Inspection on 26/03/08 for Cerne Abbas Care Home

This inspection was carried out on 26th March 2008.

CSCI found this care home to be providing an Poor service.

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

Cerne Abbas Care Home 26/06/08

Cerne Abbas Care Home 14/06/07

Cerne Abbas Care Home 11/05/06

Cerne Abbas Care Home 24/01/06

Cerne Abbas Care Home 24/01/06

Cerne Abbas Care Home 25/08/05

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

CARE HOMES FOR OLDER PEOPLE Cerne Abbas Care Home Cerne Abbas Dorchester Dorset DT2 7AL Lead Inspector Gloria Ashwell Unannounced Inspection 26th March 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cerne Abbas Care Home DS0000065834.V361622.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. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cerne Abbas Care Home Address Cerne Abbas Dorchester Dorset DT2 7AL 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) 01300 341008 01300 341111 cerne.abbas@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited ****Post Vacant**** Care Home 66 Category(ies) of Dementia (40), Mental disorder, excluding registration, with number learning disability or dementia (26) of places Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia aged 55 years and over on admission (Code DE) maximum 40 places Mental disorder, excluding learning disability or dementia (Code MD) maximum 26 places The maximum number of service users who can be accommodated is 66. 14th June 2007 2. Date of last inspection Brief Description of the Service: Cerne Abbas Care Home is situated on the outskirts of the village of Cerne Abbas in West Dorset. It is within reasonable walking distance of the village centre with amenities including a post office, church, public houses and tearooms. There is a GP practice in the village. Car parking spaces for visitors are provided at the rear of the home. A public transport bus service serves the village of Cerne Abbas, neighbouring villages and the nearest towns (Dorchester and Sherborne). The home is registered to provide specialist nursing care for 53 older people with dementia and 18 younger adults who have acquired brain injury including Huntingtons Disease. This report relates to all the 3 units, known as ‘Houses’. The part of the home delivering care to the younger adults is Cloisters House, situated on the first floor. A passenger lift provides access to the House. The parts of the home delivering care to the older persons are on the ground floor; Orchard House and Atrium House, each with lounge and dining areas. Electronic number keypads are used on the doors leading to each House. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 5 The home provides nursing and care staff on a 24-hour basis and employs catering, domestic and maintenance staff. In addition to the nursing, personal care and accommodation provided, the scale of charges for the home includes the provision of social activities, catering for all meals and laundry and housekeeping services. Fees are charged weekly; the fee range quoted in the service user guide at the time of inspection was £520 - £570 per week on Atrium House or Orchard House, and between £800 and £1500 for residents accommodated on Cloisters House. Up to date fee information may be obtained from the service. Information regarding the subjects Value for Money and Fair Terms in Contracts can be obtained from the web link: www.oft.gov.uk A report entitled Care Homes in the UK - A Market Study is available on web link: http:/www.oft.gov.uk/NR/rdonlyres/5362CA9D-764D-4636-A4B1A65A7AFD347B/0/oft780.pdf Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This was a statutory inspection required in accordance with the Care Standards Act 2000. The previous key inspection took place on 14 June 2007, and on 29 November 2007 a random inspection took place on Atrium Unit in connection with an ongoing ‘safeguarding adults’ investigation. The allegation was not substantiated by the investigation because there was insufficient evidence upon which to make a judgement. The first visit of this inspection was unannounced; the inspector arrived at 10.00 on 26 March 2008, toured the premises and spoke to residents, visitors, staff and the Acting Manager. By arrangement with the acting manager the inspector revisited the home at 10.00 on 3 April 2008 and with the acting manager discussed and examined documents regarding care provision and management of the home. The duration of the inspection (both visits combined) was 7 ¼ hours. The inspector spoke to the acting manager, care and household staff and most of the residents accommodated at the time both individually and in small groups in the communal areas, and observed staff interaction with residents and the carrying out of routine tasks. During the inspection, particular residents were ‘case tracked’; for example, for evidence regarding Standards 3, 7 and 8, records relating to the same residents were examined and the residents spoken with. The care records of eight people who live at the home were examined in detail. 4 of these people were accommodated in Atrium House, 3 in Cloisters House and 1 in Orchard House. During this inspection compliance with all key standards of the National Minimum Standards was assessed. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? Since the last inspection murals have been painted on the walls of the Atrium House conservatory area, to present a ‘street café’ aspect. A ‘relaxation room’ in Cloisters House has been equipped with lighting features, including light strands and colour changing lights. In accord with current good practice guidance visual/tactile boards have been newly installed on the walls of Orchard House, replacing much of the previously installed door furniture – knockers, sealed letter boxes etc.). Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 8 The home has obtained additional profiling beds and pressure relieving equipment, to provide greater comfort and safety to residents with reduced physical health. The variety and frequency of social and recreational activities has been increased and is provided to residents of all three Houses. 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. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 9 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 Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 10 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 (The home does not provide intermediate care so St 6 does not apply) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents (or their representatives) are provided with information about Cerne Abbas Care Home and are encouraged to visit in advance of admission to establish their impressions of life at the home and the standard of available accommodation. Prior to admission the needs of each proposed resident are assessed and the home then writes to prospective residents confirming the ability to properly care for them. EVIDENCE: Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 11 The records of two recently admitted residents included details of preadmission assessments carried out by the acting manager when she visited the prospective residents at their previous addresses. In advance of making the decision to enter the home the closest relative/representative of each prospective resident visited Cerne Abbas Care Home to view the premises and meet residents and staff. Following pre-admission assessment of each prospective residents needs and circumstances the home writes to them confirming the agreement and ability to provide accommodation and care. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and social care needs of residents are met by suitably trained staff; doctors and other professionals visit as necessary and residents receive the medicines they have been prescribed. EVIDENCE: The care records of eight people who live at the home were examined in detail (4 from Atrium House, 3 from Cloisters House and 1 from Orchard House) and found to contain risk assessments forming the basis for care plans and daily records describing the care of each person. There was evidence that individual residents or their representatives had been involved in the development and review of planned care provision. Medicine handling is carried out by registered nurses and medication administration records were properly kept indicating that residents receive Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 13 prescribed medicines at the correct times and in correct amounts. Residents wishing to do so can manage their own medicines; at present none have chosen to do so. In general, residents are treated with respect and their privacy and dignity is protected at all times. (Reference is made in this report under Standard 18, regarding specific concerns associated with aspects of safety.) Comments received from relatives visiting residents in Atrium House during the inspection included “care is excellent” and “they do look after them”. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social and leisure activities are suited to the preference and ability of residents. Residents are encouraged to maintain contact with the local community; visits by their friends and relatives are welcomed by the home. Meals provide good nutrition and are liked by residents. EVIDENCE: The home employs a full time Activities Organiser who arranges local excursions, one-to-one and small group social and recreational activities. Relatives who were visiting residents at the times of this inspection were satisfied with the range of activities, meal provision, staff and premises; one described how a particular elderly resident frequently asks for a ‘cup of tea or Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 15 a biscuit’ and said that staff always promptly provide what the person is requesting. Residents are supported and encouraged to spend their time as they wish; e.g. the times of getting up and going to bed, to be in their bedrooms or lounges during the day. The home has a minibus adapted for use by disabled people, with wheelchair facilities including a ‘tail lift’. Some staff are designated drivers of the minibus having each completed associated training with Dorset County Council; they work in association with a specific policy giving guidance on accompanying residents on excursions. Visitors are welcome at any time and those the inspector spoke to said they are always made to feel welcome and placed at ease by the staff. The home has sought to provide a ‘restaurant environment’ to each House by careful design and decoration of the dining rooms. There was evidence that every resident receives adequate nutrition and ‘healthy eating’; is actively promoted. Residents select meals in advance from menus and the home additionally operates a policy of ‘over catering’ enabling residents to change to a different meal option at the time of serving. Each House has a regular supply of ‘smoothies’ (nutritious and refreshing cold milk and fruit based drinks) and the evening meal includes a selection of ‘finger foods’ for supper. Fresh fruit is available as a healthy option for desserts. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not properly protecting vulnerable residents from risks of harm and injury. EVIDENCE: The home has developed and implemented a complaints procedure; the document must be updated to ensure it provides accurate information to persons wishing to make a complaint. Since the last inspection the local Social Services department investigated a complaint regarding aspects of adult protection but was unable to reach a conclusive outcome because there was insufficient evidence available. A separate allegation was investigated by local police; the investigation substantiated the allegation and the provider organisation has responsibility for taking disciplinary action against the involved staff member. During this inspection there was evidence of a number of recent occasions when residents and staff had been placed at risk of, or had experienced harm or injury by the actions of a particular resident; since 6 December 2007 there were 21 recorded incidents of this person’s aggressive behaviour. Many of these incidents had involved assault upon other residents e.g. “grabbed Xs Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 17 nose”, “pushing her tripod over others legs…”, “trying to grab Xs neck”, “tried to grab Xs neck”, “grabbed X by the neck…red mark”, “hands over Xs face as if trying to suffocate her…”, “pulling hair of X”. The home has a written policy and procedure for the protection of vulnerable adults, but staff have not fully adhered to it’s guidance, which includes reporting all such incidents to the local Social Services office and to the Commission. The home has not developed or implemented a policy and procedure regarding provisions of the Mental Capacity Act and has not provided associated training to staff; this report contains a related recommendation. An immediate requirement was issued to ensure compliance with the regulations to safeguard people using the service. After the inspection the inspector notified the local Social Services office of these concerns in accordance with the Safeguarding Adults protocols, to ensure that all residents are protected from risks of harm and injury. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well-appointed and comfortable home with a continuous programme of improvements. On the dates of inspection the home was clean, pleasant and hygienic and there was evidence indicating that this is the usual standard of provision. EVIDENCE: The provider organisation maintains an ongoing programme of refurbishment and redecoration. Innovative use of decoration promotes and maintains the orientation and mental awareness of the elderly residents on the ground floor. For example, Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 19 ‘staff use only’ doors have been painted the same colour as the walls to minimise residents confusion/frustration at finding these doors locked, ‘visual/tactile boards’ have been affixed to walls and doors to indicate the purpose of the room within (e.g. cutlery and a plate laid as a place setting on a mat indicate that the door leads to a dining room). At both visits of this inspection the home was clean, tidy and comfortable throughout and the visiting relatives of residents confirmed this to be the usual good standard. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs enough staff to meet the needs of residents and to ensure their safety and comfort and maintenance of the good condition of the premises. Recruitment practices ensure the protection of residents from potentially unsuitable staff. Staff receive appropriate training and are competent to carry out their jobs. EVIDENCE: The home is at all times in the charge of a trained nurse and staffing levels are provided in accordance with the assessed needs of residents to ensure that at all times sufficient staff are available to properly meet their needs. All staff spoken with during the inspection were enthusiastic about their work and felt that they provided a good standard of care to residents and are properly supported by the management and training provision. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 21 The records of two recently employed staff members were examined and found to contain all essential information including written references, interview assessment, health details and evidence of identity. Criminal Records Bureau (CRB) disclosures are obtained for all staff in advance of employment. The home has developed and implemented a comprehensive induction process for all new staff, designed to ensure their familiarity with all aspects of the home and a clear understanding of their responsibilities. There is an enthusiastic approach to staff training; the deputy manager is also the training coordinator. Clear records of staff training, supervision and appraisal are kept, indicating that all staff receive training appropriate to their needs. Care staff are required to undertake (and as necessary update) training in core subjects including fire safety, moving and handling, food hygiene, adult protection and emergency aid. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general, the home is properly managed but more must be done to ensure it operates in the best interests of service users and protects them from risks of harm. EVIDENCE: The post of registered manager has been vacant since early January 2008; an Acting Manager is at present in charge of the home. The home has processes for quality assurance; satisfaction surveys are periodically issued and the home has developed and implemented processes of internal audit reflecting aims and outcomes for service users. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 23 Records are kept of all accidents and for most there is evidence of subsequent investigation, review of the care plan and periodic audit to identify any trends e.g. time, place, person, activity. It is again recommended that fuller records are kept of all accident/incident investigation and outcomes, to ensure that due consideration is afforded to all aspects including environmental or other potentially contributing factors such as occasions when the actions of residents have placed others at risk of harm or injury. The home manages the finances of most residents with regard to the safekeeping of monies for personal expenditure; a sample of documents were examined and found to clearly show income and expenditure. Staff trained in emergency response are on duty in the home at all times; all staff receive periodic training in fire safety. The use of bedrails by some residents is in compliance with relevant Health & Safety guidance; persons involved in assessing, maintaining and checking bed rails receive training in this work. Portable bedrails are not used; only rails permanently fixed by the manufacturer to profiling beds are used. During the inspection a sample of records regarding equipment servicing and maintenance were examined and found to be in good order. All staff are supervised and each has a personal profile containing records of appraisal ensuring that performance standards are monitored and training needs are identified, in the interests of providing good care to residents. The provider organisation has not fully discharged essential duties of monitoring the home; the monthly reports required by regulation have been carried out at the necessary frequency but do not identify which residents’ care records were examined on each occasion and reports of events affecting the safety and well being of residents have not all been reported to the Commission. The home has a written assessment of the ‘Health & Safety’ of the premises and working practices and keeps records of fire safety checks and tests, including drills and staff training. Cerne Abbas Care Home DS0000065834.V361622.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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Cerne Abbas Care Home DS0000065834.V361622.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. 1. Standard OP18 Regulation Requirement Timescale for action 04/04/08 13 (5) ( c) The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. 2. OP33 37(1)(e) This means that all residents must be accommodated and cared for in an environment safe from identified hazards, including those posed by risks of assault from other residents. The registered person shall give 03/05/08 notice to the Commission without delay of the occurrence of any event in the care home which adversely affects the wellbeing or safety of any service user. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 26 No. 1. Refer to Standard OP18 Good Practice Recommendations To ensure the rights of all residents are properly protected the home should develop and implement a policy and procedure, and train staff in the principles of the Mental Capacity Act. The monthly written report on the conduct of the care home should include specific details of the sample of records examined. Comprehensive records should be kept of all accident/incident investigation and outcomes. 2. 3. OP33 OP38 Cerne Abbas Care Home DS0000065834.V361622.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Cerne Abbas Care Home DS0000065834.V361622.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. 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