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Evergreen Services, OSV 0004464, 10 October 2018

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Report of an inspection of a

Designated Centre for Disabilities

(Adults)

Name of designated

centre:

Evergreen Services

Name of provider:

Brothers of Charity Services

Ireland

Address of centre:

Roscommon

Type of inspection:

Announced

Date of inspection:

10 October 2018

Centre ID:

OSV-0004464

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About the designated centre

The following information has been submitted by the registered provider and describes the service they provide.

Evergreen Services is a respite service which is run by Brothers of Charity Services, Ireland. The centre comprises of two premises which are located on the outskirts of Athlone, Co. Roscommon. The centre provides a respite service for up to five female and male adults, who present with an intellectual disability and who may have specific healthcare, mobility and behaviour support needs. The centre is open on selected days and weekends each month to meet the needs of the residents who avail of this service. Staff are on duty both day and night to support residents.

The following information outlines some additional data on this centre.

Current registration end

date:

18/04/2019

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

10 October 2018 09:00hrs to

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Views of people who use the service

On the day of this inspection, no residents were availing of this respite service. The inspector met with the person in charge and a member of staff who provided the inspector with information about the care and support that residents receive.

Staff spoke confidently about residents who have assessed communication needs and of how they interpret residents' wishes and use various communication tools to effectively communicate with these residents. Staff also spoke confidently about the care residents receive, who have specific health care and behaviour support needs.

Prior to this inspection, some residents and their representatives completed questionnaires for review by the inspector. Within these, they stated their

satisfaction with the service they receive in areas such as staff support, promotion of their rights, their living environment, celebrating occasions with their peers and in the variety of activities available to them.

Capacity and capability

The inspector found that the centre was resourced to ensure the effective delivery of care and support of residents. There was a clearly defined management structure in place which identified the lines of authority and accountability for all areas of service provision. The person in charge had the overall responsibility for the centre and she was supported by persons participating in management in the management of this service. She was found to have a good knowledge of residents' needs and of the centre's operational management systems. She had responsibility for other services run by this provider and told the inspector that the current governance and management arrangements in place supported her to fulfill her role as person in charge for this centre.

The number, qualifications and skill mix of staff working in the centre was

appropriate to the number and assessed needs of residents. Due to the changing needs of residents, the provider had put a waking night staffing arrangements in place to meet the needs of residents with specific neurological needs. Staff who met with the inspector were found to be knowledgeable of residents' needs and were regularly informed of changes occurring within the organisation. Staff had received up-to-date mandatory training and training arrangements ensured that staff

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finish times.

Six monthly provider-led visits and the annual review of the service were occurring in line with the requirements of the regulations. Where improvements were

identified, these were addressed by the provider. Regular staff and management team meetings were occurring, which gave staff an opportunity to raise concerns regarding the care and welfare of residents. The regular presence of the person in charge in the centre enabled her to have regular oversight of care practices and of the progress made towards achieving improvements required within the service.

Since the last inspection, improvements were made to the written agreements in place for residents, ensuring these now accurately described the services to be delivered to each resident. There was a statement of purpose in place; however, it required further review to ensure it detailed all information as required by Schedule 1 of the regulations.

Regulation 14: Persons in charge

The person in charge was found to meet the criteria as set out in regulation 14. She was responsible for one other centre operated by the provider and had the capacity to fulfill her role as person in charge for this centre. She was found to have good knowledge of the service and of the needs of the residents who use the service.

Judgment: Compliant

Regulation 15: Staffing

The provider had adequate staffing arrangements in place to meet the needs of residents. Planned and actual rosters were well-maintained and clearly identified the staff on duty in the centre.

Judgment: Compliant

Regulation 16: Training and staff development

The provider had ensured all staff received mandatory training and a system for refresher training was also in place. Staff received support and supervision from their line manager on a regular basis.

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Page 7 of 17 Judgment: Compliant

Regulation 23: Governance and management

The provider had systems in place to monitor and regularly review the care

delivered to residents. The annual review and six monthly provider-led visits were occurring in line with the requirements of the regulations.

Judgment: Compliant

Regulation 24: Admissions and contract for the provision of services

The provider had a written agreement in place with each resident which included details of the services that were to be provided for that resident and the fees to be charge.

