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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Bower House
Name of provider:
Dundas Ltd
Address of centre:
Co. Dublin
Type of inspection:
Unannounced
Date of inspection:
01 and 02 August 2018
Centre ID:
OSV-0005608
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
Bower House is a community based respite service for up to six adults both male and female with an intellectual disability. It is situated on the north side of Co. Dublin within walking distance of a local village and its' amenities such as shops, cafes, restaurants, and a shopping centre. The centre is close to public transport links including a bus and train service which enable residents to access local amenities and neighbouring areas. The building is a large two-storey, six bedroomed house with a sea view. There are three shared bathrooms, two with a bath and shower. The kitchen is a domestic kitchen and residents are encouraged to partake in grocery shopping and the preparation of meals and snacks. There is one dining room, one living room and two sitting rooms in the house. The property is surrounded by a large garden. Staff encourage residents to partake in activities in the local
community. The staff team comprises a person in charge, staff nurses and direct support workers and a household staff. Staffing resources are arranged in the centre in line with residents’ needs.
The following information outlines some additional data on this centre.
Current registration end
date:
10/09/2020
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
01 August 2018 09:00hrs to
16:40hrs Marie Byrne Lead 02 August 2018 09:00hrs to
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Views of people who use the service
The inspector had the opportunity to meet and spent some time with six residents who were availing of a respite break during the inspection. The inspector observed parts of residents’ daily lives such as mealtimes, activities, and relaxation time.
Throughout the inspection residents appeared relaxed and comfortable with the support offered by staff. Residents who spoke with the inspector described how they liked to spend their day and how they were supported to engage in activities of their choosing. They were very complimentary towards the care and support in the centre and described how staff supported them in line with their needs and wishes. All residents who spoke with the inspector stated that they liked to spend time in the centre and how they particularly liked where the centre was situated. They
described their respite break as a holiday. The inspector spoke with one residents' family member who was overall complimentary towards the care and support their relative received in the centre.
Capacity and capability
Overall, the inspector found that the registered provider and person in charge were ensuring a good quality and safe service for residents in the centre. However, the inspector found that improvement was required in relation to the day-to-day monitoring of care and support in the centre particularly relating to residents' assessment of need and documentation relating to their care and support needs. Improvement was also required in relation to risk assessment and management in the centre.
The inspector found that there were clearly defined management structures in place which identified the lines of authority and accountability in the centre. The staff team reported to the person in charge who in turn reported to the registered provider representative. There was evidence that they were meeting regularly and utilising monthly governance reports to review of care and support in the centre. However, these meetings were not recognising the need for improvements in relation to risk management and personal plans in the centre. Staff meetings were held regularly in the centre and the inspector found from reviewing the minutes of these meetings that that agenda items and discussions were resident focused.
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organisations' compliance officer. In relation to the audits which had been
completed there were action plans developed from theses audits with timeframes for completion of these actions. As these audits were in their infancy they were yet to have an impact on residents' lived experiences in the centre. Plans were in place for an annual review and six monthly visits by the provider or their representative.
The inspector found that residents in the centre appeared happy, relaxed and content. The inspector spoke with six staff members during the inspection and found that they were all knowledgeable in relation to residents’ specific care and support needs. Residents were observed to be very comfortable with the care and support they were offered from staff in the centre and staff members were observed by the inspector to be caring and respectful in all interactions with residents. There were sufficient numbers of staff to meet residents' assessed needs. There were planned and actual rosters in the centre. However, the inspector found that rosters did not reflect the actual number of staff on duty in the centre on a number of occasions.
There was evidence that staff in the centre had access to training and refreshers in line with residents' assessed needs. They were in receipt of regular formal
supervision to support them to effectively carry out their duties.
A directory of residents was available and regularly updated in the centre. There was a residents' guide in place which included all the information required by the regulations including a summary of the services and facilities available for residents in the centre. There was an admissions and discharges policy and procedures in place and residents had a contract of care in place which outlined the services provided for residents and what they should supply for their respite break.
