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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Shanowen
Name of provider:
St Michael's House
Address of centre:
Dublin 9
Type of inspection:
Announced
Date of inspection:
22 March 2018
Centre ID:
OSV-0002374
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
Shanowen is a designated centre which supports adults with intellectual disabilities based in a community setting in North Dublin. The designated centre is primarily staffed by social care workers who are available to residents on a 24 hour basis. There is a staff nurse on the team to support and advise staff in relation to nursing matters, as well as working as a team member. Additional nursing supports are provided by St. Michael's House Nurse Manager On-Call Service.
The designated centre is accessible and can accommodate people with
additional physical disabilities including two people who are wheelchair users. Supports are provided on all aspects of daily living from developing financial
understanding, improving culinary skills, social and recreational choices, community activities, special social occasions, medical and other appointments. The supports offered incorporate a holistic approach to individual needs, goals and choices. A multidisciplinary clinical team is available on a referral basis to support both residents and staff develop plans to meet these needs. Residents are actively encouraged and supported to participate in all aspects of the operation of the centre including
preparation of meals, shopping and cleaning, and choosing new furnishing and decoration.
The maximum number of residents that can be accommodated is five and all individuals availing of the services of this centre are over the age of 18. Shanowen can accommodate Male and Female residents. The centre is very close to a wide range of local amenities. A shopping centre which includes a cinema, coffee shops and a wide range of restaurants is within ten minutes walk from the centre. The local area is well serviced with a wide variety of educational, social, recreational and
sporting facilities. The area is well serviced by public transport.
The following information outlines some additional data on this centre.
Current registration end
date:
07/09/2021
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
22 March 2018 09:00hrs to
17:00hrs Thomas Hogan Lead 22 March 2018 09:00hrs to
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Views of people who use the service
One the day of the inspection, inspectors met four of the five residents who availed of the services of the designated centre. The inspectors spoke with residents and had the opportunity to spend time with some of them in the communal areas of the centre. Some of the residents were happy to show the inspectors their bedrooms.
Residents who spoke with the inspectors described activities they were supported with, in particular accessing the local community, helping with activities in the centre, and decorating their own room. In speaking with the residents and
observing staff interacting with each resident the inspectors found that there was a supportive and homely atmosphere in the centre. There were opportunities for residents to participate in activities lead by support workers who came into the centre. Some of the residents spoke of enjoying this and showed inspectors their work.
The needs of the residents in the centre were changing and inspectors observed residents being supported to engage in activities of their choice and enjoy rest days in the centre.
In addition to speaking with residents and general observations on the day of inspection, five completed questionnaires were made available to the inspectors, two of which were completed by residents and three of which were completed by family members of residents. Overall, while the questionnaires communicated a high level of satisfaction with the services provided by the designated centre, three of the questionnaires raised staffing resources as an area requiring improvements.
Capacity and capability
Overall, the inspectors found that the delivery of services in the designated centre was safe and the registered provider had assured that high quality care and support was provided to residents. There were effective management structures in place in the centre with clear lines of accountability with staff members demonstrating awareness of their responsibilities and to whom they were accountable to. While assurances were evident as to the quality of care provided, some areas which required improvement were identified. These included the numbers of staff
employed in the designated centre, staff training and development, and policies and procedures in place to guide staff practice.
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assured by the arrangements in place for the governance, management and oversight of the care and support to residents. However, there were some improvements required to provide a consistent service of high standards. For example, the inspectors found that internal auditing mechanisms in place in the designated centre had failed to identify areas of non-compliance with the
regulations. There was evidence of regular team meetings taking place in the centre along with one-to-one supervision meetings with staff members in line with
organisational policy. Staff members spoke with stated that they felt supported in their roles and were aware of how to raise concerns should they need to. In addition, staff members stated that they were confident that concerns would be acted on and responded to in a timely manner.
The inspector found that five policies and procedure documents in place had not been reviewed and, or updated as required at least once every three years. In addition, it was found that a policy was not available in the centre for the
recruitment, selection and vetting of staff members. Similarly, a policy was not available in the centre for the support of residents with regards to personal property and possessions.
