs of each Guest.

The PAI is formalised according to the Internal Procedure within 15 days of admission to the residence, it is evaluated every 6 months and revised whenever there are substantial changes in the Guest. The family or caregivers are involved in the drafting of the PAI and its revisions.

Only a strategy based on a comprehensive needs assessment can guarantee a care and assistance plan aimed at preserving maximum personal and social autonomy.

The data obtained are processed in the Improvement Programme and discussed in the Management Review as elements in the evaluation of the effectiveness of the implemented plan.

Doctors and nurses, with the support of appropriate medical equipment, try to prevent all possible situations that could degenerate, treating the Guest in the facility as much as possible, and reserving hospital admission for more complicated or diagnostic cases.

The infirmary houses individual files, medical records, medical equipment, drugs to be administered, and a well-equipped trolley that allows for the rapid and immediate use of first aid measures and the activation of the First Aid unit.

NURSING ACTIVITY

Nursing activity is guaranteed 24 hours a day (with night availability), the nurse is responsible for the preparation and administration of therapies, carries out dressings, takes blood samples for haematochemical tests, checks vital parameters, and carries out all necessary interventions to protect clinical integrity.

11

of the Guest. He/she is in charge of procuring medical aids and medicines and verifying their correct preservation and expiry.

The nurse promotes all initiatives within his/her competence to meet the needs of the Guests and to maintain a climate of serene collaboration with the families. He/she records and reports any useful elements for medical diagnostics, and collaborates with doctors and other professionals in formulating the integrated care plan.

STAFF AND PROFESSIONAL DEVELOPMENT

The care workers are all salaried employees and have specific professional training, both from training courses and on-the-job training; the management takes charge of numerous initiatives through a permanent training plan on both legal updates and care-related in-depth training.

SUPPLY OF DRUGS, ARTIFICIAL NUTRITION, GARRISONS

The local health authority (ASL) directly guarantees

• the direct supply of drugs for Guests placed in accredited social-health facilities, according to a therapeutic plan prescribed by the GP. Band C drugs are paid for by the Guest

• the supply of Artificial Nutrition products, oral caloric nutritional supplements and water substitutes (for dysphagic patients), based on the nutritional plan prepared by the local health unit nutritionist

• the supply of advanced dressing material or for ostomies, on the basis of treatment plans issued by National Health Service Specialists

• for diabetic patients: material necessary for glycaemic self-monitoring

• the supply of nappies and incontinence aids in the daily quantity indicated by the GP.

Anything not provided by the local health unit and the national health service must be paid for.

PHYSICAL AND REHABILITATION ACTIVITIES

These are carried out according to the Guest's PAI by caretakers or physiotherapists, depending on whether ambulation with or without aids is required or whether particular attention is paid to the motor, psychomotor and cognitive disabilities using physical, manual, massage and occupational therapies. All programmes are aimed at maintaining and recovering the Guest's residual capacities and improving his or her mobility autonomy.

SOCIAL-ASSISTANCE ACTIVITIES

Social assistance activities are carried out 24 hours a day by qualified operators (O.S.S. socio-medical workers) and cover all care activities such as personal hygiene (bathing or showering, hair washing, shaving), dressing, feeding and hydration. The care workers collaborate during activities designed to encourage the socialisation of the Guests, carry out control and supervision activities to guarantee the safety of the Guests, and take care of all the hygienic aspects of the living environments.

FOOD PROGRAMME

The cuisine incorporates Italian and Mediterranean traditions, and the freshness of the food is guaranteed by the choice and evaluation of suppliers and scrupulous compliance with current hygiene regulations. Appropriate nutritional paths are identified according to the Guests' needs. Guests with chewing problems benefit from the daily menu in chopped or homogenised form. It is forbidden to supplement the diet with food and drinks from outside. The monthly menu is posted in the corridor and in the kitchen and offers daily first courses, main courses, side dishes, fruit or dessert and all possible variations on the planned meals.

