Inspection on 06/06/07 for Treefields Resource Centre

This inspection was carried out on 6th June 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Treefields Resource Centre 26/01/06

Treefields Resource Centre 31/03/05

Treefields Resource Centre 08/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Treefields Resource Centre 1 Treefields Close Wingfield Rotherham South Yorkshire S61 4AB Lead Inspector Ramchand Samachetty Key Unannounced Inspection 6th June 2007 11:00 DS0000033254.V331194.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 DS0000033254.V331194.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. DS0000033254.V331194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Treefields Resource Centre Address 1 Treefields Close Wingfield Rotherham South Yorkshire S61 4AB 01709 551325 01709 559885 ss.treefields@rotherham.gov.uk 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) Rotherham Metropolitan Borough Council (LDS) Carroll Elliss Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000033254.V331194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user over the age of 65, named on the variation received at this office on 8 August 2006, may reside at the home. 26th January 2006 Date of last inspection Brief Description of the Service: Treefields Resource Centre is a six-bedded residential facility, which provides respite care for adults with a learning disability. It is owned by Rotherham Metropolitan borough Council ’s Social Services Department and managed by the Rotherham Learning Disability Service. It is a detached two-storey house, situated on the Wingfield estate, about three miles from Rotherham town centre. It is accessible by public transport and is within reach of local amenities. The accommodation is offered in single bedrooms, five on the first floor and one on the ground floor. Access to the first floor is only by stairs. There is a lounge, a dining room, a kitchen and a small laundry area on the ground floor. There is an office at the side of the main entrance, which also serves as a reception point. There are garden areas at the front and back of the house. The side and rear grounds are fenced off. The back garden provides a patio area with garden furniture. The service has produced a statement of purpose and a service user guide. The fees charged are £907.26 per week and the cost of respite stays depend on the number of nights required. Further information can be obtained from the Centre. DS0000033254.V331194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out on 6 June 2007, starting at 11.00 hours and finished at 17.30 hours. The service is registered to provide respite care for up to 6 younger adults with learning disabilities. There were five people receiving respite care at the time of this inspection. The registered manager was present for part of the inspection. All the key national minimum standards for “care homes for Adults 18-65” were assessed. The inspection included a tour of the premises, examination of care documents and other records, including those pertaining to staff rota, complaints, maintenance of equipment and systems, staff records and medicines records, conversation with one relative, staff, including the manager and people using the service. The care of two people was tracked and some aspects of care provision were observed. As part of the pre-inspection planning, the completed questionnaire submitted by the manager and other documents including comment cards received from people who use the service and their relatives, were considered. The views and comments expressed in them have been included in this report. The inspector would like to thank all the people using the service, their relatives and staff who helped with this inspection. What the service does well: People who use the service and their relatives said that staff were providing an “excellent standard of care and support” and that the staff team was “good, caring and very experienced”. Relatives were also satisfied with the service, which they described as being “well organised” and providing a “valuable service to the community”. Relatives were complimentary of staff attitude and approach to the way they work, which they said was based on treating people with a learning disability as “people with rights”. There is excellent communication among staff, people who use the service and their relatives and this contributes to good collaborative work and to service improvement. DS0000033254.V331194.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000033254.V331194.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 DS0000033254.V331194.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 and 2. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service and those who expressed an interest in using it, were given appropriate information in a suitable format. This helped them to understand the service and to benefit from it. The needs of each person using the respite service were assessed before their admission to make sure that such needs could be appropriately met. EVIDENCE: Copies of the statement of purpose and service user guide were available. They were written in plain English and had pictures to make them more accessible to people who had a learning disability. Both documents were made available to people who use the service and their relatives and also to those who were interested in using the service. This helped people who want to use the service to make a positive and informed choice. DS0000033254.V331194.R01.S.doc Version 5.2 Page 9 The statement of purpose and service user guide had been revised to include all the necessary information, and in particular the criteria for emergency admission. The care records of two people who were recently admitted to the service were checked. They each had an assessment of needs carried out by the placing social workers prior to their admission. Care records showed that staff continued to review the assessments of people who regularly used the respite service, at each respite stay. They were able to update themselves on any intervening change in order to provide appropriate care and support. DS0000033254.V331194.