Inspection on 03/01/07 for Southfields Residential Home

This inspection was carried out on 3rd January 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southfields Residential Home 03/01/06

Southfields Residential Home 17/08/05

Southfields Residential Home 23/02/05

Southfields Residential Home 08/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Southfields Residential Home 349 High Road Trimley St Martin Felixstowe Suffolk IP11 0RS Lead Inspector John Goodship Key Unannounced Inspection 3rd January 2007 10:00 DS0000024490.V325533.R01.S.doc Version 5.2 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 DS0000024490.V325533.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 Adults 18-65. 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. DS0000024490.V325533.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southfields Residential Home Address 349 High Road Trimley St Martin Felixstowe Suffolk IP11 0RS 01394 277778 01394 277778 h2008@mencap.org.uk www.mencap.org.uk Royal Mencap Society Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Leslie Clifford Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000024490.V325533.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 Brief Description of the Service: Southfields home is registered to care for four adults with Learning Disabilities. The home, in a converted private bungalow set in a large garden, is situated in the Trimley villages next to the coastal town of Felixstowe. All four bedrooms are single. There are shops and other facilities in the villages as well as access by bus and train to both Felixstowe and Ipswich. Fees currently charged range from £755.00 to £878.00 pa. DS0000024490.V325533.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and covered the key standards which are listed under each section overleaf. This report includes evidence gathered during the visit together with information already held by the Commission. The inspection took place on a weekday and lasted three and a half hours. The manager was present throughout, together with staff on the early shift and, later, those on the late shift. The inspector toured the home, and spoke to one of the residents, and the staff. There were three residents in the home at the time of the visit. One resident was in an NHS assessment unit and their future accommodation was yet to be agreed. The inspector also examined care plans, staff records, maintenance records and training records. What the service does well: What has improved since the last inspection? The fire exit through a resident’s bedroom has been changed to protect the resident’s privacy. It now exits through the door in a sitting area and has been approved by the fire officer. The admission of a new resident has given staff the opportunity to implement admission procedures, and to plan and monitor the effect on the home and its residents. DS0000024490.V325533.R01.S.doc Version 5.2 Page 6 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. DS0000024490.V325533.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000024490.V325533.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is good. Prospective residents can be assured that they and their representatives will have sufficient information from documents and from trial visits to assess the home will meet their needs. They can be assured that the home will carefully assess their needs to ensure that the home is capable of meeting their needs, and that they will fit in with the other residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and the Service Users’ Guide had been revised in January 2006 and contained all the items of information required by the regulations. They were now due for review, when the manager’s qualification at NVQ Level 4 would be included. The information was in normal text and in pictographs. The manager reported that the home had recently installed computer software to enable them to devise their own signs and symbols to assist communication with residents. This programme had not yet been used. There had been a vacancy in the home since the beginning of 2006, following the transfer of a resident to nursing care. The manager reported that a number of possible replacements had been considered, with one person actually DS0000024490.V325533.R01.S.doc Version 5.2 Page 9 moving in. However within a short time, the relative of this person had decided to remove them from the home and from their day centre, and continue to care for them at home. A new resident had finally been admitted as a permanent placement on 6th December 2006. Planning for this had started in September 2006 with the gathering of information on this person’s needs by the manager, through reports from their social worker and the intensive support team, together with the manager’s own assessment of needs. This had been recorded on a comprehensive form identifying all the key areas, and formed the basis of the care plan. Visits to the home on a part day and full day basis had started in September 2006, and the first overnight stay was in November 2006. All these visits were recorded on Compatibility Notes, which recorded events, interactions and staff observations. This was the first admission to the home for many years. There was no observable impact on the residents, although not all of them had been in the home during December. All residents had a Mencap tenancy agreement called a Licence to Occupy. This included terms and conditions of their residence in the home. The home had contracts with the local authority for the funding of each placement. DS0000024490.V325533.