Judgment: Compliant

Regulation 31: Notification of incidents

A sample of incidents occurring in the centre was reviewed by the inspector and it was found the person in charge had notified the Chief Inspector of all incidents as required by regulation 31.

Judgment: Compliant

Regulation 3: Statement of purpose

The provider had ensured that there was a statement of purpose in place and that it was regularly reviewed. However, some improvements were required to ensure it detailed all information as set out in Schedule 1 of the regulations, including:

- the specific care and support needs that the centre intended to meet

- organisational structure

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Page 8 of 17 Judgment: Substantially compliant

Quality and safety

Residents availing of this respite service experienced a good quality of life in areas such as social care, healthcare, safeguarding and behaviour support. However, some improvements were required to risk management, fire precautions and restrictive practice systems.

The registered provider had provided each resident with appropriate care and support in accordance with their wishes. Residents had access to transport and adequate staffing arrangements which enabled them to regularly access the community and to participate in activities of interest to them. Some residents availing of this service had assessed communication and healthcare needs and although staff spoke confidently with the inspector about how they support these residents, improvements were required to the documentation in place to guide staff on the care to be delivered to residents with specific neurological needs.

The person in charge had ensured that staff had up-to-date knowledge and skills appropriate to their role, to respond to behaviours that challenge and to support residents with identified behaviours. These residents received regular review and clear guidance was in place to guide staff on how to respond to specific behaviours. There were restrictive practices in place at the time of this inspection and although staff demonstrated a clear understanding of how each restrictive practice was to be applied, not all restrictions had an appropriate risk assessment in place.

The centre comprised of two premises which were located a short distance from each other. Both premises provided residents with their own bedrooms, some en-suite facilities, shared bathrooms, dining and kitchen areas, utility spaces and sitting rooms. Both premises had access to garden spaces, with one premises providing ramped access to meet the mobility needs of residents who avail of respite in that house. During the last inspection, it was identified that the layout and design of a bathroom space did not meet the mobility needs of residents. In response to this, the provider gave a time-bound plan to the Chief Inspector to complete the required renovation works. These works were not completed in line with this date; however, written assurances were provided to the inspector upon this inspection

which demonstrated that renovation works were commencing the week subsequent to this inspection.

Since the last inspection, the provider had improved the fire containment and fire detection systems within this centre. Regular fire drills were occurring,

which demonstrated that staff could effectively evacuate all residents from the centre in a timely manner. Internal emergency lighting was available in

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residents in the event of a fire in the centre. Although displayed fire procedures provided clear guidance on how staff were to respond to fire in the centre, some procedures required further review to ensure they guided on the specific evacuation arrangements for residents residing in upstairs accommodation. Furthermore, some improvements were required to residents' evacuation plans to ensure they guided staff on the specific support required by each resident in the event of an evacuation.

The person in charge demonstrated a good knowledge of the centre's risk management systems and regularly reviewed the effectiveness of the controls

measures in place to mitigate against specific risks. However, the inspector observed some improvements were required to the risk assessments in place to assess

residents' manual handling needs and to the assessment of risks associated with the current layout and design of the premises.

Regulation 10: Communication

Where residents had assessed communication needs, staff were knowledgeable in how these residents expressed their wishes. Clear guidance was in place to guide staff on how to communicate with these residents and residents were supported to use assistive technology, as they wished. Residents had access to internet, television and radio in the centre.

Judgment: Compliant

Regulation 13: General welfare and development

Residents had opportunities to participate in activities in accordance with their interests, capacities and developmental needs.

Judgment: Compliant

Regulation 17: Premises

The centre was found to be clean, comfortable and in a good state of repair. Subsequent to the inspection, the provider had plans in place to increase the foot print of a bathroom area to meet the manual handling needs of residents who availed of this service.

