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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Ash Services
Name of provider:
Ability West
Address of centre:
Galway
Type of inspection:
Announced
Date of inspection:
09 May 2018
Centre ID:
OSV-0004055
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
This centre consists of two houses that are located next door to each other in a housing estate which is situated in a rural town in Co. Galway. In this centre
Ability West provides residential and respite services for up to eleven residents with an intellectual disability. One of the houses provides six full-time residential places and the other house provides respite services for up to seventeen individuals. Each house contained suitable communal areas, such as two sitting rooms, dining rooms, kitchen and utility room, bathrooms, Residents have their own bedroom which is suitably decorated. Residents have keys to their bedroom doors, which ensures their privacy and dignity.
The following information outlines some additional data on this centre.
Current registration end
date:
22/10/2018
Number of residents on the
date of inspection:
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How we inspect
To prepare for this inspection the inspector or inspectors reviewed all information about this centre. This included any previous inspection findings, registration information, information submitted by the provider or person in charge and other unsolicited information since the last inspection.
As part of our inspection, where possible, we:
speak with residents and the people who visit them to find out their experience of the service,
talk with staff and management to find out how they plan, deliver and monitor the care and support services that are provided to people who live in the centre,
observe practice and daily life to see if it reflects what people tell us,
review documents to see if appropriate records are kept and that they reflect practice and what people tell us.
In order to summarise our inspection findings and to describe how well a service is doing, we group and report on the regulations under two dimensions of:
1. Capacity and capability of the service:
This section describes the leadership and management of the centre and how effective it is in ensuring that a good quality and safe service is being provided. It outlines how people who work in the centre are recruited and trained and whether there are appropriate systems and processes in place to underpin the safe delivery and oversight of the service.
2. Quality and safety of the service:
This section describes the care and support people receive and if it was of a good quality and ensured people were safe. It includes information about the care and supports available for people and the environment in which they live.
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This inspection was carried out during the following times:
Date
Times of
Inspection
Inspector
Role
09 May 2018 10:00hrs to
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Views of people who use the service
At the time of this inspection the centre was at full capacity, the inspector met with seven residents living in this centre. Residents were observed and appeared satisfied with the care and support they received at the centre; however, they were unable to verbally communicate their opinions to the inspector.
Seven satisfaction questionnaire's had been completed by the residents and these stated that overall, they were very happy living in the centre, and stated that they enjoyed participating in activities such as, attending their day services from Monday to Friday and meeting their friends in the evening. Residents also stated that
they frequently attended concerts and liked to go shopping and go home at
weekends to visit family. Residents told the inspector that staff working in the centre were helpful and friendly to them.
Most residents said in the questionnaire they felt safe in the service. However, one person stated that they sometimes feel afraid of one other resident, and a family member also met with the inspector to raise this concerns about their siblings fear of living with a peer who they are fearful of. A second family member also met with the inspector to raise concerns about the discontinuation of a respite service for their siblings without any consultation and the family member said they were not satisfied with the management of their concerns or complaints.
Capacity and capability
The inspector found the provider had put measures in place to ensure it had the capacity and capability to deliver a safe and suitable service. However, some improvements remained to ensure full compliance with the regulations.
On the last inspection the inspector had found that there was no person in charge managing the centre, this was immediately rectified by the provider. On this inspection the person in charge had returned from leave and resumed their full-time post.
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While governance and management arrangements had improved, the inspector found some actions from the previous inspection were not addressed and were still outstanding. These included fire safety, risks management and protection. In
addition, the inspector found complaints management and the reporting of incidents required improvement.
The provider had implemented quality assurance systems, such as, an annual review the six monthly unannounced audits. These assurance systems had determined that the service was meeting the care and support needs of the residents.
However, inspector found that the provider had not identified where regulatory requirements were not being met, or the actions to address the issues were not identified in the audits including complaints management, safeguarding concerns, and notifications which had not been accurately submitted as required.
