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Name of designated
centre:
Avalon
Name of provider:
Redwood Extended Care Facility
Unlimited Company
Address of centre:
Talbot Group, Stamullen,
Meath
Type of inspection:
Announced
Date of inspection:
05 March 2018
Centre ID:
OSV-0002433
Fieldwork ID:
MON-0020986
Report of an inspection of a
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
The centre provides residential services to adults 18 years and over, who present with a diagnosis of intellectual disability, autism or acquired brain injury. This centre can accommodate a total of five residents. It is fully wheelchair accessible and each resident has their own bedroom. The centre consists of a kitchen, utility and separate dinning room. Furthermore, there are four communal living areas available to
residents. The centre also has two bathrooms and two wc's available. There is also a communal garden available to residents. The centre is located a short drive from a village in Meath.
The following information outlines some additional data of this centre.
Current registration end
date:
24/06/2018
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 and information submitted by the provider or person in charge 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 to 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 summarize our inspection findings and to describe how well a service is doing, we group and report on the regulations under two dimensions:
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
05 March 2018 10:30hrs to
21:00hrs Conan O'Hara Support 05 March 2018 10:30hrs to
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Views of people who use the service
The inspector met and spoke with four residents during the inspection. These residents were complimentary towards the care and support they received in the centre. They spoke fondly of the staff and stated that they were happy to live in the centre. They told the inspector they were getting the right supports and felt safe.
Residents gave positive feedback to the inspector in relation to the quality of the food, choices in the centre, and the range of activities they were supported to engage in. However, some residents highlighted that when staffing numbers were reduced or low, they were unable to participate in the activities they wished to. Residents told inspectors that they were involved in decision making about the day-to-day running of the centre including menu and activities planning.
Capacity and capability
Overall, the registered provider and person in charge were ensuring a good quality and safe service for residents in the centre. Care and support was found to be person-centred and in line with residents' choices, needs, and wishes. However, occasionally staffing numbers were not sufficient and this impacted
residents' opportunities to engage in community activities of their choice.
There were clearly defined management structures which identified the lines of authority and accountability in the centre. The staff team reported to the person in charge directly and person in charge reported to his line manager. Residents and staff could clearly identify how they would report any concerns about the quality of care and support in the centre. There were arrangements in place to monitor the quality of care and support in the centre including an annual review of the quality and safety in the centre and six monthly visits by the provider or their
representative. A number of audits were also completed regularly in the centre. There was evidence that residents and their representatives had been involved in the review of quality of care and supports in the centre. There was a written statement of purpose in the centre which accurately and clearly described the services provided in the centre.
The provider had undertaken a comprehensive recruitment drive, which had resulted in significant numbers of new staff being employed. However, there were still
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the centre had access to training and refresher training in line with the statement of purpose. There was a complaints procedure in place and each person's complaints and concerns were listened to and acted upon in a timely, supportive and effective manner. Staff were observed to treat residents with respect and warmth.
There were policies and procedures in place to guide staff practices to support residents.
Regulation 14: Persons in charge
The provider had appointed a suitably qualified person with the required experience to manage the designated centre.
Judgment: Compliant
Regulation 15: Staffing
Whilst the provider had engaged in a substantial recruitment drive, there were still occasions where the full staffing complement was not fully available each day.
Judgment: Not compliant
Regulation 16: Training and staff development
Staff have access to appropriate training, including refresher training.
Judgment: Compliant
Regulation 22: Insurance
The provider had adequate insurance in place to meet the requirements of the Regulations.
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Regulation 23: Governance and management
There were effective management arrangements in place to ensure that the service provided was safe, appropriate to residents' needs, consistent and effectively
monitored.
Judgment: Compliant
Regulation 3: Statement of purpose
The statement of purpose accurately reflected the facilities and services provided in the centre and contained all the information required in schedule one of the
Regulations. It had been reviewed regularly in line with the time frame identified in the Regulations.
Judgment: Compliant
Regulation 34: Complaints procedure
The provider had provided an effective complaints procedure for residents which was in an accessible format and included an appeals procedure. Complaints were effectively managed and the satisfaction of complainants was noted.
Judgment: Compliant
Regulation 4: Written policies and procedures
The provider had all relevant policies and procedures as set out in schedule five of the Regulations.
Judgment: Compliant
Quality and safety
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practices and risk management systems. That being said, for the most part residents experienced a safe service.
Residents received a health assessment and were given appropriate support to meet their identified needs. However, the medication management system in place did not safeguard the health and wellbeing of some residents. For example, when some residents went into the community, staff did not bring their emergency medication, as they were not trained to administer medication. However, despite this lack of medication training, staff were asked to administer certain types of medication whilst in the community. Additionally, some PRN protocols did not provide sufficient detail to guide staff practice.
There was a risk management system in place. However, this system failed to
capture all known risks within the centre. This led to certain residents support needs not being adequately risk assessed. Where incidents that related to these support needs occurred, they were reviewed but the learning from these reviews did not inform practice at all levels.
Residents within the centre had a personal plan which detailed their needs and outlined the supports required to maximise their personal development and quality of life. However, it was unclear how the personal plan reviews were conducted in a manner that maximised the participation of residents, and where appropriate their representatives. Whilst the centre was accessible and promoted the privacy, dignity and welfare of residents, parts of it were not homely.
