Teach Geal, OSV 0003261, 26 September 2018

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Report of an inspection of a

Designated Centre for Disabilities

(Adults)

Name of designated

centre:

Teach Geal

Name of provider:

St Hilda's Services Limited

Address of centre:

Westmeath

Type of inspection:

Unannounced

Date of inspection:

26 September 2018

Centre ID:

OSV-0003261

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About the designated centre

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

Teach Geal offers residential services to adults whose primary disability is an intellectual disability. Teach Geal caters for those with an intellectual disability who have a level of independence such that waking night cover is not required. The service can accommodate those with a range of medical and physical issues, however residents should be able to regularly attend day services outside of the house, except in the case of short - term illness when arrangements can be made to either recuperate in Teach Geal or go home to their families if residents wished. Needs are managed and accommodated by staff who have training in medication management, intimate care, first aid, manual handling, fire training, epilepsy

awareness, clamping and management of behaviours that challenge. The service has fixed closures totaling 27 days in the calendar year. Teach Geal consists of two semi detached houses that can accommodate five residents. There are four double

bedrooms and one single bedroom across the two houses. There is transport

provided to travel to and from day services and taxies are availed of outside of these times which are paid by the resident.

The following information outlines some additional data on this centre.

Number of residents on the

date of inspection:

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How we inspect

To prepare for this inspection the inspector or inspectors reviewed all information about this centre. This included any previous inspection findings, registration information, information submitted by the provider or person in charge and other unsolicited information since the last inspection.

As part of our inspection, where possible, we:

 speak with residents and the people who visit them to find out their experience of the service,

 talk with staff and management to find out how they plan, deliver and monitor the care and support services that are provided to people who live in the centre,

 observe practice and daily life to see if it reflects what people tell us,

 review documents to see if appropriate records are kept and that they reflect practice and what people tell us.

In order to summarise our inspection findings and to describe how well a service is doing, we group and report on the regulations under two dimensions of:

1. Capacity and capability of the service:

This section describes the leadership and management of the centre and how effective it is in ensuring that a good quality and safe service is being provided. It outlines how people who work in the centre are recruited and trained and whether there are appropriate systems and processes in place to underpin the safe delivery and oversight of the service.

2. Quality and safety of the service:

This section describes the care and support people receive and if it was of a good quality and ensured people were safe. It includes information about the care and supports available for people and the environment in which they live.

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This inspection was carried out during the following times:

Date

Times of

Inspection

Inspector

Role

26 September 2018 09:00hrs to

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Views of people who use the service

The inspector met with four of the five residents on the day of the inspection and observed elements of their daily lives. One of the residents spoke with the inspector several times throughout the day and the inspector met with the other three

residents when they returned from their day services. Furthermore, views of the residents were relayed through observations of the inspector, staff advocating on residents' behalf, the designated centres annual review and various other records that captured the view and opinions of the residents such as the complaints log, incident log and daily records.

The residents communicated both verbally and non verbally, the inspector

observed staff assisting residents to communicate their needs. Staff were able to interpret resident's signals, needs and preferences. Residents were observed to be comfortable in the presence of staff members on duty during the inspection, who were seen to treat residents in a caring and respectful manner. One resident spoke about their daily activities and how they were supported by staff to make choices in their daily live, and another resident showed the inspector photos of activities and trips that had taken place.

Some residents had complained about different aspects of service provision that were not adequately addressed. Some incidences had occurred in the centre where residents where recorded as being been upset over the behaviours of other

residents, safeguarding plans not been implemented to protect all residents.

Capacity and capability

Prior to the inspection the provider had notified HIQA that there was a change in the person in charge. Due to the broad remit and governance responsibilities of

the proposed person in charge an assurance report was issued to the

provider seeking assurances that the arrangements in place were appropriate to ensure effective oversight of the designated centre. One of the aims of this

unannounced monitoring inspection was to confirm that the arrangements in place were appropriate in meeting the needs of the residents. On inspection the inspector found the provider did not have adequate governance and management systems in place and significant improvements were required. The registered provider failed to demonstrate how they were ensuring that a quality and safe service was delivered. There was a lack of sufficient monitoring and auditing in place to assess progress and identify areas for improvement as evident by the level of non-compliance's found during this inspection. Actions from the previous inspection were not satisfactorily addressed; ten of the nineteen actions were reissued during this inspection.