HYDRATION

The correct water intake is guaranteed on a daily basis, consisting also of beverages of choice such as water, tea, camomile, barley, milk, fruit juice, etc. It becomes, in daily life in the Residence, a ritual in which the Guest willingly "participates", benefiting from an additional moment of socialisation.

RECREATIONAL ACTIVITY FOR COGNITIVE STIMULATION

The activity is integrated with health and welfare activities through the development of craft activities, cognitive stimulation, games, socialisation, and psycho-therapeutic support, aimed at

• stimulate motor skills, memory, attention and imagination through cultural or recreational initiatives also open to the outside world

• increasing the non-pharmacological approach where possible

• involving family members and caregivers in the life of the Guests.

12

Many projects are carried out in the facility, dedicated to groups of guests suitably distinguished by their abilities and interests: art-therapy, gentle gymnastics, Snoelezen rooms, play and recreational activities, workshops, theme parties, visits by external groups, and music therapy.

6.2 FIRST DAY OF ADMISSION TO THE FACILITY

Guests are welcomed preferably in the mornings to make their insertion harmonious and to facilitate welcoming by the entire team. 

On entry, which is finalised in the preceding days by requesting the necessary documentation and personal belongings, the contract, the Guest's consent to the processing of personal data and the medical file are signed.

The Guest and the family member are welcomed by the Director and the Guest will be accompanied to his/her room by a team of operators who will follow his/her integration.

Villa Sabrina recommends that guests do not take valuables and/or money with them for security reasons; the facility will not be held responsible for any shortages and declines all liability in the event of theft and/or loss of personal items left unattended during the stay.

Please note that no money should be paid by Guests or their families to the medical staff, neither as a tip nor as a deposit.

6.3 HOSPITAL DISCHARGE AND ADMISSIONS

Discharges may occur at the end of the rehabilitation cycle, to return home or to transfer to another facility and must be given 15 days' notice. At the time of discharge, the resident's doctor will issue a Letter of Discharge which identifies the clinical, functional and welfare problems, the programmes implemented, the results achieved, the therapy carried out and any personal aids and equipment provided. 

If the Guest is absent for hospitalisation, the place will be kept until discharge and, since the monthly fee must be paid in advance, the facility will reimburse 30% of the full days of absence.

6.4 HOSPITALISATION IN PRIVATE AGREEMENT AND FEES

The Villa Sabrina RP has an agreement with the local health authorities and municipalities for the integration of hospitalisation fees, so it is possible to carry out both agreed and private hospitalisations, in the event that the local health authority, despite having an agreement with the facility for 100% of the beds, does not occupy them with integrations. There are no different treatments depending on the type of hospitalisation, but the same services and the latest rates established by regional resolutions apply to both solutions.

In the case of private admissions, the lack of integration of the health fee by the local health unit allows the inclusion of this fee in the Health Card System by the facility and the relative reimbursement as health expenses in the Guest's tax return.

6.5 WHAT THE FEES INCLUDE

The fee includes all the services of food and accommodation, health and nursing services, care services, basic physical and cognitive stimulation activities, and recreational and entertainment services.

In detail, these are defined as:

• Accommodation services: the in-patient room and bathroom are complete with the necessary linen, and cleaning is carried out on a daily basis. Each in-patient room is equipped with a TV and alarm bells

• Food: consists of breakfast, lunch, snacks and dinner. Lunch and dinner consist of several courses with a choice for each course and include water, wine and coffee served at the table. Special diets will be proposed by the doctor depending on the clinical situation.

• Health care: all Guests benefit from the National Health Service (prescriptions and medicines included) and from the facility's medical and nursing care, scheduling check-ups, blood tests, and medications.

• Health and socio-welfare services: the Residence provides nursing and socio-welfare assistance supervised by the nursing coordinator and under the control of the Management and Health Director.

• Physical and rehabilitative activities: the service is provided under the supervision of the doctor, depending on the activity envisaged, and may be carried out by qualified nurses or physiotherapists.

13

• Entertainment: the service provides a weekly programme of occupational, play and recreational activities

• Flat and guest laundry service.