While the inspectors were satisfied that the skill mix and numbers of staff employed in the designated centre were appropriate to meet the basic needs of residents, it was found that the overall staffing compliment had reduced by 0.5
full-time equivalent in the period since the last inspection. There was evidence to
indicate that this decrease had a negative impact on residents and the availability of staff to support residents on a one-to-one basis. This finding was supported with feedback provided in three of the five questionnaires completed by residents and family members. Staff members spoken with at the time of inspection demonstrated comprehensive knowledge of the needs of residents and all interactions observed by inspectors between staff and residents were found to be respectful and warm. The inspectors found that there was evidence of continuity of care and this was ensured through a regular and consistent team employed in the centre.
A review of staff training records maintained in the designated centre found that there were gaps in training provided to staff across mandatory training courses for fire safety, first aid, safeguarding vulnerable persons at risk of abuse, and positive behavioural supports. Despite this, staff members demonstrated awareness of best practice and appropriate responses across these areas throughout discussions held with the inspectors.
Registration Regulation 5: Application for registration or renewal of
registration
The provider completed the application process and submitted the required documentation in relation to the renewal of the designated centre.
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Regulation 15: Staffing
The inspectors were informed that the overall staffing levels for the designated centre had decreased by 0.5 full-time equivalent in the period since the last
inspection. While the staffing levels in place on the day of inspection were found to be sufficient to meet the basic needs of residents, some evidence was available to indicate that supporting residents with one-to-one supports was limited.
Judgment: Substantially compliant
Regulation 16: Training and staff development
Some gaps were identified in mandatory training course during a review of staff training records. Three staff members had not completed, or were up to date with refresher training in fire safety; one staff member had not completed, or were up to date with refresher training in first aid; one staff member had not completed, or were up to date with refresher training in safeguarding vulnerable persons at risk of abuse; and four staff members had not completed, or were up to date with
refresher training in positive behavioural supports.
Judgment: Not compliant
Regulation 22: Insurance
The inspector found that the registered provider had a contract of insurance in place which included injury to residents in the form of public liability cover.
Judgment: Compliant
Regulation 23: Governance and management
While the inspectors were satisfied with the overall arrangements in place for the governance and management of the designated centre and the oversight of delivery of care and support and care to residents, some areas of improvement were
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mechanisms.
Judgment: Substantially compliant
Regulation 3: Statement of purpose
There was a statement of purpose which was in line with regulations and inspectors observed that the care and support provided on the day of inspection was reflected in this document.
Judgment: Compliant
Regulation 4: Written policies and procedures
The inspectors found that six policy documents listed as being required under Schedule 5 of the Regulations were not reviewed and/or updated in the required time frames of at least every three years or in the dates indicated as required on the document(s).
Judgment: Not compliant
Quality and safety
The inspectors found that overall that the quality and safety of the service provided to the residents was of high quality. The lived experience of individuals availing of the services of the designated centre was overall one of respect and value. There was evidence available to demonstrate that the service was resident-led and person-centred. Residents had been informed of their rights and entitlements, and had formed personal goals and aspirations with the support of their natural
networks and staff team. In addition, the inspectors found that residents had been supported to develop and maintain personal relationships and links with the wider community. Despite these findings, the inspectors identified areas which required improvement so as to enhance the support, and sustain the high quality of
care, provided in the designated centre.
The inspectors completed a full walk through of the premises of the designated centre in the company of the person in charge and found that internal spaces were decorated and maintained to a high standard. Resident bedrooms were
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was clean and tidy and equipment had been replaced and maintained. Upon inspection of the exterior spaces of the designated centre, however, it was found that a boundary wall in close proximity to the centre's building was subsiding. The person in charge was aware of this matter and had taken follow up action by
contacting the service maintenance department and seeking quotations for remedial works to be completed. The inspectors also found that the front driveway of the designated centre was not in use due to surfacing issues and associated risks to residents, visitors and staff in poor weather conditions.
A number of incident, accident and near miss records maintained in the designated centre were reviewed by inspectors for the time period since the last inspection took place. A total of six incidents were recorded as occurring, two of which related to slips, trips and falls of residents; two related to generalised behaviours of distress; and two related to the targeting of staff during behaviours of distress. The
inspectors found that there was appropriate follow up in the cases of these
incidents. The management of risk in the designated centre was an area identified by the inspectors as requiring improvements. The organisational policy in place in the designated centre was found not to have been fully implemented with evidence of gaps in the identification and appropriate management of some risks.