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effectiveness. For example a health & safety audited conducted in March 2018 did not identify risks present in the centre as discussed under Quality and Safety. The last annual infection control audit was carried out in June 2017 and the last

quarterly personal plan audit was found to be completed in April 2015. The last unannounced visit by the provider was carried out in November 2017, this

had identified a concern raised by a family member but did not identify actions to address this concern. This was later brought up again in a personal care plan meeting with the family in April 2018, it was unclear whether this issue had been addressed effectively or not. An annual review of the quality and safety of the service by the provider was carried out in December 2017, it required improvement as it did not provide details on the number of incidences, notifiable events

or restrictive practices that occurred in the centre and instead provided narrative detail of what each of these were it also did not identify who had completed the report.

The person in charge, although possessed extensive experience and the relevant qualifications, their duel role of residential services manager and person in charge did not allow them to have the capacity to fulfill their legal requirements and responsibilities of the person in charge, which had an adverse affect on the day to day operation of the centre. Upon inspection another person was introduced to the inspector as the person in charge who had recently been recruited into the role, there was some confusion over when this role had commenced and it

had not notified to HIQA as required; therefore the residential service

manager remained as person in charge for the purposes of this inspection.

The inspector found significant deficits in both mandatory training and

the training requirements being delivered to staff to meet the assessed needs of the residents. 60% of staff had lapsed training in the safe administration of medication, one staff member had not received training in this area and one staff member had lapsed training in the safeguarding of vulnerable adults. Hoists and slings were used routinely every day however training was identified as lapsed for all staff and one staff had never received this training, additionally training in clamping, people moving and handling were significantly out of date. The inspector found that there was no oversight of the training requirements in this service or plans devised to address the deficits. The training requirements were listed in the centres statement of purpose in order to accommodate those with a range of medical and physical requirements. This was brought to the immediate attention of management during the inspection and the Person In Charge at feedback.

Whilst the person in charge had a planned and actual roster in the centre it did not identify what relief staff were being used; the inspector could not confirm the training statues of the relief staff. Additionally there was a number of

shifts identified by the inspector that did not facilitate the assessed needs of

residents. For instance, there was an requirement for a two to one ratio until 11pm, this was not consistently implemented as the inspector found a number of shifts that ended at 9pm and 10pm. This was brought to the immediate attention of the person in charge. Improvements were required in the monitoring and supervision of staff to ensure that they were being effectively supervised relevant to their roles and

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line with best practice environment to discuss individual staff in a group setting to foster effective supervision practices, no other form of supervision had occurred.

From a review of the complaints log it was evident that staff were not clear on whether some verbal reports were behaviours that challenge, complaints or safeguarding issues. As a result of this ambiguity, incidents of peer to peer incidents were recorded in the complaints log and the safeguarding processes and procedures were not followed as per the organisations own and national policies, these incidents were also not notified as required by the regulations. It was found that three

complaints had been made by a resident in relation to the provision of intimate care and staffing arrangements, these were not adequately responded to,

recorded or a formal support plan put in place to prevent future incidences. One staff member who later raised deficits in this residents care to the provider as identified in a phone log in April 2018, requested that a plan to address this was implemented, no formal plan had been put in place and the staffing arrangements to address the gaps in care were unclear.

Contracts of care were reviewed by the inspector, it had stated that aids and equipment deemed necessary would be provided. In discussion with staff it was identified that a resident required a profile bed and the current bed was too heavy for staff to move easily, when asked who would be purchasing this bed it was identified that the resident would be paying for the bed but this was not referred to in the contract of care. No inventories of personal possessions were maintained in the centre to identify what items had been purchased by the resident.

Regulation 14: Persons in charge

The person in charge did not have the capacity to fulfill their roles and responsibilities of the person in charge.

Judgment: Not compliant

Regulation 19: Directory of residents

A directory of residents was maintained with the required information as listed in Schedule 3

Judgment: Compliant

Regulation 24: Admissions and contract for the provision of services

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the contract of care. Fixed closures were also not detailed.

Regulation 31: Notification of incidents

The person in charge did notify incidences of peer to peer incidences as required by regulations. On review of the quarterly notifications submitted, the person in charge did not notify incidence's of injuries not required to be notified by three working days.

Regulation 34: Complaints procedure

The registered provider did not ensure that all complaints were appropriately

managed. There was evidence that complaints had not been investigated, recorded or resolved in line with the organisation's complaints policy, or the requirement of the regulations.

Regulation 4: Written policies and procedures

All Schedule 5 written policies and procedures are in place and reviewed within the time frame set out by the Chief Inspector. Written policies and procedures were accessible to staff.

Judgment: Compliant

Regulation 15: Staffing

Relief staff that were used in the designated centre were not identified on the centres roster. The requirement for a two to one support in the evening until 11pm was not consistently implemented.

