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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Mullingar Centre 3
Name of provider:
Muiríosa Foundation
Address of centre:
Westmeath
Type of inspection:
Announced
Date of inspection:
11 October 2018
Centre ID:
OSV-0005047
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
Mullingar Centre 3 is a modern bungalow based on the outskirts of Mullingar and is operated by the Muiríosa Foundation. It is a full time community house which provides support based on a social model. The building design is suitable for individuals with high support needs and can accommodate a maximum of four individuals, both male and female. The residents are supported by a staff team consisting of nursing staff, social care workers and support workers. There is a large entrance hall and wide corridors. There are four large double bedrooms, three of which are en suite and one with a wet room. All bedrooms are personalised and designed to each individuals personal preferences. Each resident is supported to avail of community based facilities that are of importance to the individual and which reflects their centred support plan. The following services are provided by Muiríosa Foundation if required; social work, occupational therapy, physiotherapy, speech and language therapy, psychology and behavioural therapy. A wheelchair accessible vehicle is available for use by the designated centre.
The following information outlines some additional data on this centre.
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
11 October 2018 09:00hrs to
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Views of people who use the service
As part of the inspection, the inspector met with the four residents living in the centre. The residents in the centre used non-verbal communication and as such their views were relayed through staff advocating on their behalf. The inspector observed warm interactions between the residents and staff caring for them and that the residents were comfortable in the presence of staff. Residents were provided with appropriate support throughout the inspection with
staff demonstrating that they knew and understood the individual communication and support needs of residents.
Residents’ views were also taken from the Health Information and Quality
Authority's questionnaire forms, accessible personal plans and various other records that endeavoured to voice the resident’s opinion. Two family representatives had returned the questionnaires on behalf of their family member and these
relayed satisfaction with the the various elements of service provision such as the facilities provided, activities and staffing levels.
Capacity and capability
The inspector found that the registered provider and the person in charge were effective and responsive in assuring that a good quality and safe service was provided to residents. This was upheld through care and support that was person-centred which promoted an inclusive environment where each of the residents’ needs and wishes were taken into account.
This centre was found to be well governed by the registered provider and
a professional and knowledgeable person in charge and management team were in place. Good oversight and response was found in key areas of service provision to support residents on an individual basis in line with their assessed needs. The
inspector found a good level of oversight and monitoring of service provision at local level, person in charge level and provider level with effective systems of auditing found in key areas of resident's healthcare, activities/participation, risk
management, health and safety and consultation with residents and families.
The person in charge had not changed since the centres previous inspection and this person was found to be professionally knowledgeable and experienced. They demonstrated a very good understanding of the residents assessed needs, allocation of resources, managerial oversight of care delivery and regulatory requirements. The person in charge was responsible for two designated centres, the inspector was satisfied that they ensured effective governance, operational management
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person in charge and was also met on this inspection and was found to be very professionally competent and fit. It was evident that the provider had strived for excellence through the continuous monitoring of service delivery within all levels of the organisation. For example, the clinical nurse manager was responsible for conducting audits in medication management, health and safety, fire safety, person centre goals and finances. These were compiled by the person in charge on a monthly basis to report back into the area director at a monthly meeting with other persons in charge to facilitate shared learning. The regional director on
a quarterly basis chaired a meeting with all area directors and persons in charge under her remit to review and discuss current developments.
The inspector reviewed the annual review and the unannounced six-monthly audit completed by the provider, of their assessment of the quality of care and service provision in this centre. The inspector found that these quality assurance
reports had identified some areas where improvement was required, action had been taken to address these issues and the action plan was reviewed and updated as necessary demonstrating a commitment to the on-going monitoring and
improvement of service delivery.
The inspector reviewed essential policies and procedures in place for the safe delivery of care that provided guidance to staff in delivering safe and appropriate care. Whilst the provider had ensured that they had the relevant policies, three of the 21 polices were found not to be reviewed within the required time lines to ensure consistency with relevant legislation, professional guidance and international best practice.The provider had in place a statement of purpose that clearly
described the model of care and support delivered to residents in the designated centre. Some slight amendments were made on the day by the person in charge to ensure it was compliant with the regulations.