Both residents and staff spoken with by the inspectors with regards to fire safety were clear on the fire evacuation procedures. There was evidence of the regular completion of fire drills and the participation of all residents and staff in these. There were easy read evacuation procedures throughout the centre and appropriate
personal evacuation plans available for each resident. Since the last inspection a previous evacuation route was no longer usable due to subsiding external boundary wall. The new evacuation procedure had been conducted in drills and again
discussed at meetings. However, there remained directional signage indicating this as an escape route, which was in fact blocked. There were regular checks on fire safety equipment and servicing records, though there were some improvements required in relation to fire containment measures, such as a fire door in the kitchen leading to the bedroom area. The inspectors found there was an absence of fire containment measures between the central kitchen area and one hallway which contained resident bedrooms.
The inspectors completed a review of the storage facilities for medication in the designated centre and found that the medication cabinet had been left unlocked with keys hanging from a key hook on a nearby wall. A review of a
sample of prescription and medication administration records found that all regular prescribed medication had been administered to residents. It was found,
however, from a review a corresponding resident files that PRN medication
(medication taken as the need arises) guidelines were not signed by a prescribing practitioner. In addition, the inspectors found that risk and capacity assessments had not been completed for residents with regards to the self-administration of medication. Staff members spoken with who had responsibility for the administration of medication to residents demonstrated sufficient knowledge of what action to take in the event of a medication error.
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to contain a comprehensive assessment of need for each individual, however, there was evidence of contradictory information contained within these. A suite
of personal plans were in place for identified needs of residents and these reviewed by the inspectors. Plans had key worker responsibilities outlined and described residents' goals, however, they did not fully inform staff on how to care and support residents. In some cases it was not clear if information had been reviewed or
updated on at least an annual basis, or if reviews included the inputs of an allied health team.
The inspectors found that residents availing of the services of the designated centre were supported on an individual basis to achieve and enjoy the best possible health. Residents were found to have had timely access to health care services, appropriate treatments and therapies. Medical practitioners of residents' choice were made available and the services of allied health professionals were available on a referral basis. Staff were found to be knowledgeable of the health care needs of residents despite there being an absence of plans in place to guide staff on health care conditions such as memory loss and incontinence.
Staff members spoken with demonstrated sufficient knowledge of what constituted abusive experiences for residents and were able to communicate to the inspectors what the appropriate response to a concern, suspicion, allegation or observation of an abusive incident. The inspectors found, however, that there was an absence of safeguarding plans in place relating to two historical incidents where residents were reported to have experienced abuse. The inspector found these had not been managed in accordance with the Safeguarding Vulnerable Persons at Risk of Abuse National Policy and Procedures (HSE, 2014) document.
Regulation 17: Premises
While the inspectors found that the interior space of the designated centre was decorated and maintained to a high standard and good state of repair, the outdoor space was found to be of some concern. A boundary wall of the site of the building, which was in close proximity to the designated centre, was found to be subsiding at the time of inspection, and in addition, the registered provider had deemed the front driveway of the centre to be a risk in wet weather and as a result was not in use.
Judgment: Not compliant
Regulation 26: Risk management procedures
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management of risk (dated April 2016), this policy had not been fully implemented at local level in the designated centre. For example, the identification of risks associated with the permanent locking of a fire exit due to an external wall
subsiding had not been identified as a risk. In a risk assessment for the ''...storage and administration of medication'', a control measure listed stated that ''...all medication is kept in a double locked press with keys separate and out of view of service users'', however, at the time of inspection this measure was found not to be satisfactorily implemented.
Judgment: Not compliant
Regulation 28: Fire precautions
There were improvements required in some areas of fire containment and information relating to evacuation routes.
Judgment: Not compliant
Regulation 29: Medicines and pharmaceutical services
The inspectors found that the keys to the medication cabinet were left in the
unlocked cabinet at the time of inspection. In addition, it was found from a review a sample of resident files that PRN medication (medication taken as the need arises) guidelines were not signed by a prescribing practitioner. Capacity and risk
assessments had not been completed for residents regarding the self-administration of medication.
Judgment: Not compliant
Regulation 5: Individual assessment and personal plan
On the day of inspection there were gaps in the documentation relating to personal plans, however staff spoken to were knowledgeable in how to support each
resident. In addition, there was an absence of reviews of personal plans to assess their effectiveness on at least an annual basis.
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Regulation 6: Health care
There were health care plans available which included appropriate input and support by allied health care professionals.
Judgment: Compliant
Regulation 8: Protection
The inspectors found that there was an absence of safeguarding plans in place relating to two historical incidents where residents were reported to have
experienced abuse. The inspector found that these incidents had not been managed in accordance with the Safeguarding Vulnerable Persons at Risk of Abuse National Policy and Procedures (HSE, 2014) document.