For example, on review of the actions from the last inspection, the inspector found that only the failings identified in a specific house were addressed such as, fire evacuation procedures, and risk management, but the same risks were not reviewed in the second house to ensure the issues had been fully resolved.
While there were no open complaints in this centre, the inspector met with two family members during the inspection who express their dissatisfaction with the providers management of complaints, as they felt their complaints were not listened to and not addressed. On review, the inspector found all complaints were closed, without clear details of the actions taken to investigate these complaints or measures put in place to rectify the complaints. Furthermore, there was no records available to state whether the complainant's were satisfied with the outcome of the complaint.
There was a clear management structure in place in the centre and staff confirmed that they were well supported by the person in charge, who in turn was well
supported by their line manager. In addition, both were well known to residents and were very familiar with their up-to-date care and support needs.
On review of staffing, the inspector found that there was appropriate skill mix and number of staff allocated to support all residents in the centre. In addition, where residents required additional support, the management team had ensured that this was in place.
Registration Regulation 5: Application for registration or renewal of
registration
The provider had ensured that the prescribed documentation, required for
the renewal of designated centre's registration, was submitted to the Chief Inspector as required.
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Judgment: Compliant
Regulation 14: Persons in charge
On the last inspection the inspector found that there was no person in charge managing the centre following the full-time person in charge going on long term leave. This was immediately rectified by the provider. The person in charge has returned from leave and resumed their full-time post and has the required skills and qualifications necessary to manage the designated centre.
Judgment: Compliant
Regulation 15: Staffing
The provider had ensured that an appropriate number of qualified and skilled staff were engaged to meet the assessed needs of the resident. Furthermore, the provider's recruitment process ensured that all staff documentation required under Schedule 2 of the regulations was obtained.
Judgment: Compliant
Regulation 16: Training and staff development
The person in charge had ensured that staff had access to appropriate training, including refresher training, as part of a continuous professional development programme.
Judgment: Compliant
Regulation 23: Governance and management
The governance and management arrangements had been strengthened since the initial inspection and the inspector found there was a better oversight by the provider of the service provided in this centre. However, improvements in governance systems were still required.
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Judgment: Substantially compliant
Regulation 24: Admissions and contract for the provision of services
The registered provider ensured that each application for admission to the
designated centre was determined on the basis of transparent criteria in accordance with the statement of purpose.
Judgment: Compliant
Regulation 3: Statement of purpose
The statement of purpose reflected both the services and facilities provided at the centre and contained all information required under Schedule 1 of the regulations. Furthermore, the statement of purpose was being regularly reviewed and was available to the resident and their representatives.
Judgment: Compliant
Regulation 31: Notification of incidents
The person in charge failed to submit a written report to the chief inspector at the end of each quarter of the calendar year in relation to minor injuries received by residents.
Judgment: Substantially compliant
Regulation 34: Complaints procedure
Improvements were required to the management and resolution of complaints to ensure that complainants were satisfied with the outcome of any complaints processes.
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Quality and safety
The inspector found that the quality and safety of care had improved in this centre since the last inspection; however, the inspector found actions identified in the last inspection were not addressed in both houses; in areas such as, fire safety, risk management and protection.
The inspector found the provider had strengthened the operational management of the centre since the last inspection, by enhancing the leadership and governance arrangements in the centre. There was a competent workforce maintained in the centre who were supported by allied health professionals.
Safeguarding plans were in place and were monitored effectively with the support of allied health professionals. All staff had received training and were knowledgeable about the requirements to maintain and support all residents in the centre. The person in charge told the inspector that residents were safe in this centre and that safeguarding concerns had significantly reduced with the introduction of one to one staff supervision for two residents living in this centre.
Since the last inspection, arrangements had been put in place to ensure that residents' personal plans were updated to reflect annual review meeting outcomes and recommendations from multi-disciplinary professionals. Residents healthcare needs were fully met and medicines and pharmaceutical services were fully compliant.