There were policies and procedures in place for the management of complaints which were on display and available in an accessible format. There was a
nominated complaints officer and systems in place to investigate and respond to complaints. The inspector reviewed a number of complaints in the centre and there was evidence that they were fully investigated and that the complainants
satisfaction levels were recorded. Residents who spoke with the inspector were aware of the complaints process and stated they would feel comfortable utilising the process if they needed to.
Regulation 15: Staffing
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Judgment: Substantially compliant
Regulation 16: Training and staff development
Staff had the required competencies to deliver safe care and support for residents in the centre. They had access to training and refreshers in line with residents' needs and were in receipt of formal supervision to support them to carry out their roles to the best of their ability.
Judgment: Compliant
Regulation 19: Directory of residents
A directory of residents was developed and maintained in the centre.
Judgment: Compliant
Regulation 23: Governance and management
The centre had been operational four months at the time of the inspection and some systems were in their infancy. There were clear lines of authority and accountability and staff had specific roles and responsibilities in the
centre. Improvement was required in relation to the day-to-day monitoring of care and support in the centre particularly relating to risk management and residents' assessment of need and personal plans. There were plans in place for annual review of care and support in the centre and six monthly visits by the provider.
Judgment: Substantially compliant
Regulation 24: Admissions and contract for the provision of services
Residents' admissions and discharges were found to be in line with the centres' policies and the statement of purpose. Each resident had a contract of care in place which contained all the information required by the regulations.
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Regulation 3: Statement of purpose
The statement of purpose contained all the information required by schedule 1 of the regulations and had been reviewed in line with the timeframe identified in the regulations.
Judgment: Compliant
Regulation 34: Complaints procedure
There were complaints policies and procedures including a user friendly complaints process in the centre. There was a local complaints officer and residents and staff who spoke with the inspector could describe the complaints process.
Judgment: Compliant
Quality and safety
Overall, the inspector found that the quality of the service provided to residents of this centre was good. Each resident was observed to be supported in a person-centred manner in keeping with their wishes. Areas for improvement were identified in relation to risk assessment and management, residents' assessment of need and personal plans, review and update of residents' personal emergency evacuation plans and guidance in relation to positive behaviour support in the centre.
The inspector found that the premises was clean, well maintained and homely. There was adequate private and communal space for residents including private space available to meet visitors in private if residents so wished. Residents who spoke with the inspector stated that they loved how much space was in the house and how it was situated so close to a town and the sea.
The inspector found that residents' assessment of need and personal plans were in development in the centre. Personal plans which were in place were found to be person-centred and residents had access to a keyworker. However, some residents' personal plans were not fully completed and did not contain sufficient detail to guide staff to support residents. The inspector found that plans of care were not in place in line with some residents' assessed needs.
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clearly guided staff to support them, there were also a number of residents who required support to manage their behaviour who did not have appropriate assessments or plans in place. Staff who spoke with the inspector were knowledgeable in relation to residents’ behaviour support needs. There was evidence that restrictive practices in the centre were regularly reviewed to ensure they were the least restrictive measures for the least amount of time.
There were suitable arrangements in place to detect, contain and extinguish fires in the centre. There was evidence that equipment was maintained and regularly serviced in line with the requirement of the regulations. Each resident had a
personal emergency evacuation procedure in place. However, a number of residents' personal emergency evacuation procedures had not been updated in line with issues identified and learning from fire drills in the centre.
There were policies, procedures and practices in place relating to health and safety and risk management in the centre. There was a system in place for keeping
residents safe while responding to emergencies. There were also systems in place to identify, record, investigate and learn from adverse events incidents in the centre. There was a risk register in place and general risk assessments with appropriate control measures. However, the inspector found that a number of residents did not have risk assessments in place in line with their assessed needs.
There were effective measures in place to safeguard residents. Staff had completed safeguarding training and were found to be knowledgeable in relation to
what constituted abuse and the steps to take if there was an allegation of abuse. In response to a recent safeguarding concern in the centre there was evidence that the provider had put appropriate measures in place to protect residents in the centre.
Regulation 17: Premises
The inspector found that the design and layout of the centre was in line with the statement of purpose. There was adequate private and communal space for residents. The environment was clean and kept in good structural and decorative repair. There was adequate space and suitable storage facilities for residents' personal use.
Judgment: Compliant
Regulation 26: Risk management procedures
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line with their assessed needs.