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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 15: Staffing Substantially
compliant Regulation 16: Training and staff development Not compliant
Regulation 22: Insurance Compliant
Regulation 23: Governance and management Substantially compliant Regulation 3: Statement of purpose Compliant Regulation 4: Written policies and procedures Not compliant
Quality and safety
Regulation 17: Premises Not compliant
Regulation 26: Risk management procedures Not compliant Regulation 28: Fire precautions Not compliant Regulation 29: Medicines and pharmaceutical services Not compliant Regulation 5: Individual assessment and personal plan Substantially
compliant
Regulation 6: Health care Compliant
Regulation 8: Protection Substantially
compliant
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Compliance Plan for Shanowen OSV-0002374
Inspection ID: MON-0021311
Date of inspection: 22/03/2018
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 15: Staffing Substantially Compliant
Outline how you are going to come into compliance with Regulation 15: Staffing:
The organization has undertaken a recruitment drive, and this half-time equivalent vacancy has been highlighted as needing to be filled, taking into account the growing needs of the residents in this designated centre.
Regulation 16: Training and staff development Not Compliant
Outline how you are going to come into compliance with Regulation 16: Training and staff development:
The Person in Charge has met with the Training Officer in relation to our training audit. It was noted that the Person in Charge was mistaken in agreeing with the inspector on the day that four staff in the designated centre were out of date in Manual Handling training. I attach the feedback form 21311 with the correction. All of our staff were up to date in Manual Handling on the day, according to the St. Michael’s House policy on Manual Handling training being refreshed every three years.
With regard to Fire Safety training, two of the three staff found to be out of date in their training have been scheduled to train in the coming weeks (10/07/18). The third staff member did refresher training on 31/05/18.
The staff member who was out of date in First Aid training, has revealed to us that she is leaving us this month.
The one staff member who is out of date in Safeguarding training has been put forward for the next available training, and we await a date for this training.
Regulation 23: Governance and management Substantially Compliant
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In the three instances where the inspectors noted deficiencies, we have undertaken the following:
The staff member whose Safeguarding training was found to be out of date on the day has been put forward for the next available Safeguarding training. We await a date for that training.
With regard to Fire Safety, our boundary wall subsidence (and buttressing, which blocks off access to the back garden) is a factor in more than one of our non-compliances, including fire safety. It is scheduled to be entirely rebuilt by the end of September, 2018. On account of this issue, the directional sign in the utility room will be decommissioned until boundary wall is addressed to ensure no one is directed to same. This exit is not used by residents, as it is not suitable for everyone’s needs in the house and there are more suitable alternatives used.
Swing free door closers on kitchen doors to be completed by the end of September. In the interim practice of closing doors at night time is in place and continues to be implemented.
Intumescent strips and cold smoke seals to be installed on door leading from kitchen to bedroom corridor thus upgrading it to FD30s. To be completed by end of July.
In the area of medication management, it was noted that the keys to the medication press were not securely locked away, but were hanging near the meds press on a hook. We have since purchased a box with a combination lock that has been mounted to the wall beside the press for the purpose of rendering the keys inaccessible to anyone but staff.
Regulation 4: Written policies and procedures Not Compliant
Outline how you are going to come into compliance with Regulation 4: Written policies and procedures:
All of the Schedule 5 Policies which were not present (or out of date) at the time of the inspection have been updated by St. Michael’s House and approved by our Executive Manangement committee.
Regulation 17: Premises Not Compliant
Outline how you are going to come into compliance with Regulation 17: Premises:
The boundary wall is scheduled to be rebuilt by the end of September. The decision was taken to rebuild it entirely, rather than make repairs to the section that is damaged, as that would not solve the problem that has caused the damage.
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falling. In the meantime, we are not using this driveway for pedestrian access/egress and signage is in place to warn people not to use this drive. Furthermore, from October
through April, we have Technical Services call out to spray the moss monthly. They also significantly cut back the trees bordering the drive in 2017 in order to allow a good deal more sunlight, reducing the amount of moss that grows.
Regulation 26: Risk management procedures Not Compliant
Outline how you are going to come into compliance with Regulation 26: Risk management procedures:
The Person in Charge and the PPIM have been put forward for further training in Risk Assessment. This training will be undertaken by year’s end.