However, a resident's satisfaction questionnaire and another family member told the inspector during the inspection that their sibling was fearful about living with one of their peers and that they did not feel safe living in the house with them. This
safeguarding concern was previously identified on inspections and the provider had put a safeguarding plan in place and had completed a safeguarding and compatibility assessment which had identified the need for a more suitable living environment for two residents. However, the provider had not progressed any plans to transition the residents to more suitable living environment.
Improvements were also required to the centre's fire safety arrangements. Fire evacuation procedures were inadequate and did not ensure residents could be evacuated swiftly or safely from one of the houses in the centre. Furthermore, the provider audits had not identified any fire safety concerns following a recent audit of fire safety procedures in the centre.
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concerns raised on this inspection, the person in charge completed a fire drill
the night of the inspection to assess the evacuation time and hazards and put a plan in place immediately to ensure fire evacuation was safe.
Risk management also required improvement in this centre. The inspector found that the person in charge had failed to recognise, review and monitor all risks in the centre. For example, one resident had seventeen falls over the past 16 months and one of these incidents had resulted in a serious injury; however, the impact and the frequency of this resident's falls had not been identified as a risk on the centre risk profile and there was no falls management plan or risk assessment in place for this resident.
Regulation 26: Risk management procedures
Risk management processes in the centre did not adequately detect, assess, control and mitigate the risks to residents. In particular improvements were required to the oversight and management of falls within the service.
Judgment: Not compliant
Regulation 28: Fire precautions
The registered provider failed to ensure that there were effective fire evacuation procedures in place in this centre. The provider failed to ensure that there
was an safe means of escape from one of the fire exit doors.
Judgment: Not compliant
Regulation 29: Medicines and pharmaceutical services
The resident's medications were securely stored at the centre and administered in accordance with provider's policy by suitably trained staff. Arrangements were in place for the separate storage and disposal of out-of-date or discontinued
medication, and regular audits into medication administration practices were being conducted by designated nursing staff. The findings of the last inspection had been addressed.
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Judgment: Compliant
Regulation 5: Individual assessment and personal plan
Residents' personal plans were comprehensive, up-to-date and reflected their assessed needs and staff knowledge.
Judgment: Compliant
Regulation 6: Health care
Appropriate healthcare arrangements were in place for each resident, which were reflected in their personal plans.
Judgment: Compliant
Regulation 7: Positive behavioural support
The provider had put appropriate measures in place to implement positive
behaviours supports. Staff were knowledgeable on residents' behavioural support plans. Restrictive practices had been reviewed from the last inspection, and there was evidence of positive improvements in the residents' quality of life.
Judgment: Compliant
Regulation 8: Protection
Since the last inspection there was a significant reduction in the number of incidents of behaviours that challenge and peer to peer altercations reported in this centre. However, the provider had failed to suitably implement the recommendations from a safeguarding plan in the centre.
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Appendix 1 - Full list of regulations considered under each dimension
Regulation Title
Judgment
Capacity and capability
Registration Regulation 5: Application for registration or
renewal of registration Compliant
Regulation 14: Persons in charge Compliant
Regulation 15: Staffing Compliant
Regulation 16: Training and staff development Compliant Regulation 23: Governance and management Substantially
compliant Regulation 24: Admissions and contract for the provision of
services Compliant
Regulation 3: Statement of purpose Compliant Regulation 31: Notification of incidents Substantially
compliant Regulation 34: Complaints procedure Not compliant
Quality and safety
Regulation 26: Risk management procedures Not compliant Regulation 28: Fire precautions Not compliant Regulation 29: Medicines and pharmaceutical services Compliant Regulation 5: Individual assessment and personal plan Compliant
Regulation 6: Health care Compliant
Regulation 7: Positive behavioural support Compliant
Regulation 8: Protection Substantially
compliant
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Compliance Plan for Ash Services OSV-0004055
Inspection ID: MON-0021858
Date of inspection: 09/05/2018
Introduction and instruction
This document sets out the regulations where it has been assessed that the provider or person in charge are not compliant with the Health Act 2007 (Care and Support of Residents in Designated Centres for Persons (Children And Adults) With Disabilities) Regulations 2013, Health Act 2007 (Registration of Designated Centres for Persons (Children and Adults with Disabilities) Regulations 2013 and the National Standards for Residential Services for Children and Adults with Disabilities.