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Regulation 28: Fire precautions

The provider had made improvements to the fire detection and fire containment arrangements in this centre. Fire drills were regularly occurring and staff were aware of their role in supporting residents in the event of an evacuation. However, some improvements were required to:

- fire procedures did not include the evacuation arrangements for residents residing in upstairs accommodation

- residents' personal evacuation plans did not clearly guide on the support residents would require to effectively evacuate the centre

Judgment: Substantially compliant

Regulation 8: Protection

There were no safeguarding plans in place at the time of this centre. The provider had systems in place to ensure staff were supported to identify and report any safeguarding concerns they had about the care and welfare of residents. All staff had received up-to-date training in safeguarding.

Judgment: Compliant

Regulation 26: Risk management procedures

The provider had systems in place to identify, assess, monitor and review risks in this centre. However, some improvements were required to:

- the risk assessment of residents with manual handling needs

- not all organisational risks had an appropriate risk assessment in place

Judgment: Substantially compliant

Regulation 6: Health care

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were knowledgeable of the support they were required to give these residents. Residents also had access to a variety of healthcare professionals, as

required. However, improvements were required to the documentation in place to support the needs of residents with specific neurological healthcare needs.

Judgment: Substantially compliant

Regulation 7: Positive behavioural support

Where residents presented with behaviours that challenge, systems were in place to ensure these residents received regular review and clear documentation was in place to guide staff on how to support these residents. There were some restrictive practices in place at the time of this inspection and although staff demonstrated strong knowledge on how these restrictions were to be applied in practice, not all restrictive practices had an appropriate risk assessment in place

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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 Compliant

Regulation 16: Training and staff development Compliant Regulation 23: Governance and management Compliant Regulation 24: Admissions and contract for the provision of

services Compliant

Regulation 31: Notification of incidents Compliant Regulation 3: Statement of purpose Substantially

compliant

Quality and safety

Regulation 10: Communication Compliant

Regulation 13: General welfare and development Compliant

Regulation 17: Premises Compliant

Regulation 28: Fire precautions Substantially compliant

Regulation 8: Protection Compliant

Regulation 26: Risk management procedures Substantially compliant

Regulation 6: Health care Substantially

compliant Regulation 7: Positive behavioural support Substantially

compliant

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Compliance Plan for Evergreen Services

OSV-0004464

Inspection ID: MON-0021884

Date of inspection: 09/10/2018

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 3: Statement of purpose Substantially Compliant

Outline how you are going to come into compliance with Regulation 3: Statement of purpose:

The Statement of Purpose has been reviewed and updated to ensure that it clearly describes all the information as required by Schedule 1 of the regulations. Clarity has been provided to the following information as required:

- the care and support needs that the designated centre intends to meet

-organsiation structure

-arrangements for day support

Regulation 28: Fire precautions Substantially Compliant

Outline how you are going to come into compliance with Regulation 28: Fire precautions:

Fire procedures have been updated to include clear evacuation arrangements for people supported residing upstairs in the service.

Individual emergency plans have been amended to reflect the individual support needs of people supported to effectively evacuate the centre.

Regulation 26: Risk management

procedures Substantially Compliant

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Risk management procedures will be reviewed and improvements made in order to fully comply with Regulation 26.

Specific areas that will be addressed:

-risk assessments of people supported with manual handling needs

-risk assessments for relevant organisational risk

This organisational risk has been removed as of the 19/10/18 as the necessary renovation work on the premises has been carried out.

Regulation 6: Health care Substantially Compliant

Outline how you are going to come into compliance with Regulation 6: Health care:

Health care documentation is currently being reviewed and updated in order to meet the needs of people being supported by the service specifically neurological healthcare needs.

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 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.

Substantially

Compliant Yellow

15/11/18

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

15/11/2018

Regulation 28(5) The person in charge shall ensure that the procedures to be followed in the event of fire are

Substantially

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displayed in a prominent place and/or are readily available as appropriate in the designated centre. Regulation 03(1) The registered

provider shall prepare in writing a statement of purpose containing the information set out in Schedule 1.

Substantially

Compliant Yellow

30/10/2018

Regulation 06(1) The registered provider shall provide

appropriate health care for each resident, having regard to that resident’s personal plan.

Substantially

Compliant Yellow

15/11/2018

Regulation 07(4) The registered provider shall ensure that, where restrictive

procedures

including physical, chemical or

environmental restraint are used, such procedures are applied in accordance with national policy and evidence based practice.

Substantially

Compliant Yellow

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