Residents were supported to develop and maintain relationships and links within the community in accordance with their wishes. This included residents maintaining positive contact and relationships with family. Additionally, residents were supported to engage in activities that were of interest to them.
Residents were proactively protected from abuse and residents stated they felt safe in the centre. Residents experienced care that supported positive behaviour and emotional wellbeing. Residents living within the centre were not subjected to restrictive procedures unless there was evidence that they had been assessed as being required.
Regulation 13: General welfare and development
The provider made appropriate arrangements to ensure that residents had
opportunities to participate in activities in accordance with their interests, capacities and developmental needs.
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Regulation 17: Premises
The design and layout of the premises promoted residents' safety, dignity, independence and wellbeing. The centre made adequate provisions to meet the requirements set out in schedule six of the regulations. However, some areas of the centre required additional attention as they were not homely or suitably decorated.
Judgment: Substantially compliant
Regulation 26: Risk management procedures
The provider did not ensure that all appropriate risks were identified and appropriately risk assessed.
Judgment: Not compliant
Regulation 28: Fire precautions
There were systems in place for the prevention and detection of fire and all staff have received suitable training in fire prevention and emergency procedures. Regular fire drills were held and accessible fire evacuation procedures were on display in the centre.
Judgment: Compliant
Regulation 29: Medicines and pharmaceutical services
The centres practices relating to the administration of certain medication, did not meet the requirements of the regulations. Furthermore, the guidance given in some PRN protocols did not sufficiently guide staff practice.
Judgment: Not compliant
Regulation 5: Individual assessment and personal plan
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personal, and social care needs of residents. Care plans were developed in line with residents' identified needs. There was evidence that the centre worked together with residents to identify their strengths, needs and goals.
There was evidence of some review and evaluation of personal plans. However, it was not clear how these reviews were conducted in a manner that maximises the participation of residents, and where appropriate their representatives.
Judgment: Substantially compliant
Regulation 6: Health care
The provider ensured residents health care needs were met in line with their personal plan.
Judgment: Compliant
Regulation 7: Positive behavioural support
There were appropriate positive behaviour supports implemented, which included the support of relevant allied health care professionals to support the assessed needs of residents.
Judgment: Compliant
Regulation 8: Protection
The provider is ensuring that each resident is assisted and supported to develop the knowledge, self-awareness, understanding and skills needed for self-care and
protection.
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Appendix 1 - Full list of regulations considered under each dimension
Regulation Title
Judgment
Capacity and capability
Regulation 14: Persons in charge Compliant
Regulation 15: Staffing Not compliant
Regulation 16: Training and staff development Compliant
Regulation 22: Insurance Compliant
Regulation 23: Governance and management Compliant Regulation 3: Statement of purpose Compliant Regulation 34: Complaints procedure Compliant Regulation 4: Written policies and procedures Compliant
Quality and safety
Regulation 13: General welfare and development Compliant
Regulation 17: Premises Substantially
compliant Regulation 26: Risk management procedures Not compliant
Regulation 28: Fire precautions Compliant
Regulation 29: Medicines and pharmaceutical services Not compliant Regulation 5: Individual assessment and personal plan Substantially
compliant
Regulation 6: Health care Compliant
Regulation 7: Positive behavioural support Compliant
Regulation 8: Protection Compliant
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Compliance Plan for Avalon OSV-0002433
Inspection ID: MON-0020986
Date of inspection: 05/03/2018
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 Not Compliant
Outline how you are going to come into compliance with Regulation 15: Staffing:
• There is ongoing recruitment of staff -1DSW is starting the week of 30/04/2018
• A total of 4 relief DSW in place to fill the vacancies
• Roster review will be completed the introduction of a new roster which will allow a greater flexibility of staff.
Time Frame:30/06/2018
Regulation 17: Premises Substantially Compliant
Outline how you are going to come into compliance with Regulation 17: Premises:
• Plans in place to redecorate the bath room to make them more homely for the residents.
Time Frame:20/05/2018
Regulation 26: Risk management
procedures Not Compliant
Outline how you are going to come into compliance with Regulation 26: Risk management procedures:
• Review risk assessment and ensure there is correlation between the risk assessment and restrictive practice which are quarterly notified.
Time Frame:31/05/2018 Regulation 29: Medicines and
pharmaceutical services Not Compliant
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• Some of the DSW will be commencing training on 01/05/2018 and will continue to train all DSW as soon as possible.
• Protocol for administration of Buccal to residents is now completed, signed by Psychiatrist. This will be communicated to DSW.
Time Frame:30/06/2018
Regulation 5: Individual assessment
and personal plan Substantially Compliant
Outline how you are going to come into compliance with Regulation 5: Individual assessment and personal plan:
This will be discussed in the house meeting that their keyworkers will be reviewing the Care plans with the residents. The key worker will support the keyworker will support the residents I n understanding and support the residents in signing his/her individualized and personal care plans
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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
17(1)(c) The registered provider shall ensure the premises of the designated centre are clean and suitably decorated.
Substantially
Compliant Yellow 20/05/2018
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 IF 31/05/2018
Regulation
29(4)(b) The person in charge shall ensure that the designated centre has appropriate and suitable practices relating to the ordering,
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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. Regulation
05(6)(b) 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 conducted in a manner that ensures the maximum participation of each resident, and where appropriate his or her
representative, in accordance with the resident’s wishes, age and the nature of his or her disability.
Substantially