The person in charge had reviewed and reissued the contracts of care to residents family representative's in light of a recent decreased contribution fee to reflect the Health Service Executives' Residential Support Services Maintenance
and Accommodation Contribution Guidelines (RSSMAC).
The inspector found that there were arrangements in place for the continuity of staff so that support and maintenance of relationships were promoted. There was
a consistent and knowledgeable staff team in place in the centre. Staff members spoken with were able to accurately describe the specific needs of the residents and the supports required to provide for these. The inspector also observed staff
members engaging with residents in a positive, respectful manner and providing appropriate support if required.The person in charge informed the inspector that one agency staff member was used in the designated centre and the
inspector identified that improvements were required in the information obtained under Schedule 2 of the regulations for agency staff. For example evidence of identification, qualifications and employment history were not available, the person in charge rectified this on the day of inspection. The inspector reviewed the
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held on a monthly basis with fixed agenda items such as review of resident meetings, care plan development, accidents and incidents, complaints and audit outcomes. The inspector saw that staff mandatory training was up to date and that training specific to the needs of the residents was also completed by staff.
The inspector reviewed the accident and incident log in the centre and
found that overall, adverse events that required notification to HIQA had occurred. In one incidence of an injury sustained this was not notified as per regulation.
The provider had put in place an effective complaints procedure which was in an accessible format, included an appeals process and was displayed in a prominent position in the centre. There was evidence that the provider had ensured that this policy had been implemented fully within the service
Registration Regulation 5: Application for registration or renewal of
registration
The provider had complied with the requirements to renew their application and all required documentation had been submitted.
Judgment: Compliant
Regulation 14: Persons in charge
The inspector found that the person in charge met the requirements of this
regulation with regard to her qualifications, background, knowledge and experience. Additionally, it was noted that there were clear systems in operation to facilitate the person in charge's current regulatory responsibilities for two designated centres.
Judgment: Compliant
Regulation 15: Staffing
The provider had ensured that an appropriate number, qualification and skill mix of staff were employed to meet the assessed needs of the resident.
Judgment: Compliant
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The person in charge ensured that staff were appropriately trained, including refresher training and also training in areas of good practice. Staff received formal and informal supervision by the management team which proved effective in providing a safe service to residents.
Judgment: Compliant
Regulation 19: Directory of residents
The provider maintained a directory of residents which outlined a summary of the services and facilities provided and the terms and conditions relating to residency.
Judgment: Compliant
Regulation 23: Governance and management
There were governance, leadership and management arrangements in place to govern the centre and to ensure the provision of a good quality and safe service to residents. There was a clear management structure, and there were systems in place, such as audits and management meetings, to ensure that the service provided to residents was safe and as described in the statement of purpose. Six-monthly audits of the service were carried out by representatives of the provider, and an annual review, which included the views of residents and their
representatives, had been completed and supplied to the provider.
Judgment: Compliant
Regulation 24: Admissions and contract for the provision of services
Each resident had a written agreement in place which clearly outlined the fees that they would be charged and any additional charges which they may incur. These agreements were signed by the resident and their representative, and also by a nominated person from the registered provider of the centre.
Judgment: Compliant
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The inspector reviewed the centre's statement of purpose and found that it
contained the information as outlined in Schedule 1 of the regulations. The provider made a copy available to the residents and their families
Judgment: Compliant
Regulation 31: Notification of incidents
The provider maintained a record of all notifications submitted to the Chief
Inspector. On inspection of incidents that occurred in the centre, one injury had not been notified to HIQA as required by the regulations.
Judgment: Substantially compliant
Regulation 34: Complaints procedure
A complaint policy was present within the centre giving clear guidance for staff in relation to complaints procedure. Details of of complaints officer was visible in an accessible format throughout centre.