The fee does NOT include any additional hotel and/or customised services beyond the basic services.

They are therefore at the total expense of the user:

• Guests' laundry for particularly valuable garments that could be ruined

• Hairdresser, barber and podiatrist managed by a third party with a constantly updated price list available at reception

• Special medication material not guaranteed by the NHS and drugs and prescriptions that are also chargeable for the facility.

• The physiotherapy service for individual treatments with a price list

• The ambulance transport service, if not authorised by the USL

• Incontinence aids: provided by the local health authority and, if necessary, supplemented by the family member or facility, in this case, charged in the monthly bill.

• Voluntary expenses for bars, newspapers, mail, subscriptions, etc.

6.6 METHOD OF PAYMENT

When the Guest enters the residence the balance of the remaining days of the current month is requested and by the 5th day of each month, the balance of the month is paid in advance. It is preferable to pay the balance by bank transfer both for tuition and for any personal expenses advanced by the Facility.

7 WHAT IS MEANT BY QUALITY SERVICES

Current legislation requires the Service Charter to express the Residence's quality standards with regard to the aspects that each Guest or their relative can personally experience in the environments and in their relationship with the staff: this is why we speak, in this case, of perceived quality.

The standards of technical-professional quality of the services and of the efficiency of the work processes are therefore not considered in the Service Charter, since the evaluation of these aspects requires special tools and methodologies, left to the internal Quality Service and to the competent local health authority.

7.1 HOW TO UNDERSTAND QUALITY

We can define Quality as the meeting of two areas of needs: those of the Guest and those of the operators who must provide services that are as satisfactory as possible. In this perspective, quality is "global", since it is developed by combining the quality perceived directly by people, the technical-professional quality, and the quality delivered in the work processes. This encourages interaction between the activities carried out by the various professionals working in the residence, in a human and environmental context that respects people's dignity.

7.2 QUALITY INDICATORS AND STANDARDS

In defining standards, reference is made to different types of indicators, i.e. "significant facts" that indicate whether the result obtained corresponds to what was intended.

Indicators:

• organisational: hours of the presence of medical staff, nursing service, physiotherapy and animation programmes, training of internal staff;

• structural: absence of architectural barriers, air treatment facilities in the summer season;

14

• of processes: timeliness of staff intervention in the event of a bell call, periodicity of cleaning and environmental sanitisation, choice of alternative dishes on the menu

• of satisfactory/unsatisfactory events (e.g. positive/negative judgements expressed by Guests and/or Family members with respect to the services provided);

• of sentinel events, i.e. situations which are considered "near-events" and which must be dealt with to prevent their transformation into a problem.

The indicators used to monitor quality in the Residence were chosen in compliance with the provisions of the regulations in force and the regional accreditation checklist.

7.3 PERFORMANCE TIMING

They represent the quality factor that can be quantified with greater precision, controlled in its trend and evaluated objectively. The average waiting time referred to as a sample week is indicated for each service.

7.4 VERIFICATION TOOLS

The declared quality standards are subject to constant verification with specific methods and tools, prepared, managed and monitored in the Management Review.

In particular, the following tools are used

• processing of complaints received (they provide information on the type of events of most frequent dissatisfaction)

• observation grids on significant indicators in relation to the various aspects of perceived quality

(information, cleanliness, relationship with staff);

• questionnaires on the level of satisfaction with the services received, which are administered to guests and/or caregivers. The results are published on the notice board of the Residence and on the website (see attachments Customer Satisfaction Guests and Relatives);

• the operators of the Residence are subject to monitoring work environment satisfaction

7.5 COMMITMENTS AND IMPROVEMENT PROGRAMME

Commitments and improvement programmes with respect to current quality standards are defined by the Management, both in accordance with the company's orientation of striving for constant improvement in the services offered to Guests, and for the periodic need to adapt to new requests coming from national and regional regulations, aimed at better protecting citizens. According to current legislation, the protection and participation of Guests are achieved through an effective information system on the services provided and the methods of access;

• surveying the level of user satisfaction with the services received;

• the monitoring of perceived quality;

• suggestions to the Management to guarantee the constant adequacy of the facilities and services to the Guest's needs.