Judgment: Substantially compliant
Regulation 28: Fire precautions
There were suitable arrangements in place to detect, contain and extinguish fires in the centre. There was documentary evidence of servicing of equipment in line with the requirements of the regulations. Staff had appropriate training and fire drills were held regularly in the centre. Residents had personal emergency evacuation plans in place. However, a number of residents' personal emergency evacuation plans had not been updated in line with issued identified during fire drills.
Judgment: Substantially compliant
Regulation 5: Individual assessment and personal plan
Personal plans were in development in the centre. The ones that were fully completed were found to be person-centred and each resident had access to a keyworker to support them to develop their goals. However, some were not fully completed and required further detail to guide staff practice to support residents with their care and support needs.
Judgment: Substantially compliant
Regulation 7: Positive behavioural support
Some residents who required them had positive behaviour support plans in place. Staff who spoke with the inspector were knowledgeable in relation to the
implementation of positive behaviour support plans. However, a number of residents who required support to manage their behaviour did not have appropriate
assessments in place or plans in place to guide staff to support residents. There were restrictive practices in place in the centre and evidence that they were reviewed regularly to ensure they were the least restrictive measures for the least amount of time.
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Regulation 8: Protection
Residents in the centre were protected by safeguarding polices, procedures and practices in the centre. A previous safeguarding issue was being
managed appropriately in the centre. Staff who spoke with
the inspector were knowledgeable in relation to keeping residents safe from all forms of abuse and had a clear understanding of their role in adult protection.
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Appendix 1 - Full list of regulations considered under each dimension
Regulation Title
Judgment
Capacity and capability
Regulation 15: Staffing Substantially
compliant Regulation 16: Training and staff development Compliant Regulation 19: Directory of residents 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 34: Complaints procedure Compliant
Quality and safety
Regulation 17: Premises Compliant
Regulation 26: Risk management procedures Substantially compliant Regulation 28: Fire precautions Substantially
compliant Regulation 5: Individual assessment and personal plan Substantially
compliant Regulation 7: Positive behavioural support Substantially
compliant
Regulation 8: Protection Compliant
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Compliance Plan for Bower House OSV-0005608
Inspection ID: MON-0024224
Date of inspection: 01 & 02/08/2018
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:
Roster is now typed and clear to the viewer that all staff hours are accurately accounted for, thus ensuring that the appropriate staffing are on duty at all times.
Regulation 23: Governance and
management Substantially Compliant
Outline how you are going to come into compliance with Regulation 23: Governance and management:
Process put in place for manager to meet with keyworkers on a fortnightly basis to
review processes and ensure that all documentation is up to date with regard to personal plans and risk assessments.
Regulation 26: Risk management
procedures Substantially Compliant
Outline how you are going to come into compliance with Regulation 26: Risk management procedures:
All resident’s files have been reviewed and appropriate risk assessments devised or updated. On admission all risk assessments must be completed.
Regulation 28: Fire precautions Substantially Compliant
Outline how you are going to come into compliance with Regulation 28: Fire precautions: Where there is any issue with a service user evacuation during a fire drill, a risk
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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:
A review of all current service users’ plans will be conducted, and amendments made as necessary. For all new admissions, the personal support plan will be reviewed with the family to ensure there are no gaps in the documentation.
Regulation 7: Positive behavioural
support Substantially Compliant
Outline how you are going to come into compliance with Regulation 7: Positive behavioural support:
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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(4) The person in charge shall ensure that there is a planned and actual staff rota, showing staff on duty during the day and night and that it is properly maintained.
Substantially
Compliant Yellow 31
st August
2018
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 27
th August
2018
Regulation 26(2) The registered provider shall ensure that there are systems in place in the designated centre for the
Substantially
Compliant Yellow 27
th August
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assessment, management and ongoing review of risk, including a system for responding to emergencies. 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 to safe locations.
Substantially
Compliant Yellow 2
nd September
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 30
th September
2018
Regulation 07(1) The person in charge shall ensure that staff have up to date knowledge and skills, appropriate to their role, to respond to behaviour that is challenging and to support residents to manage their behaviour.
Substantially
Compliant Yellow 30
th September