Judgment: Compliant
Regulation 4: Written policies and procedures
All schedule 5 written policies and procedures were adopted and implemented, however improvement was required in relation to the review dates of some policies.
Judgment: Substantially compliant
Quality and safety
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to the local arrangements in place for the disposal of medication.
The design and layout of the premises ensured that each resident could enjoy living in an accessible, comfortable and homely environment. This enabled the promotion of independence, recreation and leisure and enabled a good quality of life for the residents living in the house. The inspector found that it was suitable to
support individuals with high support needs as outlined in the statement of purpose.
The care and supports provided to residents were informed by a comprehensive assessment of each resident’s needs which reflected the high support requirements and medical needs of the residents. The approach to care was individualised,
consistent and regularly reviewed. This was evident from speaking to staff that were clearly very knowledgeable of residents assessed needs, the observation of staff providing care to the residents and how interventions were documented. Care plans were devised from the assessment of need and identified healthcare needs which included the input of nursing staff, speech and language therapy, occupational therapy and psychology. Residents did not present with challenging behaviour but assessments by the psychology team had been carried out to assess the potential behavioural needs. Communication supports were required by all residents and trialling of communication devices had commenced in the centre alongside assistive technology assessments. The presence of regular staff, known to the residents enhanced effective communication.
The personal planning process ensured that residents' social, health and
developmental needs were identified. Personal planning arrangements ensured that each resident's needs were subject to regular review on an annual basis and more frequently if their needs changed. Whilst some activities were based in the designated centre, the provider and person in charge were committed to promoting and improving resident involvement in the community. The person in charge had implemented a new system to improve how goals were being reviewed and updated to ensure that residents' personal development were maximised.
Overall, the centre had a good medicines management system to support the residents' needs. Medication was administered and monitored according to best practice as individually and clinically indicated to increase the quality of each person’s life. There was evidence of review of residents' medical and medicines needs and medication audits had taken place. Non nursing staff that administered medicines to residents were trained in its safe administration. The
inspector identified that improvements were required in the local procedure and practice for the safe disposal of medication. Also the protocols in place for the administration of emergency medication in the incidence of seizure activity required review to avoid ambiguity. On review of the medication cabinet it was noted that there was no arrangement for the segregation for out of date or unused medication. It was also unclear what the procedures were for the return of medication to the pharmacy due to the omission in the local policy for disposal of mediation as required by organisational policy.
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residents which contained a good level of detail, were specific to the resident and had appropriate measures in place to control and manage the risks identified. Risks in this centre included the risk of falls, aspiration, infection and allergies. All risk assessments were found to be up to date, reviewed, control measures were implemented and staff were aware of same.There were a low number of incidents and accidents in the centre but there were arrangements in place for investigating and learning from incidents and adverse events involving residents. This
included quarterly health and safety meetings that were attended by representatives from all designated centres within the region, fire officer, maintenance and
operations manager which promoted opportunities for learning to improve services and prevent incidences.
There were appropriate arrangements in place regarding fire safety and equipment with servicing and reviews undertaken at required intervals. Staff were all trained in fire safety and evacuation drills were completed to ensure the centre could be safely evacuated. Monthly fire, heath and safety audits took place to review
emergency readiness and the work environment. Additionally daily and weekly checks were completed by staff.
There were established systems to protect the resident from possible abusive situations, with staff awareness and knowledge found to be strong. The usage of a restrictive practice was underpinned by a due process mechanism which included communication with the resident's representative.There were no safeguarding concerns in the centre and the provider had systems in place which promoted the safety of residents, which included ensuring that staff had received appropriate training. Staff had a good understanding of these systems and were observed to interact with residents in warm and caring manner.
Regulation 17: Premises
The design and layout of the centre was suitable for its stated purpose and met residents’ individual and collective needs. The centre was clean, comfortably furnished and well decorated.