• the handling of complaints within 15 days of their submission with the application of Procedures for the handling of complaints by the persons in charge of the area concerned.

7.6 GUEST SAFETY

To guarantee the Guest absolute serenity during his or her stay, the Residence guarantees high safety standards in relation to the different types of risk to which the resident may be subject.

For this reason, as part of a broader risk management system, specific procedures have been implemented, including:

1) Safety in the use of drugs 3) Prevention and management of falls

2) Control of skin lesions 4) Monitoring of adverse events and sentinel events

8 HOW TO REACH US

Villa Sabrina is located in Otricoli (Terni) along the SS3 Flaminia road to Rome, 8 km from the exit of

Magliano Sabina exit of the A1 in the direction of Terni. It is about 28 km from Terni and 20 Km from Orte

15

ANNEXES TO THE SERVICE CHARTER

• Form no. 83.02 DISEASE REPORT SHEET OR DISRUPTION IN THE SERVICE

• Form no. 82.04 GUEST AND/OR FAMILY SATISFACTION QUESTIONNAIRE

Form no. 83.02 Rev.1

16

Villa Sabrina

Residenza Protetta

Report of dissatisfaction or appreciation form

N° OF _________________

SERVICE DISSERVICE OR APPRECIATION REPORT CARD :

Care Entertainment Medical

Cleaning Rehabilitation Nursing

Food Other___________________________________

Surname and name:________________________________________________________________

Resident at _____________________________ at __________________________________

Tel.:_________________________ as ________________________________________

 Signature of declarant ______________________

 Reserved for the Office (which has 7 days to reply and verify the event and 15 days to resolve it)

Date _________________ Signature of service manager ______________________

Your suggestions will be a valuable help in improving our service.

To be reported: ____________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Suggestions : ___________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

How you solved the problem or dealt with the appreciation:______________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

17

GUEST AND/OR FAMILY CUSTOMER SATISFACTION

Dear Madam, Dear Sir

as part of our programme for the continuous improvement of the quality of our services, we have decided to systematically conduct a Customer Satisfaction survey of our facility.

In particular, we are interested in knowing the degree of overall appreciation of the facility, the care services and the professionalism of the doctors, nurses and operators; we are only asking you for a few minutes of your time to fill in the questionnaire, which for your protection will be anonymous and will not allow us to trace the person who filled it in. Your suggestions, together with those of other guests and family members, will help us to improve the services we offer, and we thank you in advance for your willingness to collaborate.

The questionnaire must be filled in directly by the guest and/or his/her family members; if you need help filling it in, you can contact: the director of the facility; an operator you trust; your family members.

For each question/statement in the questionnaire, place an X next to the number that you consider adequate to express your level of satisfaction with the subject.

In order to make it easier for you to complete the questionnaire, please note that number 1 expresses the lowest level of satisfaction (very negative judgement) and number 4 is the highest level of satisfaction (very positive judgement).

VILLA SABRINA Mod.82.04 rev.3

GUEST AND/OR FAMILY SATISFACTION QUESTIONNAIRE

How long have you been a guest of the facility: less than 6 months or between 6 months and 1 year or more than 1 year

