Inspection on 31/05/05 for Passmonds House

This inspection was carried out on 31st May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Passmonds House 26/07/06

Passmonds House 29/11/05

Passmonds House 16/11/04

Passmonds House 26/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Passmonds House Edenfield Road Rochdale Lancashire OL11 5AG Lead Inspector Ruth Hughes Unannounced 31 May 2005 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 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. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Passmonds House Address Edenfield Road Rochdale OL11 5AG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01706 644483 01706 647701 Denehurst Care Ltd Mrs Irene Ingram CRH - Care home only 35 Category(ies) of OP - Old Age over 65 years registration, with number of places Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Within the total number of 35 places there can be up to 35 service users in the category of OP. The service should employ a suitably qualified and experienced manager who is registered with CSCI. Date of last inspection 16 November 2004 Brief Description of the Service: Passmonds House is a care home providing care for older people. The property has been extended over the years to offer accommodation for 35 service users over the age of 65 years, in 2 double and 31 single rooms. Twenty-two of the rooms have en-suite facilities. There are four lounges, one of which is used for residents who wish to smoke, and one dining room. Toilets and bathrooms have aids to assist residents who have a problem with mobility. The home is set in its own grounds and situated adjacent to Denehurst Park. It is approximately 1½ miles from Rochdale town centre and a regular bus service passes the home. Several shops are situated around the locality. Parking is provided to the front of the house. Ramped access is provided to all entrances. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over 7.5 hours on one day. The first part of the day was spent in the office talking to the manger, checking care plans and staff training records. The remainder of the day was spent speaking to six residents, four visitors, and three members of staff, as well as making a tour of the premises. What the service does well: What has improved since the last inspection? The home has done a lot of decorating and bought some new furniture for some parts of the home. The entrance area, corridors, two lounges and bathrooms have been decorated. This has made a big improvement to the home and the residents living there. Residents and relatives said how much brighter this part of the place is now. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 6 New staff get the support and guidance when they first start work. A more senior member of staff helps them to understand, what each resident needs help with and how best to give them that help. All staff get regular support from senior staff. They said they had got a lot more training this year and this had given them a better understanding of how to care for the residents. 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. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 and 5 Overall the system for ensuring that all prospective residents had an assessment undertaken prior to admission to the home gave an assurance both to residents, relatives and staff that a resident was only admitted if the home could meet their needs. EVIDENCE: Before any resident was admitted to the home, the manager or the deputy manager visited them either in their own home or in hospital. This was to assess whether the home could meet their specific needs. The majority of residents were admitted via the care management process and service delivery agreements were in place. The home continues to assess residents prior to admission and their preadmission assessment form covered all the areas of health and social assessment that is recommended by the standards. However only part of the form was being used. One resident’s pre admission assessment contained only half the information recommended by standard 3.3. The deputy manager explained that half the document was missing and that they usually took two Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 9 pages. The manager must ensure the full document is used on every assessment to give a clear explanation of the persons needs. For those residents admitted on an emergency basis, copies of the care plan were faxed to the home by social workers prior to admission. Prospective residents were invited by the manager to come for a visit prior to admission and some liked to come for lunch and stayed for the afternoon. One resident, who said “that before her first respite stay, she came for lunch”, confirmed this. Eventually after several respite stays she has become a permanent resident. The homes contract with residents stated, there is a month’s trial period available for residents to assess the suitability of the home for them. To meet the needs of some of the residents. The deputy manager and 6 carers have this year undertaken dementia care training and 16 had completed risk assessment training. All service users interviewed stated they were satisfied with their care and felt their needs were being well met. Two residents spoken to say the home was very friendly and had a relaxed atmosphere. One resident said, “they could please themselves when they got up or were they had their meals”. She frequently had her lunch in the dining room but sometimes preferred her evening meal in her room, depending what was on television. Other permanent service users interviewed all felt their individual needs were being well met. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 In the main, care plans were detailed, up to date and reflected the care needed. However, when a ‘high-risk’ falls assessment is not addressed then the residents are at risk of injuring themselves. The health care needs of residents were met, with evidence of close multi professional links being maintained i.e. District Nurses. EVIDENCE: Individual care plans were in place for each resident. 4 care plans were looked at during the inspection. 2 of which were for residents admitted for 2 weeks respite care. The care plans gave clear information on how the care needs of residents were to be met. The content of the care plans was based on the initial assessment of needs and then developed as more information became available. Detailed risk assessments were in place in each of the files inspected. They covered areas such as nutrition, pressure areas, moving and handling and falls. However despite a high risk of falling being identified for one resident. No plan of care to address this risk was developed. Risk assessments and care plans, were seen to have been reviewed. But, none of the care plans identified how often to review or when the next review was due. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 11 All risk assessments must be regularly evaluated and any identified risk must be addressed by a plan of care to minimise that risk. Only 2 of the care plans inspected, had been signed by the resident or their relative. A discussion with the deputy manager identified that the majority of care plans had not been seen or signed by residents or relatives. The deputy stated “it was sometimes difficult to get relatives involved in things like care plans”. However she would set time aside to ensure care plans were discussed and developed with the resident or relative and their signatures were obtained to confirm their involvement. Residents spoken to were unaware of a care plan, 1 resident said “Oh, I know they write things down for me because otherwise I would forget”. Records were available of visits made by the optician and the chiropodist. These were seen in residents own plan of care. 1 resident stated, “when she had needed her hearing aid checked the manager had arranged this”. A hospital out patient appointments was being made for 1 resident and arrangements were discussed for someone to escort this resident to the hospital. District Nurses regularly visit and close liaison between the home and this service is maintained. A discussion with residents and several relatives identified that they feel they are treated with respect and their right to privacy is upheld. During the inspection, members of staff were observed interacting with residents in a warm, friendly and respectful manner. 1 resident spoken to stated she had been coming to Passmonds on several respite visits. Eventually this last year she decided to make Passmonds her permanent residence. She said, ‘she felt safe and staff were so good with her, they really looked after her without making her feel uncomfortable’. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 Residents social and recreational needs, preferences and capabilities were not yet met leaving some residents feeling bored and lacking in stimulation. The dietary needs of the residents were well catered for ensuring that a varied and nutritious diet is taken. EVIDENCE: Although a requirement had been made at the last inspection, there had been only a little improvement with regard to provision of social activities. Recordings in an activities/ photo album showed that only a few activities had taken place since the last inspection. 2 monthly programmes of activities, that had previously been displayed were shown to the inspector but unfortunately this practice of organising activities had not continued. 1 resident said, “It was usually a bit boring in the afternoons and so she went for a sleep, unless anything was on”. Staff interviewed said that some residents were difficult to motivate but that they realised more will need to be done to formally address the importance of improving the quality of daily life and social activities. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 13 At the time of inspection a pianist was present at the home, entertaining residents in the conservatory lounge. This was well attended and the pianist said she felt they had thoroughly enjoyed it. 1 care assistant spoken to said they also at times took residents to the local shop or to town. Residents wishing to maintain their religious links were encouraged and enabled to do so. Relatives interviewed said they could visit whenever they wanted and that staff made them welcome. Visitors were observed in all lounges during the day and residents stated they usually stayed for a cup of tea and a biscuit in the afternoon. Visitors spoken to said they could visit at any time and no restrictions were imposed. 