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Regulation 16: Training and staff development

There was significant gaps in the training requirements for staff and oversight of the training needs by management for both mandatory training and training specific to residents assessed needs.

Regulation 23: Governance and management

The governance and management arrangements did not ensure that residents' needs were being adequately met. The management systems in place did not identify some of the failings as evidenced by inspectors during this inspection. For example, the provider's monitoring systems had not identified that incidents of peer to peer allegations of abuse were not submitted to the Authority, personal

emergency evacuation plans were not reflective of residents assessed needs and complaints were not adequately addressed.

Regulation 3: Statement of purpose

The statement of purpose did not accurately reflect the registered bed numbers, the person in charge and their full time equivalent

Quality and safety

The inspector reviewed the quality and safety of the service provided to the residents and found that there was poor oversight and response in key areas of service provision to support residents on an individual basis in line with their

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and in receipt of a safe and quality driven service.

From a review of documentation and discussions held with management relating to residents including assessment of needs and personal plans, it was found that there were gaps in knowledge and documentation was incomplete and not reflective of the needs of the residents. The person in charge had not assured that an annual review of the health, personal and social care needs of each resident had been carried out, it was unclear when this review had last taken place, the inspector was not satisfied that the appropriate arrangements were put in place to meet the assessed needs of the residents. For example intimate care plans and support plans did not provide sufficient information to promote consistent and safe care.

One intimate care plan simply stated that full assistance was required; it did not identify that hoists, slings and equipment were to be utilised. It also stated that one staff member was required for assistance which conflicted with a physiotherapy report that specified that two staff members were required, the staffing

arrangements and roster did not fully promote the supports required to assist the resident in self-care.

It was evident that the provider had failed to implement a comprehensive system to assist residents achieve optimum health and development. Within the centres' statement of purpose and contract of care the provider noted that the onus of facilitating healthcare appointments lay with the families of the residents. This was deemed a contravention of the regulations and presented as a high risk in the designated centre as the provider had not implemented a robust system to ensure that the healthcare needs of the residents were being continually reviewed and essential appointments were being attended. It was unknown to management when the last health appointments and allied health professional appointments had taken place or where next due. One resident had seen a GP in June 2017 due to an allergic reaction, it was unknown what this allergy was, or what if any

investigations taken place. From a review of blood tests appointments, it was found that some appointments attended were not followed up for results. Abnormal results received had not been reviewed or managed and a recommendation for a specific blood test in 2013 was not completed. One resident was identified as having feeding, eating and drinking difficulties it was not known if a swallow assessment was carried out and there was no corresponding support plan to guide staff. A dental appointment from August 2017 recommended that repeat visits occur every two months; the last appointment recorded was September of the same

year. Physiotherapy exercises were in place for one resident dated 2013 but there was no evidence that these were occurring or if the resident had been reassessed when new equipment and aids were purchased. A pain assessment dated 2013 had not been filled completed.

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process.

On review of the complaints log and incident log it was identified that a number of peer to peer incidents that occurred that were not recognised as a safeguarding concern or appropriately managed as per the organisations own policy and the national policy. There were no safeguarding plans or positive behavioural support plans in place to effectively manage any potential behaviours that concern or guide staff. In one incident witnessed by a staff member involving two residents that where not meant to be the same house together due to previous altercations; the staff reported that they ''waited behind a door to see what would happen'' before one resident grabbed another resident by the hand and twisted it before staff had to physically intervene. This incident was rated as a low risk by the person

in charge with a negligible impact or occurrence risk even though this had occurred previously.

The inspector found conflicting documentation on the fire evacuation process and there were gaps in knowledge regarding this information by the management team. For example there was a rescue mat was in place for one resident but it could not be explained how this would be utilised with one staff working by themselves, and no training had been provided for the use of the mat. A stimulated night time drill had not been carried out and due to the complex needs of the resident's, the number of staff on at night time and the inaccessibility of the lift during a

fire, the inspector was not assured that appropriate measures had been put in place to mitigate against these risks. The Personal Emergency Evacuation Plans

(PEEPS) contained inaccurate information that did not provide guidance to staff in the event of a fire. In one fire drill it was recorded that the fire brigade could have difficulty accessing the house, no details were available to the inspector to ensure that the fire brigade could have access in the incidence of a fire. The

inspector issued the Provider with an immediate action to provide evidence on the effectiveness of the fire evacuation process. The provider was able to respond to this action and an excavation process and fire safety report was submitted to

the inspector that evidenced the involvement of the local fire service. Improvements were still required in the designated centre as the fire report submitted dated 2010, raised issues that were outstanding in the centre. It noted that the evacuation process required immediate attention with PEEPS implemented for all residents to ensure that the duty of care to the residents is discharged fully. The PEEPS viewed by the inspector did not contain this information. It also highlighted the importance of fire safety training for staff, three staff were found not to have fire training even though this was regarded a critical training due to the complex fire arrangements in place.