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10. Quality in this outcome area is good. Residents are able and supported to make many choices about their daily lives. They attend reviews to ensure their wishes are expressed. The home respects their privacy, but must ensure more security for confidential data. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plan, which is called a Support Plan in this home, was examined for the recent admission. Information had been drawn from the needs assessment described in the previous section. Some entries were awaiting a review to give a fuller description of the level of support required by this person. For example there were suggestions for the activities and help in the running of the home which the person had the ability and interest in doing. There were clear instructions on how medication should be administered. DS0000024490.V325533.R01.S.doc Version 5.2 Page 11 Other residents’ support plans listed the regular health checks that should be done, and the level of personal care needed. One resident did not need support with intimate personal care but needed prompting. Risk assessments were present for all residents, including the newest resident. These were being updated by a support worker during the inspection. Examples of risks assessed were bathing, being in the kitchen, triggering challenging behaviour, walking out of the home. Ways to reduce or eliminate the risks were clearly laid out for staff. The risk assessments for one resident had recently been reviewed to reflect changes in their health and well being following medical problems. Other support plans showed that the resident and their relatives were invited to full care reviews. The software programme referred to in the previous section would be used to translate key information in the support plan into a format suitable for each resident to understand. One resident had been enabled to make a positive choice about their daytime activities. As they were dissatisfied with the previous arrangement, the funder had agreed to fund a one-to-one support worker during the week for this person as an alternative to attending the Day Centre. Direct payments had been considered but no trustees could be found for the trust fund needed to be set up to channel the payments. The support plans for each resident were kept on an open shelf in the office on the first floor. Other personal information on residents was kept in an unlockable filing cabinet. This room was not usually locked according to the manager. Although there was only one resident who could access this room on their own, the security of the data did not meet the standard. The manager said that he would discuss with the staff the best method of securing the room, eg with lockable cabinets, or a keypad entry system. DS0000024490.V325533.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. Quality in this outcome area is good. All residents take part in activities of their choice, and maintain family links. The diet of residents is healthy, varied and chosen to meet their preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the current residents had leisure interests of their own, and the home supported them as far as possible. All took part individually in shopping for the home with staff. One resident was about to go to buy some batteries with a member of staff when the inspector arrived. The preferred activities of each resident were listed in their support plans. One had a long-standing love of riding on trains and buses. Now that they had a one-to-one worker, this could happen more frequently. One resident liked to DS0000024490.V325533.R01.S.doc Version 5.2 Page 13 sort cards. Staff had been bringing in their old Christmas cards. The resident had also been taken to fetch some from the home of a staff member. They were sitting with them in a box in the lounge during the visit, and showed one to the inspector. The other preferred activities for this resident were listed as shopping, going to the cinema and to the library. Another resident was taken swimming on Saturdays, often in the company of their mother. All residents had contact with their families, some on a weekly basis when they went to their parents’ home. Another resident had been taken to the local church but it was not yet clear if they wished to continue. One resident had been enabled to make a positive choice about their daytime activities. As they were unhappy with the previous arrangement, the funder had agreed to fund a one-to-one support worker during the week for this person as an alternative to attending the Day Centre. Direct payments had been considered but no trustees could be found for the trust fund needed to be set up to channel the payments. Tea was being prepared by the staff during the inspection. It consisted of chicken curry and rice, followed by chocolate pudding and cream. The food was served in dishes suitable for the ability of each resident. One was seen to need support from staff to feed themselves. Particular care with the diet of one resident who had been treated for some time for digestive disorders. Their support plan included an eating chart, and weight record. DS0000024490.V325533.