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 and 9. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service and their relatives were satisfied with the care and support they were receiving. Care is planned in a manner that allows the individual to take reasonable risks and to make choices about their daily activities. Individuals are well supported by the staff team to lead as independent a lifestyle as possible. EVIDENCE: The care records of two people, who were using the respite service, were checked. They were both relatively new to the service. One person had her first stay in March 2007. She had not been provided with a care plan. Staff were referring to the placing social worker’s assessment to guide them in providing care and support for that individual. Staff explained that in some DS0000033254.V331194.R01.S.doc Version 5.2 Page 11 cases, they needed a period of time before they could assess the capabilities of an individual before developing an appropriate care plan. The other person who started using the service at about the same time was provided with a basic care plan. Other care plans showed evidence of person-centred planning. It was noted that people using the service, their relatives and day centre staff had all contributed to their individual care plan. Individuals had clearly documented aims and goals and there was evidence that these were appropriately monitored and their care plans regularly reviewed. People who were using the service stated that they were happy with the care and support they were receiving. Two people were observed making their own drinks, under staff supervision. One person commented that he would decide whether to go out to a social event in the evening or stay at the centre. He added that he would check with staff to make sure someone would accompany him, if he should decide to go out. A member of staff discussed his plan for the evening with him and volunteered, with his consent, to accompany him. People using the service were able to take reasonable risks, with the support of staff. These were assessed and action to manage them was stated in care plans. There was evidence that individuals had been involved in deciding how identified risks would be managed. DS0000033254.V331194.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 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The lifestyle aspirations of people who use the respite service are well met. The service continues to offer excellent opportunities for people using it to take part in a range of fulfilling and meaningful activities. This helps people using the service to enjoy a good quality of life. EVIDENCE: The manager described a wide range of leisure and social activities that people using the service participate in, both at the home and in the local community. People attend day services, local college, social clubs, gardening groups, work placements, concerts, sports and also take part in board games, and watch their films at the centre. DS0000033254.V331194.R01.S.doc Version 5.2 Page 13 Staff explained that there was a meeting every Friday evening for people who were in for respite care. This meeting helped to plan the activities for the weekend. Records showed that people using the service made good use of the meeting to express their preferred activities. One person who was receiving respite care said that she was doing drama at the day centre and was thoroughly enjoying the experience. She was supported and encouraged by her key worker to rehearse her part. Another person said that he was working on a farm one day a week, as part of his college work. He also liked football and would go to the local pub to watch matches in the company of staff. Records of social and leisure activities undertaken by people who use the service, included trips to local parks and shopping centres. In discussion with people using the service, it was noted that they had opportunities to make friends and develop relationships with other people. It was noted that a ‘ sexuality’ policy was being developed in order to offer appropriate support to people using the service. There was evidence that people receiving respite care had their rights respected. Staff were observed asking permission before entering people’s bedrooms. Staff interactions with people using the service were friendly and courteous and showed respect for the individual. People using the service and their relatives commented that staff were helpful in making sure that there was good communication between them. One person said “staff help me ring my parents if I need to talk to them”. People using the service stated that they liked to go on shopping trips as it helped them choose their favourite foods. Some of them would also help staff to prepare the meals. The manager commented that staff would offer support and guidance, to people receiving respite care, in making healthy food choices whilst promoting independence as far as possible. People spoken to said that they always choose what to eat and that they liked the food that was provided at the centre. DS0000033254.V331194.