1 relative said they had stayed occasionally for a meal with the person they were visiting and really enjoyed it. Staff said several visitors had stayed for lunch over the years and generally could be accommodated at short notice. The dietary needs of residents were well catered for with a balanced and varied selection of food available. The individual likes/dislikes of residents were catered for and resident comments were generally good with regard to the food. 1 person said how much they enjoyed a cooked breakfast, whilst other staff said they preferred cereals and toast. The inspector dined with the residents at lunchtime. A board is in place for detailing the daily menu. Residents stated they were asked that morning, what they wanted for lunch. The choice that day was from two hot meals with fresh carrots, peas and potatoes. There were hot and cold drinks served throughout the meal and staff was seen to be attentive to residents needs. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Systems were in place with regards to the investigation of complaints and adult protection issues, ensuring that’s residents were listened to and protected. EVIDENCE: A detailed and accessible complaints procedure was displayed in the home, and also attached to the Service User Guide. 3 residents spoken to during lunch stated they knew that they could raise concerns with a member of staff or with the manager, and that ‘they always sorted things out’. No complaints have been received at Passmonds since the last inspection. A copy of the Local Authorities Vulnerable Adults Procedure was in place and a discussion with the senior staff identified that they were aware of the procedure to follow in the event of any allegation of abuse. Senior staff had attended adult protection training and cascaded information to other staff. Due to the demand of places on this course other staff were attending training as and when places were available. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21 and 25 A recent programme of decoration and refurbishment, although not yet completed, had made a significant improvement to the home, providing residents with a clean, pleasant and comfortable environment. Several safety issues were noted on inspection and requirements to ensure the safety of residents have been set. EVIDENCE: From a tour of the building, it was seen that the premises were being maintained. There was evidence of redecoration and some renewal of fabric and furnishings. This has yet to be completed but a significant amount of work has been done. It is recommended that the programme of maintenance and renewal of the fabric is reviewed and a current plan is reviewed and re developed to ensure remaining work is budgeted. The two lounges in particular were well decorated and nicely personalised with pictures and ornaments to compliment the decor. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 16 Residents spoken to stated they were very pleased with the lounges and that they were comfortable to sit in. The curtains for both lounges have yet to be re-hung and some residents stated there was a cold draft from the window, especially in the evening and when it was cold outside. These curtains must now be replaced. The Proprietor stated he now intends to progress with decorating the corridors towards the rear of the building and the conservatory/lounge area. It was noted that light bulbs from several light fittings had been removed. Three bulbs were from one light fitting in the conservatory. Inadequate lighting could contribute to the risk of residents falling and these bulbs must be replaced. Regular checks must be made of light fittings to ensure light bulbs are effective. The premises overall were clean and free from offensive odours throughout and residents and relatives spoken to complimented the domestic staff, saying, ‘they are always so helpful’. The provider said that armchairs in all lounges are disinfected and cleaned by night staff on a regular rotating basis. It was noted however, that several chairs in the smoking lounge had food and tea stains running down the arms and sides of the chairs. These chairs must be thoroughly cleaned. The majority of bathrooms and toilets had recently been decorated and nicely personalised to create a more homely and attractive environment. It was noted however that the shower chair in the ground floor shower room was rusty and required removal. And the mop and bucket stored in bathroom 40 must be removed. Following a report by a Health and Safety consultant the home had agreed to comply with it’s recommendations to ensure staff carry out hot water monitoring whenever assisting residents to bathe. This was not complied with. Staff had not regularly recorded water temperatures in each bathroom. 2 days following inspection the home forwarded to the commission a record of monthly cold and hot water storage temperature checks required. This was for Legionella checks and was satisfactory. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 ,28 and 30 The residents were cared for by sufficient number of staff. The staff were properly trained and given the knowledge and skills to deliver the care required to meet resident’s needs. EVIDENCE: Examination of the duty rotas, a discussion with staff and with residents identified that there was sufficient staff on duty to meet the needs of the 29 residents living at Passmonds. There are some staff that have worked at Passmonds for several years. This has been useful in providing continuity of care and for induction of new staff. Those staff who have wanted to progress are now senior carers. Residents spoken to were complimentary about staff. Comments such as, “ you can have a good laugh with most of them” and “ they will do anything for you” was made. The home continues to provide NVQ training in Care. At present 33 of staff have achieved NVQ level 2 or above and 4 staff are near to completing the course. This will then bring the total percentage to 58 , which exceeds the minimum standard of 50 . Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 18 A structured induction programme is in place and further training continues to be provided in moving and handling, fire safety, food hygiene, dementia care training and risk assessing. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33 and 36 The Manager is an experience practitioner of care of the elderly. Who, along with the deputy manager, who is commencing the Registered Manager’s award in September effectively manage the home. The home has yet to produce a plan that will show residents and others how their views are being used to develop the service. EVIDENCE: The manager, who is a qualified RGN, does not hold a management qualification, nor does she intend to undertake such training. She has however, extensive experience in care of the elderly and kept herself abreast of current care practice by her ongoing prep work. She is aware of the requirement in relation to all registered managers being qualified to NVQ 4 in management and care by April 2005. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 20 The Deputy Manager is due to commence the NVQ level 4/Registered Managers Award in September 2005. The manager and deputy manager have set up a structured supervision system for staff. This was on the whole was well on tract for meeting the minimum recommendation of supervision 6 times per year. The short fall in this system was that the deputy manager has no records of supervision by the manager. The inspector was assured that supervision had occurred but was not recorded. Supervision must be recorded as evidence. The manager and provider of the home, work there 5 days a week. They are therefore able to speak with service users and relatives informally, on an almost daily basis. Relatives spoken to during the day confirmed how accessible and approachable the manager is. Service user questionnaires had been formulated and circulated prior to the last inspection however the response was said to have been poor. No further development of this had occurred. Separate questionnaires for circulation to relatives, staff or other visiting professionals to the home had not yet been formulated and therefore there is no annual development plan in place. The manager must evidence how she enables staff, service users and stakeholders to affect the way the service is delivered. The quality assurance scheme, ‘Investors in People’ was to be commenced shortly at Passmonds, however as yet a full system is still not in place. A requirement has been made that an effective quality assurance system is available based on seeking the views of service users, reviewing the care and meeting the aims and objectives and the statement of purpose of the home. Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 2 x x x 2 x STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 x x 3 x x Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? 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 7 Regulation 15(1) Requirement There must be evidence of resident/representative involvement in the care planning process. A plan of care must be developed for any risk assessment that identifies a risk. These must be dated regularly and reviewed. A planned programme of activities must be formulated in consultation with residents. This is to be displayed for residents to see. A menu offering an acurate choice of meals must be displayed and regularly reviewed. The remaining corridors must be decorated. There must be curtains at the lounge windows Light bulbs must be replaced when not effective. Armchairs must be regularly cleaned to remove spillages and stains. The shower chair must be replaced. Mops and buckets must not be stored in bathrooms. Timescale for action 31/07/05 2. 7 12(1)(a) 31/0705 3. 12 16 31/08/05 4. 15 12(2)(3) 31/07/05 5. 6. 7. 8. 9. 10. 19 20 25 26 21 26 23(2)(d) 16(2)(c ) 23(2)(p) 23(2)(d) 23(2)(c ) 13(3) 30/09/05 31/08/05 30/06/05 30/06/05 31/07/05 30/06/05 Page 23 Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 11. 12. 13. 14. 25 33 36 37 13(3)(4) 24(1) 18 23(4) Hot water temperature checks must be recorded. An annual development plan must be available The supervision system must include the deputy manager. The emergency lighting system must be tested monthly. 30/06/05 31/09/05 31/07/05 31/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 3 19 33 Good Practice Recommendations The full pre admission assessment document should be used when assessing residents needs. A revised programme of maintenance and renewal of the fabric of the premises is to be developed. As part of the quality assurance/ annual development plan, relatives and other visiting proffessionals to be circulated with feedback questionnaires. (Previous recommendation). Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 24 Commission for Social Care Inspection Turton Suite, Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 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 Passmonds House F56 F06 S25487 Passmonds V228578 260505 Stage4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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