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21. Quality in this outcome area is good. Residents receive personal support in the way they prefer. Their health is closely monitored and the staff provide excellent support even if the resident is in hospital. Residents are protected by the home’s medication procedures, but reporting of errors to the Commission must be improved for the protection of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence from support plans and discussion with staff confirmed that three of the residents needed waking personal care, although it was sufficient to have only a sleep-in staff at night. The fourth resident needed encouragement and prompting to care for themselves. Staff were well informed about the healthcare needs of residents, and support plans evidenced this. One resident had been referred to the specialist DS0000024490.V325533.R01.S.doc Version 5.2 Page 15 assessment unit following incidents of self-harm. Another resident had been in hospital twice recently because of their digestive problems. Staff from the home had been supporting them there with feeding and communication. After three weeks in hospital, the resident needed support to regain their previous level of mobility, although it was expected that their longer-term moving and handling needs would increase. This resident had been assessed by the wheelchair service in September and been supplied with an appropriate chair. There was evidence in the support plans of the involvement of health professionals including the primary care team and the intensive support team. In the previous few weeks, there were records of appointments with, and visits by, the dietitian, physiotherapist, occupational therapist, orthopaedic clinic, continence nurse and the dentist. The medication cupboard was inspected. A sample of Medicine Administration Record (MAR) sheets was examined. All had been completed fully with signatures for each administration. There was a photograph of each resident at the front of their sheet, except for the newest resident. The stock level of one drug was checked against the MAR sheet. The amount remaining tallied with the amount delivered and dispensed. The monthly visit report under regulation 26 stated that there had been a number of medication errors recently. These had not been reported to CSCI under regulation 37, although they had been reported internally. The manager was not aware that he must report any event in the care home that adversely affected the well-being orn safety of a resident. The errors included: sending a resident home with an incorrect tablet, finding a tablet on the floor, apparently spat out by a resident, and finding that the lunchtime medication of one resident had not been administered by their day centre. Appropriate action had been taken by the staff to rectify the errors and review procedures to prevent a recurrence. The manager was discussing with the day centre how one resident’s lunchtime medication could be dispensed and recorded within legal requirements. He was able to refer to a copy of the Royal Pharmaceutical Society Guidance: The Administration and Control of Medicines in Care Homes. In conjunction with Mencap, he would discuss with the pharmacy if they would provide a suitable blister pack for weekday lunchtime medication for this resident to take to the day centre, where staff there would sign for its administration. Certificates for all staff were seen confirming their attendance on the course run by the local pharmacy supplier. A parent of one of the residents had died in December 2006. The other parent had asked for the resident not to be taken to the funeral. Staff were not sure that the resident was aware of the death but were observing them for any signs of a reaction. DS0000024490.V325533.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. Residents are protected by the home’s complaints procedure that would act on formal complaints. Staff training and practice ensure that residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure was clear and up-to-date. There was a complaint log book but no complaints had been received by the home. Staff received training in Safeguarding Adults on joining the home, and then each year were required to re-familiarise themselves with the policy and procedure and sign to confirm they understood. The newest recruit was booked to attend a course in February 2007. The local Mencap office was producing a updated learning tool for staff which would become an annual requirement. Staff were aware of the issues around protecting residents. This had been evidenced during the settling in period of the newest resident, whose behaviour had occasionally been challenging. This was a new experience for some of the staff, although all of them had attended Unisafe training prior to the admission. DS0000024490.V325533.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,30. Quality in this outcome area is good. Residents live in a well-maintained home, with personalised rooms, and hygienic facilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The bungalow had belonged to the parents of one of the residents who had lived there all their life. It had been adapted to provide suitable accommodation for four residents. The home had level access for wheelchair users, and communal areas, residents’ rooms and bathing facilities were all of a size sufficient to allow wheelchair access and use. The Housing Association which owned the property had agreed to refurbish the kitchen. This had been the situation at the last inspection in January 2006. No work had yet been undertaken, and the manager showed the inspector a letter DS0000024490.V325533.R01.S.doc Version 5.2 Page 18 he had written to the landlord recently asking for this project to be definitely scheduled into their estates programme. The vacant room had been redecorated before the new resident was admitted, and it was refurnished more suitably to their needs. The previous fire exit route had been through this room. However on advice from the Fire Safety Officer, a new route was now signposted through a communal sitting area. The new resident spoke to the inspector about his room. They said it was nice and comfortable. The home was clean and odour free. The communal areas were comfortably furnished with one small area equipped to provide a relaxation and stimulation atmosphere. DS0000024490.V325533.