This document is divided into two sections:
Section 1 is the compliance plan. It outlines which regulations the provider or person in charge must take action on to comply. In this section the provider or person in charge must consider the overall regulation when responding and not just the individual non compliances as listed section 2.
Section 2 is the list of all regulations where it has been assessed the provider or person in charge is not compliant. Each regulation is risk assessed as to the impact of the non-compliance on the safety, health and welfare of residents using the service.
A finding of:
Substantially compliant - A judgment of substantially compliant means that the provider or person in charge has generally met the requirements of the regulation but some action is required to be fully compliant. This finding will have a risk rating of yellow which is low risk.
Not compliant - A judgment of not compliant means the provider or person
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Section 1
The provider and or the person in charge is required to set out what action they have taken or intend to take to comply with the regulation in order to bring the centre back into compliance. The plan should be SMART in nature. Specific to that regulation, Measurable so that they can monitor progress, Achievable and Realistic, and Time bound. The response must consider the details and risk rating of each regulation set out in section 2 when making the response. It is the provider’s responsibility to ensure they implement the actions within the timeframe.
Compliance plan provider’s response:
Regulation Heading Judgment
Regulation 23: Governance and
management Substantially Compliant
Outline how you are going to come into compliance with Regulation 23: Governance and management:
• The Registered Provider ensures that unannounced audits are carried out on a 6 monthly basis. Any actions required arising from these audits will be
communicated to the Person in Charge in a timely manner and an action plan completed; the Registered Provider will ensure that where a designated centre comprises of more than one locations, the same areas audited will be inspected in all locations of the designated centre, and noted accordingly in action plans as required. This will ensure that such issues are reviewed and addressed to take account of the overall designated centre and ensure robust oversight.
Regulation 31: Notification of incidents Substantially Compliant
Outline how you are going to come into compliance with Regulation 31: Notification of incidents:
• Person in Charge will ensure that a written report is provided to the Chief Inspector at the end of each quarter of each calendar year, ensuring to include any minor injuries to residents.
• This has been addressed at staff meeting and is part of support/development process between the Person in Charge and the Person Participating in
Management.
Regulation 34: Complaints procedure Not Compliant
Outline how you are going to come into compliance with Regulation 34: Complaints procedure:
• Policies and Procedures in place on complaints and feedback.
• Complaints information leaflet available in the front porch area of each unit
• List of Nominated Complaints Persons (Complaints Officers) displayed in both units.
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• Local Nominated Complaints Persons have undertaken training on complaints handling.
• Information on Advocacy Services is available in both units.
• The Person in Charge has processes in place to oversee complaints management, including regular review of complaints, and communication with complainants.
• The Registered Provider will ensure that all complaints are dealt with in a timely manner and that the satisfactions of the complainants with the Register Provider’s actions are noted.
Regulation 26: Risk management
procedures Not Compliant
Outline how you are going to come into compliance with Regulation 26: Risk management procedures:
• Person in Charge has reviewed areas of risk in the designated centre, and updated the risk register and centre risk assessments, to ensure that there is adequate information with regard to control measures to mitigate against specific risks in the centre.
• Centre Risk register is reviewed and updated on a scheduled basis, or before scheduled dates if required.
• The Person in Charge will continue to assess, review and manage residents’ individual risks and ensure that appropriate control measures are adequate.
• All learning from such incidents will be shared with the team.
