Inspection on 07/06/07 for Aylsham Manor

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Aylsham Manor 02/02/06

Aylsham Manor 01/08/05

Aylsham Manor 20/01/05

Aylsham Manor 02/09/04

Aylsham Manor 04/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Aylsham Manor 5 Norwich Road Aylsham Norwich Norfolk NR11 6BN Lead Inspector Ann Catterick Unannounced Inspection 7th June 2007 09:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Aylsham Manor DS0000027331.V342792.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. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aylsham Manor Address 5 Norwich Road Aylsham Norwich Norfolk NR11 6BN 01263 733253 NO FAX # aylsham.manor@btinternet.com 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 Carl Denis Mrs Denise Denis Mrs Lynda Ann Howes Care Home 28 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (28) of places Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 Brief Description of the Service: Aylsham Manor is a care home providing personal care and accommodation for 28 older people, four of whom may have dementia. The registered Providers are Mr Carl Denis and Mrs Denise Denis and the registered manager is Mrs Lynda Howes. The home is situated in the market town of Aylsham and is convenient for all local amenities. The property is a large Elizabethan Manor House that stands in its own three acres of grounds. The property is a grade 2 star listed building and has been tastefully modernised and extended over the years to provide comfortable accommodation in a period setting. There are 24 single bedrooms, two sheltered flats and one double room. Many of the rooms have en suite facilities and communal space is plentiful and varied. There is a stair lift to the first floor in the main house and a stair lift to the first floor in the coach house. The grounds are large and well maintained and provide a very good facility in the summer months. The home also offers day care to a small number of people and these people are accommodated, during the day, in the main areas of the home. The cost of care and accommodation is from £420 to £480 a week. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced key inspection and the site visit took place on the 7th of June and was over a period of eight hours. Prior to the inspection the Commission received a pre inspection questionnaire that included all requested information about the home. Other data and information was taken into consideration when compiling this inspection report. Of those comment cards received there were two from health professionals, seven from residents and two from relatives. Comment cards from professionals and relatives were all very positive. Mostly, all comments from residents were positive. On the day of the site inspection the inspector was able to speak with residents, relative/friends, staff, the manager and proprietors as well as look a plans of care, staff files and other documents and policies. All residents spoken to were very satisfied with the care they received and all staff spoken enjoyed their work and felt supported by the management team. The overall conclusion is that Aylsham Manor offers good quality care in an attractive and comfortable environment. Comments made by residents and staff can be seen throughout the report. What the service does well: Prior to admission residents are fully assessed to ensure that their needs can be met within the home. They are given all of the information needed to ensure that they can make an informed decision. Plans of care give staff the information needed to ensure person centred care can take place. The meals within the home are varied and of good quality taken in a comfortable setting. The environment is of good quality and provides residents with an attractive and comfortable place to live. Delightful gardens that are easily accessible to residents. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 6 Staff are trained and supported to ensure that they offer a good quality service to residents. The home is well managed. The management are good at self-auditing and continually monitors and assess the service publishing their findings and responding to any identified issues. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can be assured that their needs will be assessed prior to admission ensuring that if they do move into the home their identified needs will be met. EVIDENCE: Most residents living at the home are privately funded. When prospective residents or their family make first contact with the home initial information is gathered and recorded on an enquiry form. The enquiry form then has a tick list to ensure that all aspects of the assessment prior to admission take place. These include, assessment visit, visit to the home by the resident, relative/ advocate involved in decision making and time to decide. This was seen as good practice suggesting the admission procedure is unrushed and thorough. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 9 There was also a tick list identifying what documents were given to the resident at the time of admission and the date that these were given. These included the homes brochure, service user guide, contract, complaints procedure and a new residents questionnaire. All of those people living in the home were having their needs met. All residents receive a statement of the terms and conditions of the placement. The home does not provide intermediate care. Aylsham Manor DS0000027331.V342792.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 who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents living in the home can be assured that their needs will be identified within a plan of care and that they and/or their relatives and advocates will be involved in the process. This enables residents to feel they have some control and influence in what care they receive and how this is provided. EVIDENCE: Five care plans were looked at in detail and these were comprehensive including all of the relevant information needed to enable staff to have the information to care for residents. Within the care plan clear guidance is give to staff on how to assist the resident with their day-to-day living. There are also progress charts to monitor this. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 11 Nutritional assessments were seen on file and some staff are completing the malnutrition universal screening tool (MUST) training. Residents are weighed on a regular basis and the home has just purchased ‘sit on scales.’ Pressure care charts were seen on file and residents with vulnerable skin are monitored on a regular basis. Continence care plans were on file and the home liaises with the local continence nurse. Manual handling risk assessments were on file and specific risk assessments when needed. For example one resident sometimes left their bedroom during the night and could walk about the home being at risk or disturbing other residents. The home is using assisted technology in the form of a mat and door alarm to enable staff to know when the resident leaves their room. Social and personal history was included in most files. For some of those residents who had lived in the home for a number of years this information had been filed away from the care plan. It was suggested that this was included within the care plans to ensure that new staff had all of the information they needed to be able to care for a talk with residents. A recommendation has been made in this area. The home has a good relationship with the community health staff and all residents were having their health needs met. All staff who administer medication have had the appropriate training and generally the administration and care of medication is good. Evidence of good practice was seen on the day of inspection. Medication systems are audited on a regular basis and evidence of this audit was seen as the proprietor had identified some areas for improvement and had monitored practice, recording improvements in these areas. On the day of inspection some gaps in the medication administration record (MAR) were seen. Reasons for this were given but there is still opportunity for improvement in this area. A recommendation has been made in this area. At all times throughout the day staff were seen to engage with residents in a way that was respectful and upheld privacy. For example when a resident became unwell at lunchtime staff cared for them and supported other residents in a calm and professional way that did not bring unnecessary attention to the situation as well as supporting all involved. All residents spoke highly of the care they receive. Comments made by residents “I have my own hairdresser come into the home.” “Staff treat me in a respectful way.” “Sometimes kept waiting when I want to go to the toilet.” “Staff are always helpful and would do anything for me.” Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 12 “Sometimes feel I do not see staff for ages.” “Very pleasant staff try to accommodate all of your needs.” Comments made by staff “A way I protect a person’s dignity is for example if I am asking if they need the toilet facility I do this quietly so others do not hear.” “I would be happy for a relative of mine to live here.” “I read care plans and find them useful.” Aylsham Manor DS0000027331.V342792.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 who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents who live in this home will have the opportunity, wherever possible to continue with the life preferences and choices that they had prior to admission and will have the opportunity to develop new interests. This will enable residents to feel as independent as possible. Residents are provided with good quality meals in an attractive setting therefore making the taking of meals a positive experience. EVIDENCE: The home aims to work in a person centred way seeking to meet the individual needs of residents. Some residents chose to spend most of their time in their room whilst others enjoy using the communal areas. The home has a notice board that identifies different activities that take place in the home and outings are arranged using the homes mini bus. On the day of inspection some residents were watching television whilst others were sitting in small groups and others were with visitors. In the afternoon there was a poetry session. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 14 Friends and family are welcomed in the home and those seen on the day of inspection confirmed that they were always made welcome. The husband of one resident said that he had been told if ever he wanted to come to lunch he would be very welcome. Residents are encouraged to care for their own money or to have a professional or family financial advocate. Dinner on the day of inspection looked appetising and well presented. Residents said that the home has two cooks - one who cooked traditional meals and the other who is more adventurous. The cooks appeared to compliment each other enabling a wide variety of meals. Residents can choose to have meals in their rooms although most choose to eat in one of the two dining areas. Once a month there is a themed meal and this offers interest and encourages discussion and interest. The cooks seek feedback and suggestions from the residents. A food and nutrition questionnaire was given to residents in February and those comments made were acted upon. This was seen as good practice. Comments made by residents and relatives. “Very good on entertainment.” “Staff willing to take me outside.” “I am always made welcome when I come to see my wife.” “Food good and try to cater for all preferences.” “There is a certain sameness about the menu.” “Food fair, lots of choice.” “Family always made welcome.” Aylsham Manor DS0000027331.V342792.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 who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that the home has a clear complaints policy and if they ever had any concerns these would be taken seriously. The homes policy and procedures promotes safe practice and staff are trained in adult protection issues and this helps to protect residents. EVIDENCE: The home records all complaints or concerns and acts on them accordingly. Residents spoken to felt confident that if they had any concerns they would be listened to and dealt with. Since the last key inspection two allegations were made that were referred to the Adult Protection Unit for advice. Both situations were dealt with within the home under the homes disciplinary and grievance procedure. One of these was not substantiated and the other was part substantiated. Both were dealt with appropriately. Comments by residents “Would take any concerns to Carl or Denise.” “If my family have any views they are listened to.” Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 16 Comment by staff “Would always report poor practice and know something would be done.” “Have had training with regard adult protection.” Aylsham Manor DS0000027331.V342792.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, 20 and 26 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are living in a safe well-maintained environment and the overall quality of the home, garden and accommodation has been commended. EVIDENCE: Residents live in a safe, well-maintained environment that offers good quality accommodation that is comfortable, well decorated and furnished. The proprietors are on site most days and are continually monitoring the environment and improving, repairing or refurbishing as appropriate. Access to the first floor is by the staircase or use of a stair lift. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 18 Since the last inspection a shower has been upgraded and a walk in shower installed in a bedroom. The floor has been raised outside one resident’s room to improve access. Communal areas are well furnished and offer a variety of sitting areas. A small sunroom offers a private space for residents to meet with visitors and on the day of inspection a resident was using this facility in this way. A recent fire inspection had identified that new fire doors were needed in several areas of the home and these were being fitted on the day of inspection. Several residents gave permission for the inspector to look into their bedrooms and those seen were very homely with occupants clearly making them their own personal space. The grounds accommodate many well-established trees and shrubs as well as many flowerbeds and borders. The garden, like the house is well managed and maintained. The home is clean and well cared for free from any offensive odours. Comments made by residents “Very pleasant here.” “I have my own room.” “Like my room, would definitely recommend it here.” Aylsham Manor DS0000027331.V342792.