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 and 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The personal and health care needs of people using the respite service are well met and this ensured their continued good health and wellbeing. EVIDENCE: Individual care plans and care records of people using the service showed that care and support was tailored to their specific needs. In discussion, staff were able to demonstrate that they were familiar with the needs of each person using the respite service and were thus able to offer them a personalised service. People using the service and staff confirmed that routines were flexible. Times for getting up, going to bed and for eating varied, depending on what individuals had planned to do. DS0000033254.V331194.R01.S.doc Version 5.2 Page 15 Records showed that the health care needs of individuals were met, with the support of staff. People using the service were encouraged and supported in keeping any appointments they had with health care professionals. None of the people who were in for respite care at the time of this inspection were self-medicating. Records of medicines handling, storage and administration were checked and found satisfactory. Medicines were administered by senior staff who had all received the appropriate training to do so and evidence of this was seen in staff training records. The manager stated that where it was relevant, people using the respite service would be asked if they could share their health action plan with staff at the centre. Health action plans were usually developed as part of the ‘person centred’ planning and these were led by other services like the day centres. DS0000033254.V331194.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 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service, their relatives and staff work well together and have good communication. This allows for concerns to be addressed promptly and openly, without developing into complaints. People using the service were appropriately protected from harm and abuse. There were procedures in place on complaints and on adult protection, but they were not set out in a manner, which people using the service could easily understand. EVIDENCE: The service had use of a corporate complaints procedure provided by the Social Services of Rotherham Metropolitan Borough Council. A copy of the procedure was available at the centre. A summary of it was also included in the statement of purpose and service user guide. People spoken to, said they knew they could tell somebody if they were not happy. One person said that he would tell his mother and she would make a complaint for him. People who completed a survey about their views of the service, stated that they were aware of the complaints procedure but did not have to use it as staff would listen to their concerns and promptly act on them. DS0000033254.V331194.R01.S.doc Version 5.2 Page 17 The pre-inspection questionnaire stated that no complaints had been received at the centre. The manager confirmed this and explained that staff and relatives of people using the service, were in regular contact with each other and this helped in resolving any issues they had before they developed into complaints. However, it was noted that the complaints procedure and its summary was not set out in a format that helped people with learning disabilities understand it. A copy of the corporate adult protection policy and procedures was in place. Information about safeguarding adults from abuse was also included in the statement of purpose and service user guide. Staff confirmed that relatives and advocates were provided with information on the adult protection procedures used at the centre. It was noted information on this policy was not set out in a format to assist its understanding by people who using the service. The pre-inspection questionnaire stated that there had been no adult protection issues at the centre and the manager confirmed this. Training records showed that all staff were provided with annual training on adult protection. In discussion, staff showed that they had a good understanding of the policy and procedures and were able to protect people in their care. DS0000033254.V331194.R01.S.doc Version 5.2 Page 18 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 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Treefields provides a good standard of accommodation, which is homely, comfortable and safe for people who use the service. EVIDENCE: Treefields provides its accommodation and services in an ordinary house, domestic in character. There was one bedroom on the ground floor and five on the first floor. Access between the two floors is by stairs. The premises were checked. It was partially wheelchair accessible. The bedroom on the ground floor was often used for people who have mobility problems. The building was in good state of repair. The manager stated that some refurbishment had taken place since the last inspection. New carpets had been laid in two bedrooms and the staff sleep-in room has been fitted with an DS0000033254.V331194.R01.S.doc Version 5.2 Page 19 electromagnetic lock, which complies with fire safety regulations. All the communal areas were appropriately maintained. People using the service said that they liked the place and found it to be safe and comfortable. The laundry facility was well maintained. The centre was found to be clean and tidy. The garden areas to the front and back were appropriately maintained and made the place pleasant. There was a good range of garden furniture, including a large gazebo for use in the summer months. DS0000033254.V331194.R01.S.doc Version 5.2 Page 20 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, 33, 34, 35 and 36. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The service was facing some temporary difficulties in providing sufficient care staff to meet needs of people using it. These were mostly due to the restructuring of the service and to staff absences. These difficulties were starting to affect the management of the home and therefore could affect the standard of service. EVIDENCE: The manager explained that there had an important change in the staff roles and responsibilities. Staff will no longer provide a community support service to people with a learning disability. The Rotherham Learning Disability service has set up a separate stand -alone service for community support. The service at Treefields will be dedicated to respite care and the staff team will provide respite care only. This change is currently being implemented. DS0000033254.V331194.R01.S.doc Version 5.2 Page 21 The manager stated that the staffing level for the respite service was being recalculated by the Human Resources section of the service and that a small number of staff were being redeployed to the community support service. On the day of this inspection the manager and two Residential Care and Support Officers (RCSOs) were on duty. Four people were in for respite care and the staffing level was sufficient to meet their needs. However, it was noted that the manager was working about 32 hours as a care and support worker, leaving him little time to undertake his management duties. In discussion, staff commented that a combination of sickness absence, unfilled vacancies and the reorganisation of the service were causing staffing difficulties. The manager was providing cover for support staff at the expense of his management duties. There had been no recruitment of staff to the service since the last inspection. The pre-inspection questionnaire stated that four members of the care team had already left since the last inspection. The profile of the current staff team showed that the gender balance was adequate, but did not reflect the wider diversity of the local population. It was noted that the manager was unable to offer effective guidance to his team. A number of care staff had not received the required level of supervision. Planned training has been deferred. However, staff spoken to, were satisfied with the training they had received. This included moving and handling, food hygiene, first aid, mental health issues and makaton. There were 16 care staff (RCSOs) and 12 were qualified to National Vocational qualifications (NVQ) level 3 in Care. Three other care staff had started their NVQ training. DS0000033254.V331194.R01.S.doc Version 5.2 Page 22 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 and 42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The service was well managed and strived to meet the needs of people who were using it. Health and safety issues were appropriately managed. The quality monitoring and quality assurance methods were satisfactory. EVIDENCE: The registered manager has experience of working and managing services for people with a learning disability. He was completing his NVQ level 4 in Care and Management in July this year. DS0000033254.V331194.R01.S.doc Version 5.2 Page 23 In discussion, people who use the service, relatives and staff said that they were satisfied with the way that the service was managed. Feedback from our survey confirmed this view. One relative said “ They do their best, here, to fit us in, when we need a break” Staff were found to be working well together to ensure the wellbeing of people who use the service. They were committed to the service and were assisting as best they could, in its restructuring. The manager said that the service had developed further its quality monitoring and quality assurance methods. He commented on a yearly ‘client’ satisfaction survey that the centre had undertaken in September 2006. Questionnaires seeking feedback on the quality of the service were sent to 42 relatives and 38 of them replied. A very positive response was obtained. The manager explained that a survey, for this year, was being undertaken and they were looking forward to the results. Staff were publishing a quarterly newsletter to assist with information sharing for people who use the service, their relatives and other people interested in the service. The manager stated that staff would also use the regular ‘Friday’ meetings of people who were in residence as a method of obtaining feedback on the quality of the service. There was evidence that the provider was completing monthly unannounced visits and reporting on the quality of care provided. The manager said that the visits were helpful as they led to action planning to continually improve the service. The manager also commented on the annual business plan, which has been developed for the service. It was noted that the restructuring of the service was appropriately addressed in it. The pre-inspection questionnaire indicated that the maintenance of equipment and the relevant health and safety checks were undertaken as required. These were confirmed at the inspection. It was noted that general risk assessments were in place and that staff had received relevant training on health and safety matters, including fire safety. DS0000033254.V331194.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 X 4 X 5 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X 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 3 3 X 3 X 3 X X 3 X DS0000033254.V331194.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Individual care plans must be provided to all persons who are admitted at the Centre, in a timely manner, so that staff are appropriately guided in providing care and support to individuals concerned. Sufficient care and support staff must be deployed at all times in order that the needs of people using the service are fully met. The registered provider must also make sure that the hours worked by the registered manager allow him to effectively fulfil his management tasks at all times. The manager’s post must be supernumerary to care staffing arrangement. All staff must be provided with appropriate and regular supervision. Timescale for action 27/07/07 2 YA33 18 27/07/07 3 YA36 18 27/07/07 DS0000033254.V331194.R01.S.doc Version 5.2 Page 26 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 Refer to Standard YA22 YA23 Good Practice Recommendations The complaints procedure should be made available to people who use the service in a format that they can easily understand. The policy on adult protection should be made available to people who use the service in a format that they can easily understand. 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