Judgment: Compliant
Regulation 26: Risk management procedures
The provider had a risk management policy in place and all identified risks had a risk management plan in place. The provider had ensured that all risk management plans had been regularly reviewed. The provider ensured that there was a system in place in the centre for responding to emergencies.
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Judgment: Compliant
Regulation 28: Fire precautions
The provider had ensured that effective measures were in place for the prevention of fire. These included up-to-date servicing of fire safety equipment, fire
containment doors, internal fire safety checks by staff, completion of fire evacuation drills, and individualised emergency evacuation plans for all residents.
Judgment: Compliant
Regulation 29: Medicines and pharmaceutical services
Whilst there was a medication management policy and processes in place, improvements were required for the safe disposal of medication.
Judgment: Substantially compliant
Regulation 5: Individual assessment and personal plan
Each resident had a personal plan which detailed their needs and outlined the supports they required to maximise their well-being, personal development and quality of life. The plan was developed and reviewed by staff and members of the multi-disciplinary team in consultation with the resident and their representative as appropriate and in accordance with their wishes.
Judgment: Compliant
Regulation 6: Health care
The health care of residents was being supported in the designated centre.
Healthcare plans were in place and support was given to residents to attend medical appointments as required.
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Regulation 7: Positive behavioural support
Were restrictive procedures such as physical, chemical or environmental restraint are used, such procedures are applied in accordance with national policy and evidence based practice.
Judgment: Compliant
Regulation 8: Protection
The inspector observed that there were systems and measures in operation in the centre to protect the residents from possible abuse.
Staff were facilitated with training in the safeguarding of vulnerable persons.
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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 19: Directory of residents Compliant Regulation 23: Governance and management 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 Compliant Regulation 4: Written policies and procedures Substantially
compliant
Quality and safety
Regulation 17: Premises Compliant
Regulation 26: Risk management procedures Compliant Regulation 28: Fire precautions Compliant Regulation 29: Medicines and pharmaceutical services Substantially
compliant Regulation 5: Individual assessment and personal plan Compliant
Regulation 6: Health care Compliant
Regulation 7: Positive behavioural support Compliant
Regulation 8: Protection Compliant
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Compliance Plan for Mullingar Centre 3
OSV-0005047
Inspection ID: MON-0021940
Date of inspection: 11/10/2018
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.
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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 31: Notification of incidents Substantially Compliant
Outline how you are going to come into compliance with Regulation 31: Notification of incidents:
PIC will review all incidents as they occur and monthly to ensure that all incidents have been notified to HIQA as required by the regulations
Regulation 4: Written policies and
procedures Substantially Compliant
Outline how you are going to come into compliance with Regulation 4: Written policies and procedures:
PIC will alert the Regional Director when a policy has not been reviewed within the three year timeframe.
Regulation 29: Medicines and
pharmaceutical services Substantially Compliant
Outline how you are going to come into compliance with Regulation 29: Medicines and pharmaceutical services:
Local protocol will be reviewed to include procedures and practices for the safe disposal of medication.
A container is in place in the medication cabinet for the segregation of out of date or unused medication for storage prior to return to the pharmacy.
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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
29(4)(c) The person in charge shall ensure that the designated centre has appropriate and suitable practices relating to the ordering, receipt, prescribing, storing, disposal and administration of medicines to ensure that out of date or
returned medicines are stored in a secure manner that is
segregated from other medicinal products, and are disposed of and not further used as medicinal products in accordance with any relevant national legislation or guidance.
Substantially
Compliant Yellow 31/12/2018
Regulation
31(1)(d) The person in charge shall give the chief inspector notice in writing within 3 working days of the following adverse incidents occurring in the designated centre: any serious injury to a resident which requires
immediate medical or hospital treatment.
Substantially
Compliant Yellow 30/11/2018
Regulation
04(3) The registered provider shall review the policies and procedures referred to in paragraph (1) as often as the chief inspector may require but in any event at intervals not
exceeding 3 years and, where necessary, review and update them in accordance with best practice.
Substantially