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 who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are cared for by staff who are in sufficient numbers and are well trained and supported in their role. This ensures that staff have the support skill and experience to provide good quality care. EVIDENCE: When speaking to staff and residents it seems that the home provides enough staff at anyone time to meet the needs of residents. The staff group is varied with some staff having been working in the home for many years and others at the beginning of their career. Staff observed on the day of inspection were working with residents in a caring professional manner. All residents spoke very positively about the staff. The home has seventeen staff who have NVQ level 2 or above and this is 55 of the care staff working in the home. Staff spoken to were very positive about the training they received and felt training and the manager and proprietors promoted staff development. Four staff files were inspected and these all contained the relevant information needed prior to a person starting to work in the home. This included evidence of the application form, references, CRB, statement of terms and conditions, evidence of training and appraisal forms. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 20 All staff receive induction and foundation training and this was evidenced within the files and staff spoke of the training they had received. Comments made by residents “Staff are very kind.” “I have never regretted coming in here.” “After six years as a resident I count myself lucky to have been able to come to this home.” Comments made by staff “Enjoy working here, good staff team.” “Training updated regularly.” “We have sufficient staff on duty.” “Stable staff group with experienced staff and young staff developing.” Aylsham Manor DS0000027331.V342792.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, 32, 33, 35, 36 and 38 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are living in a home that is well managed. The quality of care provided is continually audited and monitored to ensure that practice is good. This means that residents can be assured that they are being cared for in a home that is well run and has their interests as paramount. EVIDENCE: Since the last inspection the manager has cut down the hours that she works. One of the proprietors is taking on the responsibility of manager on the days the manager is not at work and another member of staff is being trained and supported with a view to them having the skills and training to fulfil a management position. This arrangement appears to be working well and the home continues to be well managed. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 22 The ethos within the home is one of openness and transparency and this view was reflected when talking with staff and residents. The manager and proprietor involve staff in what is going on in the home and there are regular staff and resident meetings with the sherry parties that take place whenever there is a birthday also being an opportunity to talk and engage residents in what is happening in the home. The home has a comprehensive quality assurance system that enables different aspects of the home and the care provided to be audited and reviewed on a regular basis. All residents receive a new admission questionnaire when they first are admitted to the home to enable them to express their views and questionnaires regard food care and other aspects of the service provided are collated at regular periods. Once information is collated the proprietor and manager aim to address any issues raised. For example with regard meals suggestions such as more custard and less cream and apples needing to be cooked more were acknowledged and change took place. All findings around quality assurance are recorded and made available to residents, staff and relatives. Some resident’s money is looked after for safekeeping and an audit of three of these was carried out. All was correct and safe policy and procedures are in place. Staff do not receive regular formal individual supervision that is recorded. A recommendation has been made in this area. The manager and proprietor are supervising staff on a regular basis with regard day-to-day support and training. Annual appraisals take place and the proprietor views staff meetings and training meetings as a form of group supervision. All training with regard safe working practice takes place and the home has a record of what training staff have received and can easily identify when training needs to be completed or updated. Not all radiators are covered although it is acknowledged that some of these do not work as the home has some under the floor heating. Risk assessments need to be completed to ensure that residents are not at any unnecessary risk. A recommendation has been made in this area. Incidents and accidents are recorded collectively and these needed to be recorded separately to comply with the Freedom of Information Act 2000. A recommendation has been made in this area. All staff receive induction and foundation training. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 23 Comment made by staff “Denise will go the extra mile.” “Good proprietor all for the residents needs and choices.” “Have an appraisal once a year.” “Good support and training.” Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 4 x x x x x 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 x 3 2 x 3 Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Social and personal history for those residents who have been living in the home for some time would be best kept in the care plan and not filed away to ensure new staff are aware of this information. The completion of medication administration records needs to continue to be monitored as some omissions were seen on the day of inspection, although explanations were given for these. Although the proprietor sees the regular meetings and training she has with staff as supervision it would be beneficial for a formal supervision process to be arranged for all staff. Those radiators that do not have covers or low surface temperatures need to have a written risk assessment completed. 2. OP9 3 OP36 4 OP38 Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 26 5 OP38 Records of incidents and accidents need to be recorded separately to comply with the Data Protection Act 2000. Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Aylsham Manor DS0000027331.V342792.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!