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36. Quality in this outcome area is good. Residents benefit from staff understanding their roles, and being trained to undertake them. Residents also benefit from the stability of staffing which has given staff a good understanding of residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was fully staffed with no current vacancies. The only new person appointed since the previous inspection in January 2006 was a part-time support worker who had started on 27/11/06. This appointment had been specially funded by the local authority for three months to support the new resident, until a permanent funding package could be organised. The recruitment file for this person evidenced that all the required documentation such as references, CRB certificate and photo identification was present. The training programme for this person was detailed in their file. Certificates for all staff were kept in a separate folder and confirmed training activity to date. There was a training plan for the home with dates of planned and DS0000024490.V325533.R01.S.doc Version 5.2 Page 20 completed sessions. All staff had recently attended training on challenging behaviour to enable them to support the new resident. For this day, agency staff had been used to cover to allow staff to be released for the training. All staff had NVQ Level 2, with two people booked to start Level 3. The manager had now completed Level 4. Staff meetings were held every six weeks. The most recent had given the opportunity to talk about the care needs of a resident and how staff should support them. The schedule of staff supervision sessions were seen to be up-to-date and recorded. The stability of the staffing allowed each support worker to know the residents well, and for the residents to feel comfortable with the staff. It was observed that staff were able to communicate with residents, and to understand what they needed, in a patient and friendly way. Staff were able to explain the preferences of the residents for how they spent their day, what they liked to eat, and how to encourage them to participate as far as they were able in the daily life of the home. One support worker was a qualified moving and handling trainer, and was the lead on all risk assessments. These were being updated during the inspection. DS0000024490.V325533.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42. Quality in this outcome area is good. The residents can be confident that their home is run for them as they wish. The manager and staff, and Mencap, are trying to improve the quality of residents’ lives at all times. In order to ensure residents’ protection, the home must improve its data security and incident reporting. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was qualified to NVQ Level 4. He regularly attends area meetings of managers which he believed kept him up-to-date on current issues of care and management. DS0000024490.V325533.R01.S.doc Version 5.2 Page 22 The home had a monthly visit from the Area Manager, which included a quality review report. This met the CSCI requirement under Regulation 26. The review covered all areas of staffing, management, environment and care. The home had a rolling improvement plan that was reviewed monthly by this process. It included a list of required actions. The inspector considered it was an example of good practice. The fire log was inspected and contained details of regular maintenance of equipment, drills and tests. The fire risk assessment was dated April 2006. Staff had responsibility for carrying out health and safety checks. The records sampled showed that these are regularly carried out. It was noted that the door of the upstairs office was always open, even if unoccupied. Staff records were locked in a filing cabinet, but resident support plans were on a shelf, and other information about them was in a non-lockable cabinet. The drug cupboard was always locked. Improved security was discussed with the manager. It was suggested that he should discuss alternatives with staff to agree the best system to prevent unauthorised access to records. The manager had not been aware that medication errors might be reportable to the Commission under Regulation 37. DS0000024490.V325533.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 Adults 18-65 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 3 2 4 3 3 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 3 3 X 4 X 2 2 X DS0000024490.V325533.R01.S.doc Version 5.2 Page 24 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 2 Standard YA10 YA41 YA42 Regulation 37 37 Requirement The security of the office must be improved to protect confidential resident information. The registered person must ensure that any event, including medication errors, that adversely affect the well-being or safety of any resident are reported to the Commission. Timescale for action 31/01/07 03/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA42 Good Practice Recommendations The manager should consider using the Commission’s template and accompanying guidance for reporting all incidents under Regulation 37. 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