Care Home: Passmonds House

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What the care home does well From observations made during this visit, and from information provided by the manager in the Annual Quality Assurance Assessment ( AQAA) , there was evidence that the manager and staff in this home are constantly working towards improving the service.All the residents spoken to were extremely positive about their experiences in the home, and about the way the home was run and managed. All written feedback from residents stated satisfaction with the services provided. They were very complimentary about the way in which staff provided care and support. Some of the comments from residents were as follows: "I like it here, it`s my home and I treat it as my home. Staff are smashing and they do everything for me. They do all my shopping. My room is lovely and if anything was wrong I would report it". "I like it here, everyone seems to be nice". "The meals are excellent". "Its very acceptable here. The staff are very kind and both owners are kindly people". "They are very good , the staff here. I`m so happy here". Comments from relatives and visitors were also positive, and mirrored the experiences and comments made by residents in the home. There was a relaxed and welcoming atmosphere noticeable during this visit. Families and visitors were made welcome by staff Care plans provided staff with information on how residents wanted to be supported. The home continues to provide training for all staff. There was evidence of ongoing training opportunities for all staff working in the home. Although there had been no recent complaints about the home, the manager One resident said that she felt confident in approaching the staff or the manager with any concerns. What has improved since the last inspection? Care plans had improved since the last inspection. The manager was working towards reviewing all care plans, and there was an assessment of need carried out on all new residents admitted to the home. There was evidence that the manager was working hard and being pro active in involving residents and their families in developing care plans. Significant improvements have been made to the environment, and new carpets have been fitted, and decoration was ongoing at the time of this visit. What the care home could do better: Some activities were available to residents in the home. However, most residents spoken to said they would like more activities to be available. One resident said, "The best thing about here are the people, but I think there should be more activities". The service must continue to improve the environment and replace damaged furniture, so that residents benefit from a pleasant and well maintained environment. CARE HOMES FOR OLDER PEOPLE Passmonds House Edenfield Road Rochdale Lancashire OL11 5AG Lead Inspector Ann Connolly Unannounced Inspection 21st February 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 Passmonds House DS0000025487.V360365.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. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Passmonds House Address Edenfield Road Rochdale Lancashire OL11 5AG 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) 01706 644483 01706 647701 Denehurst Care Limited Margaret Alice Welsby Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Passmonds House DS0000025487.V360365.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 only: Code PC, to people of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP. The maximum number of people who can be accommodated is: 35. 26th July 2006 Date of last inspection 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 two 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. The home’s Service User Guide advised residents and their relatives that the most recent Commission for Social Care Inspection (CSCI) report was available in the reception hall. At the time of this inspection weekly fees ranged upwards from £331.00 £346.00 per week, approximately £1436 - £1500 per month. Additional charges were for hairdressing, chiropody and newspapers. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes This was a key inspection that included a site visit to the home. The manager was not told beforehand that we were coming to inspect, this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit information was taken from various sources, including observing care practices and talking to people in the home. The manager, relatives and some members of the staff team were also interviewed. A tour of the home was undertaken and a sample of care, employment and health and safety records were seen. Comments from questionnaires returned from residents and their relatives are also included in this report The CSCI requires the home to complete an annual quality assurance assessment (AQAA) in order to demonstrate the level of care provided. The manager had completed this in full and comparisons were made with this document at the time of inspection. On this inspection the outcomes for people in the home did reflect that indicated by the manager in the AQAA, especially in relation to daily life, personal care and protection. However, the manager had recognised what improvements could be made and was taking steps to address the issues. What the service does well: From observations made during this visit, and from information provided by the manager in the Annual Quality Assurance Assessment ( AQAA) , there was evidence that the manager and staff in this home are constantly working towards improving the service. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 6 All the residents spoken to were extremely positive about their experiences in the home, and about the way the home was run and managed. All written feedback from residents stated satisfaction with the services provided. They were very complimentary about the way in which staff provided care and support. Some of the comments from residents were as follows: “I like it here, it’s my home and I treat it as my home. Staff are smashing and they do everything for me. They do all my shopping. My room is lovely and if anything was wrong I would report it”. “I like it here, everyone seems to be nice”. “The meals are excellent”. “Its very acceptable here. The staff are very kind and both owners are kindly people”. “They are very good , the staff here. I’m so happy here”. Comments from relatives and visitors were also positive, and mirrored the experiences and comments made by residents in the home. There was a relaxed and welcoming atmosphere noticeable during this visit. Families and visitors were made welcome by staff Care plans provided staff with information on how residents wanted to be supported. The home continues to provide training for all staff. There was evidence of ongoing training opportunities for all staff working in the home. Although there had been no recent complaints about the home, the manager One resident said that she felt confident in approaching the staff or the manager with any concerns. What has improved since the last inspection? Care plans had improved since the last inspection. The manager was working towards reviewing all care plans, and there was an assessment of need carried out on all new residents admitted to the home. There was evidence that the manager was working hard and being pro active in involving residents and their families in developing care plans. Significant improvements have been made to the environment, and new carpets have been fitted, and decoration was ongoing at the time of this visit. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 was not assessed, as Passmonds does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ needs are assessed prior to admission to the home so they are confident their needs will be met, and the home is sure it can meet their personal needs. EVIDENCE: Improvements had been made to care plans, and each file contained an assessment of needs. The new manager said that home visits were made to prospective residents so that it could be establish whether the service had the appropriate skill mix of staff to meet assessed needs. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 10 Four residents files were looked at, and all of them contained an assessment of need. Assessments were carried out by care managers from the funding authority, and supplemented by an assessment carried out by a representative from the home. Information in the assessments was used to generate a working care plan. Information in the Annual Quality Assurance document, (which was filled out by the manager before the inspection visit took place), explained in detail how the assessment was carried out. The manager focused on the importance of consulting with residents and their relatives about how they wanted to be supported with their care needs. It was also acknowledged that involving families and service users in reviews was something the service intended to focus on in the forthcoming months. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Care plans are in place, and these provide staff with the information they need to support residents appropriately. Policies and procedures are in place, which provide staff with specific guidance to ensure that residents receive their medication safely. EVIDENCE: Four care plan files were examined during this visit. These were well organised, and written in a clear way, so that staff had the information that was needed, to help them to provide care and support to residents. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 12 Since the last inspection visit, improvements had been made to care plans, and it was evident that the manager has worked hard to develop care plans. There was evidence that a number of plans had been re-written. The manager and staff team had been pro-active in involving residents and their family or representatives where possible in developing an individual care plan. It was noticeable in some of the plans that individuals had been consulted in how they wanted to be supported. For example, in one plan the daily routine was written in a way that talked the carer through the day in the way the resident wanted to be met. This provided evidence of a person centred approach in how care plans were being developed. There was evidence that the cultural needs of residents had been considered when developing care plans, and they included information on meeting specific dietary needs as well as social and religious needs. Documentation showed that the care plans are reviewed at regular intervals. Some reviews were in more detail than others, and on some care plans it was not made clear if the resident had been involved in the review. Care plans include risk assessments to ensure that any hazards are identified, and strategies and interventions are put into place to minimise any risks. Moving and handling assessments, pressure sore prevention and nutritional risk assessments are included in all the care plans and assessments. There was documentary evidence that residents had appropriate access to the full range of medical services available in the community. Residents spoken to said that they only had to ask for a doctor if it was felt one was needed, and one of the staff would arrange this. The home uses a pre-dispensed monitored dosage system. Medication administration records (MAR), were appropriately maintained. In order to improve the auditing of medication, the manager carried out a weekly audit to check stock levels of all medication, and to check records had been filled in correctly. This will minimise any risks, and ensure that medication is handled safely. Controlled drugs were stored appropriately, and the records balanced with stock levels. Medication was dispensed multiply and most packs contained a description of each medication for identification purposes. One supplying pharmacist had failed to do this, and the manager addressed this at the time of inspection. There were no samples of staff signatures on the medication record, and the manager addressed this at the time of inspection. This ensures that any audit of medication can be tracked properly and provides an additional safeguard in ensuring that staff administer medication safely to resident in the home. Passmonds House DS0000025487.V360365.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Meals served to residents were of a good quality, providing a well presented and nutritionally balanced meal. Residents are supported and encouraged to maintain links with their family and friends, this allows residents to exercise as much choice and control over their lives as they can. There are limited activities available, and as a result this meant residents did not gain the benefits of a stimulating environment. EVIDENCE: The meal served during this visit was well presented and consisted of home made meat pie with fresh vegetables and mashed potato. One resident said, “ The pie is really lovely, the pastry is nice. I’m very funny about food, but this is good”. All residents who were spoken to said that there was always a choice of meals available, and that staff would endeavour to find an alternative meal, if the meal on the menu wasn’t to their liking. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 14 Most residents said they would like to see more activities on a day-to-day basis. One resident said that activities were offered occasionally, such as gentle exercise and art and craft. Staff said that time and resources were limited to offer a more structured programme. However, most staff recognised the importance of offering activities to residents. One member of staff was keen to develop this area, and it was strongly recommended that this was an area that was developed so that residents enjoy positive outcomes from their experience of living in the home. There was a written policy in place, informing residents and their families and friends that visitors were welcome at any reasonable time. Relatives were seen coming and going, and all were made welcome by staff on duty. Passmonds House DS0000025487.V360365.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 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Policies and procedures are in place so that residents and relative can raise concerns, and so that the health, safety and well being of residents is protected. EVIDENCE: There is a clear and comprehensive complaints procedure in place. This is made visible and accessible to residents and any visitors to the home. All residents who were spoken to expressed confidence in raising any issue of concern with a member of staff or the manager. The Commission has not received any recent complaints about the home. The home has received two complaints since the last inspection, and examination of records showed that the home had responded to this appropriately. The complaints logbook was examined, and all complaints and concerns were appropriately recorded. The records detailed the nature of the complaint, the investigation process, and the outcome. In the AQAA, the manager indicated that there were plans to improve the complaints process, so that staff develop skills in handling complaints more effectively. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 16 Training programmes demonstrated that priority was given to providing all staff with training in safeguarding adults. The staff induction programme included an introduction into the safeguarding policies and procedures ensuring that all staff are confident and have the appropriate up to date knowledge, so that they knew what to do in the event of an allegation of abuse. All staff who were spoken to during this visit, had a sound knowledge of the procedures, and were clear that all allegations of abuse must be reported to the social services who take the lead in any investigation. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Some areas of the home require improvement and some furnishings need replacing so that residents and their visitors benefit from a pleasant environment. The home provided a clean and hygienic environment for residents. EVIDENCE: Since the last inspection visit there have been positive improvements in the standard of decoration and furnishings, and there was evidence that this was part of an ongoing programme of renewal and decoration. New flooring and carpets had been fitted to a number of rooms, including the conservatory. The dining room was in the process of being redecorated at the time of this visit. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 18 Communal areas and bedrooms were found to be tidy and were cleaned to a high standard. Information provided by the manager in the AQAA stated that all staff have been made aware of infection control, and there was evidence during the visit that protective clothing was provided, and used by staff. The manager provided documentation confirming that all health and safety checks had been carried out in the environment and on equipment as required. There was evidence that bedrooms had been personalised with personal effects and furnishings. All residents spoken to and visitors at the time of the visit expressed satisfaction about the environment. It was noted that some armchairs needed replacing, as the foam was exposed from wear and tea, and one bedside cabinet was falling to pieces. These items need replacing to provide and pleasant environment, and for health and safety reasons. It was noted that ground floor bedrooms and rooms facing the front did not provide privacy, as the windows were exposed to people passing by. It was recommended that appropriate window coverings are provided to ensure the privacy of those people in these rooms. The kitchen units were old and in need of repair. The manager said that this was scheduled for replacement. The floor covering was damaged in parts, and a risk assessment is needed to ensure that there are no risks for people using the kitchen area. It was noted that the kitchen was clean and tidy. Passmonds House DS0000025487.V360365.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are supported by a well-trained staff team, and are protected by robust recruitment procedures. EVIDENCE: At the time of this visit, there were sufficient numbers of staff on duty to meet the needs of residents in the home. Staff on duty during this visit, included the manager, the two owners, four care staff, a dining room assistant, two domestics, a cook and one laundry assistant. The atmosphere in the home was relaxed, and staff were seen engaging in meaningful conversation and interactions with residents. All comments made by residents about staff were extremely positive. Four staff files were examined, this included the file of a recently recruited member of staff. All files examined contained appropriate paperwork and Criminal Record Bureau checks and two written references. An employment history was also included on the files. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 20 There was one file that didn’t contain a reference from the last employer. The manager said that everything had been done to acquire this. In these instances, the manager must document the reason for such situations, and obtain additional information so that she is confident of the fitness of the applicant in order to protect the safety and well being of residents in the home. All staff are given a copy of the Code of Practice published by the General Social Care council this provides staff with guidance on good care practice when working with adults in care homes. Staff files included details of training. Staff who were spoken to confirmed that there were plenty of opportunities for training. Records confirmed that training was being prioritised. Staff confirmed that they received a period of induction prior to commencing work. Information in the AQAA provided details about the training programme delivered by the company. National Vocational Qualifications were encouraged, and the information in the AQAA stated that the training programme for staff was in the process of being developed in order to widen the opportunities for ongoing training and development. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home is run in the best interests of the residents, and clear policies and procedures help to ensure that the rights and best interests of residents are promoted. EVIDENCE: The manager holds appropriate qualifications and has the management experience to ensure that the health, safety and well being of residents is promoted. From discussion with residents and staff, it was evident that the manager operated an ‘open door’ policy and welcomed discussion about ways in which the service can be developed to improve outcomes for residents living there. One relative said he felt comfortable in approaching the manager with concerns and that any issues of concern were responded to positively. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 22 The manager outlined plans to develop the Quality Audit and Quality Monitoring systems, in order to obtain the views and opinions of those people using the service. She said that she intends to look at key aspects of the service delivery and highlight areas that were good and positive, and also areas that required improvement and development. Staff who were spoken to confirmed that the manager had started a programme of supervision and appraisals. Information provided by the manager in the AQAA provided evidence that policies, procedures and systems were in place to ensure that the safety and welfare of residents was promoted. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X x X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 2 3 Refer to Standard OP12 OP15 OP19 Good Practice Recommendations Activities suitable to the needs of residents must be regularly provided, recorded, monitored and reviewed. Care plan reviews should include the signature of the resident and their representative to confirm that they have been involved in the review process where possible. A new maintenance and renewal plan must be in place, and damaged furniture should be replaced so that resident can enjoy positive outcomes from a pleasant environment. Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Passmonds House DS0000025487.V360365.R01.S.doc Version 5.2 Page 26 - 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. 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