ADMISSION AND RECEPTION Rating: 1 = very negative; 4 = very good

Clarity of information received for access 1 2 3 4

Courtesy in responses from the administration 1 2 3 4

Welcome at the entrance 1 2 3 4

ACCOMMODATION ASPECTS Rating: 1 = very negative; 4 = very good

CLEANLINESS

Room 1 2 3 4

Bathroom 1 2 3 4

Common areas 1 2 3 4

MEALS

Quality 1 2 3 4

Quantity 1 2 3 4

Choice of menu 1 2 3 4

COMFORT

Room 1 2 3 4

Common areas 1 2 3 4

Furnishings and maintenance 1 2 3 4

DURING YOUR STAY Assessment: 1 = very bad; 4 = very good

Willingness to listen and respond to your requests 1 2 3 4

Received adequate information about your state of health 1 2 3 4

You received information about examinations, care and treatment 1 2 3 4

Your confidentiality was respected 1 2 3 4

Suitability of the facility and equipment 1 2 3 4

Problem-solving skills 1 2 3 4

ASSISTANCE ACTIVITIES Rating: 1 = very negative; 4 = very good

How satisfied are you with the care activities of the care workers? 1 2 3 4

How satisfied are you with the nursing activities? 1 2 3 4

How satisfied are you with the medical activities? 1 2 3 4

How satisfied are you with the rehabilitation activities? 1 2 3 4

How satisfied are you with the entertainment activities? 1 2 3 4

How satisfied are you with your hospitalisation experience? 1 2 3 4

Would you recommend the establishment to someone you know 1 2 3 4

Starting from the corporate mission, the Management intends to direct the entire organisation towards the

pursuit of its vision in accordance with the following principles and core values:

IMAGE

I: Innovation

Prevent risks and be creative in identifying opportunities for improvement.

Engage in training and professional development.

M: Mastery

Knowing, Knowing how to do, Knowing how to be.

Freedom and responsibility of professional and personal action, in compliance with laws, technical, scientific and professional guidelines, and company rules.

A: Authenticity

Transparency in management and relations.

Communicating and committing to the achievement of objectives consistent with the company's principles and values.

G: Guft - Courage

Courage in thinking, acting and communicating.

Being an active part of the organisation.

Express one's personality in what one does by working.

E: Ethics

Legality and honesty in behaviour, actions and

relationships.

Listening and active participation while respecting confidentiality.

All. 2 – QUALITY POLICY

Sec.: 01 Ed. 2 Rev.: 2 Date: 05/05/22 Page: 2 of 2

The Mission of Villa Sabrina srl is set out in the corporate purpose, briefly summarised

in the following lines:

“… the Company's purpose is to manage a secure residence for the elderly, in compliance with the provisions of Resolution 647/1999 of the Regional Council of Umbria and any different and subsequent regulatory provisions”

The company aims to offer social and healthcare assistance to the self-sufficient and non-self-sufficient elderly, seeking to reconcile the excellence of technical and professional services, with the preservation of a familiar atmosphere in which the guest does not lack human relations and the warmth of a real family.

To support this mission, the facility has always favoured the access and support of

relatives - even unannounced - collective and/or personal recreation for the continuation of manual and intellectual functions.

The technical services and professional activities are carried out with the aim of continuous improvement in the qualitative and quantitative handling of the guest, by means of professional training of the staff and monitoring of existing situations.

The inclusion and study of management indicators of the various systems, both medical and non-medical, are clear proof of the intense work of monitoring, control and inspection of the various processes or procedures that the structure has established over time and that it is always ready to modify and update if conditions require it.

The efforts of all the internal systems of the organisation of the facility are directed towards the satisfaction of the user and the client and the evaluation of the organisational effectiveness adopted to guarantee an efficient quality system.

The Vision is to offer quality, safe, professional and reliable services to all institutions, entities, individuals and collaborators to whom it is addressed. Villa Sabrina srl aims at being a reliable partner of excellence, capable of making a difference in the quality of the social and healthcare service provided.

To this end, Villa Sabrina orients its actions towards the intention to meet the implicit and explicit expectations of the interested parties by using the elements expressed in its Vision:

✓ Promote maximum user and worker safety;

✓ Ensure compliance with mandatory regulations and company rules;

✓ Grow together with your staff to increase the competence, appropriateness, effectiveness and safety of the services provided;

✓ Monitor its processes to enhance activities for improvement;

✓ Promote quality training, oriented towards professional and organisational growth;

✓ Realise customised services based on the needs of the guest and all interested parties;

✓ Promote maximum information and sharing to stimulate participation by the parties involved;

✓ Striving for innovation and development.

To ensure that the policy is well known, understood and applied, Villa Sabrina has adopted the Code of Ethical Behaviour published and available for download on the website www.villasabrina.eu.