Regulation 28: Fire precautions Not Compliant
Outline how you are going to come into compliance with Regulation 28: Fire precautions:
Above, under Governance and Management, I have detailed the actions we will take in relation to fire precautions: rebuilding our boundary wall, decommissioning one of the fire exits leading to the walkway that is blocked at the moment, installing intumescent strips and cold smoke seals as well as a self-closing mechanism on the kitchen door leading to the corridor to the rear bedrooms.
Regulation 29: Medicines and pharmaceutical services Not Compliant
Outline how you are going to come into compliance with Regulation 29: Medicines and pharmaceutical services:
At the time of the inspection, it was found that the keys to the double-locked meds press were not locked away and out of sight of residents. We have purchased and installed a wall-mounted lock box for the keys, which is in use now.
Our Medication Management Committee has met regarding the PRN guidelines and a memo to HIQA is being drafted by our Chief Medical Officer in relation to prescribing practitioners signing PRN guidelines. I have asked that they forward to me the memo, as well, in order to direct our practice in relation to PRN guidelines.
Finally, St. Michael’s House is piloting a new Self-medication assessment tool and I have asked our medications trainer to forward this tool to me, so that we might assess each of our residents in terms of their capacity and willingness to take responsibility for
administering their own medication.
Regulation 5: Individual assessment and personal
plan Substantially Compliant
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The Person in Charge has scheduled for a trainer in personal planning to attend our July staff meeting to discuss the feedback from HIQA around Individual assessment and
Personal Planning. The Person in Charge is developing an audit mechanism to insure that each Assessment of Need and Personal Plan is audited and reviewed on at least an
annual basis.
Regulation 8: Protection Substantially Compliant
Outline how you are going to come into compliance with Regulation 8: Protection:
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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 15(1) The registered provider shall ensure that the number,
qualifications and skill mix of staff is appropriate to the number and assessed needs of the residents, the statement of purpose and the size and layout of the designated centre.
Substantially
Compliant Yellow 30/09/2018
Regulation
16(1)(a) The person in charge shall ensure that staff have access to
appropriate training, including refresher training, as part of a continuous
professional development programme.
Not
Compliant Orange 31/08/2018
Regulation
17(1)(b) The registered provider shall ensure the premises of the designated
Not
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centre are of sound construction and kept in a good state of repair externally and internally. 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 31/07/2018
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 31/07/2018
Regulation
28(3)(a) The registered provider shall make adequate arrangements for detecting, containing and extinguishing fires. Not
Compliant Orange 31/07/2018
Regulation
28(3)(d) The registered provider shall make adequate
arrangements for evacuating, where necessary in the event of fire, all persons in the designated centre and bringing them
Not
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to safe locations. Regulation
29(4)(a) 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 any medicine that is kept in the designated centre is stored securely.
Not
Compliant Orange 30/06/2018
Regulation
29(4)(b) 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 medicine which is prescribed is administered as prescribed to the resident for whom it is prescribed and to no other resident.
Not
Compliant Orange 31/07/2018
Regulation 29(5) The person in charge shall ensure that following a risk assessment and assessment of capacity, each resident is
encouraged to take responsibility for his or her own
medication, in accordance with his or her wishes and
Not
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preferences and in line with his or her age and the nature of his or her
disability. Regulation 04(1) The registered
provider shall prepare in writing and adopt and implement policies and procedures on the matters set out in Schedule 5.
Not
Compliant Orange 30/06/2018
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.
Not
Compliant Orange 30/06/2018
Regulation
05(4)(a) The person in charge shall, no later than 28 days after the resident is admitted to the designated centre, prepare a personal plan for the resident which reflects the resident’s needs, as assessed in
accordance with paragraph (1).
Substantially
Compliant Yellow 31/08/2018
Regulation
05(4)(b) The person in charge shall, no later than 28 days after the resident is admitted to the designated centre, prepare a personal plan for the resident
Substantially
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which outlines the supports required to maximise the
resident’s personal development in accordance with his or her wishes. Regulation
05(6)(a) The person in charge shall ensure that the personal plan is the subject of a review, carried out annually or more frequently if there is a change in needs or
circumstances, which review shall be multidisciplinary.
Substantially
Compliant Yellow 31/08/2018
Regulation
05(6)(c) The person in charge shall ensure that the personal plan is the subject of a review, carried out annually or more frequently if there is a change in needs or
circumstances, which review shall assess the
effectiveness of the plan.
Substantially
Compliant Yellow 31/08/2018
Regulation 08(2) The registered provider shall protect residents from all forms of abuse.
Substantially