• The Person in Charge has undergone training on risk management and this area is continually reviewed at staff meetings.
Regulation 28: Fire precautions Not Compliant
Outline how you are going to come into compliance with Regulation 28: Fire precautions:
• Policies and Procedures in place to support fire safety management systems. A review of the service was undertaken by a Fire Safety consultant. Awaiting written report, however verbal report recommended a ramp be put in place at the back door and thumb locks be put on all internal exit doors. Reported to the Facilities Manager and works required will be undertaken in a timely manner.
• Appropriate firefighting equipment, fire doors, door closers and emergency lighting in place.
• Regular fire drills carried out, and the Person in Charge will ensure all service users in each unit will complete at least one fire drill each year, and that staff will all complete at least one fire drill in each unit. Schedule in place for same.
• Fire Drill outcomes will be discussed at team meetings.
• CEEP (Centre Emergency Evacuation Plan) is in place and reviewed by the Person in Charge following each fire drill and amended as necessary.
• PEEPS (Personal Emergency Evacuation Plans) in place for all residents which are reviewed following each fire drill and amended as necessary.
• Staff are trained in the use of fire safety equipment as required.
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Regulation 8: Protection Substantially Compliant
Outline how you are going to come into compliance with Regulation 8: Protection:
• Policies and procedures in place in relation to Safeguarding Vulnerable adults.
• All staff have received training in relation to safeguarding vulnerable adults.
• Designated Officer in place and picture of same visible in both units.
• A number of safeguarding plans are in place, which are read, signed off by staff and are reviewed with the Designated Officer as required.
• Assessment of needs are completed for all residents and reviewed regularly.
• Re–referral submitted to psychology department with regards to resident presentation within the service.
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Section 2:
Regulations to be complied with
The provider or person in charge must consider the details and risk rating of the following regulations when completing the compliance plan in section 1. Where a regulation has been risk rated red (high risk) the inspector has set out the date by which the provider or person in charge must comply. Where a regulation has been risk rated yellow (low risk) or orange (moderate risk) the provider must include a date (DD Month YY) of when they will be compliant.
The registered provider or person in charge has failed to comply with the following regulation(s).
Regulation Regulatory
requirement Judgment Risk rating Date to be complied with
Regulation
23(1)(c) The registered provider shall ensure that management systems are in place in the designated centre to ensure that the service provided is safe, appropriate to residents’ needs, consistent and effectively monitored. Substantially
Compliant Yellow 20 June 18
Regulation 26(2) The registered provider shall ensure that there are systems in place in the designated centre for the
assessment, management and ongoing review of risk, including a system for responding to emergencies.
Not Compliant Orange 22 May 18
Regulation
28(3)(d) The registered provider shall make adequate
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arrangements for evacuating, where necessary in the event of fire, all persons in the designated centre and bringing them to safe locations. Regulation
28(4)(a) The registered provider shall make
arrangements for staff to receive suitable training in fire prevention, emergency procedures,
building layout and escape routes, location of fire alarm call points and first aid fire fighting
equipment, fire control techniques and arrangements for the evacuation of residents.
Not Compliant Yellow 31 July 18
Regulation
31(3)(d) The person in charge shall ensure that a written report is provided to the chief inspector at the end of each quarter of each calendar year in relation to and of the following incidents occurring in the designated centre: any injury to a resident not required to be notified under paragraph (1)(d).
Substantially
Compliant Yellow 09 May 18
Regulation
34(2)(e) The registered provider shall ensure that any
Substantially
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measures required for improvement in response to a complaint are put in place.
Regulation
34(2)(f) The registered provider shall ensure that the nominated person maintains a record of all complaints including details of any investigation into a complaint, outcome of a complaint, any action taken on foot of a complaint and whether or not the resident was satisfied.
Substantially
Compliant Yellow 19 June 18
Regulation 08(2) The registered provider shall protect residents from all forms of abuse.
Substantially