There was a risk management policy in place to address the risks present to

residents, visitors and staff.The policy advised that these risks were to be recorded on the organisational risks register; however, the risks in the centre were not recorded on the risk register, safeguarding concerns, risks of behaviours that challenge and lone workers. It had not identify the deficit in staff training and outstanding fire actions. Residents individual risks were assessed on a risk

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utilised in in the centre to manage these risks. For example, in the management of the risks associated with behaviours that challenge, intimate care, choking risks, safeguarding risks from peers and restrictive practices.

Whilst the provider had provided guidance for the emergency plan for a closure of a centre and fire it did not details the measures and actions for other adverse events such as flooding, power outage, loss of water etc. The emergency plan stated that if the centre could not reopen arrangements would be made with families for residents to remain at home. This did not identify that the designated centre was the home of the resident or consolation with families regarding their capacity to facilitate

these arrangements and what alternative procedures would be enacted if these arrangements could not be made.

Regulation 12: Personal possessions

There was no process in place to ensure that personal possessions purchased by the resident retained in their control.

Regulation 26: Risk management procedures

A risk management policy is in place but not all risks in the centre had been identified, risk rated or control measures implemented.

Regulation 28: Fire precautions

Personal emergency Evacuation Plans did not contain the relevant details for

evacuating residents, stimulated night drills had not occurred to ensure the effective evacuation and there was gaps in fire safety training and knowledge within the centre.

Regulation 9: Residents' rights

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views sought regarding fixed closures of the organisation and emergency planning procedure.

Regulation 5: Individual assessment and personal plan

A comprehensive assessment of the health, personal and social care and support needs of each resident had not been carried out.

Regulation 6: Health care

There was evidence that medical treatment was recommended but not facilitated and some healthcare needs were not met.

Regulation 8: Protection

National policy and statutory requirements were not followed when there had been incidents of peer to peer abuse.

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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 Not compliant Regulation 19: Directory of residents Compliant Regulation 24: Admissions and contract for the provision of

services Not compliant

Regulation 31: Notification of incidents Not compliant Regulation 34: Complaints procedure Not compliant Regulation 4: Written policies and procedures Compliant

Regulation 15: Staffing Not compliant

Regulation 16: Training and staff development Not compliant Regulation 23: Governance and management Not compliant Regulation 3: Statement of purpose Not compliant

Quality and safety

Regulation 12: Personal possessions Not compliant Regulation 26: Risk management procedures Not compliant Regulation 28: Fire precautions Not compliant Regulation 9: Residents' rights Not compliant Regulation 5: Individual assessment and personal plan Not compliant

Regulation 6: Health care Not compliant

Regulation 8: Protection Not compliant

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Compliance Plan for Teach Geal OSV-0003261

Inspection ID: MON-0021750

Date of inspection: 26/09/2018

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 14: Persons in charge Not Compliant

Outline how you are going to come into compliance with Regulation 14: Persons in charge:

A New Person in Charge was been appointed 1/8/18. Documentation posted 27/9/18 – returned in correctly signed, resent 18/10/2018 – returned pending confirmation letter re authorize signature resent 25/10/2018

Regulation 24: Admissions and

contract for the provision of services Not Compliant

Outline how you are going to come into compliance with Regulation 24: Admissions and contract for the provision of services:

The Contract of Care will be revised in Compliance with Regulation 24 to include the following:

• When residents wish to purchase additional aids, equipment or enhanced aids or

equipment thy may do so form their own funds. The inventory of personal possessions is in place for each resident. Completed 6/11/18

Regulation 31: Notification of incidents Not Compliant

Outline how you are going to come into compliance with Regulation 31: Notification of incidents:

The incident was reported retrospectively under Regulation 31(1)(f) on 26/08/18. A review of the prior quarter (3rd quarter) incidents will be completed and where necessary a written report provided, this will be completed by 16/11/18

Regulation 34: Complaints procedure Not Compliant

Outline how you are going to come into compliance with Regulation 34: Complaints procedure:

The provider will ensure the complaints procedure will be reviewed with PIC and monthly returns to nominated officer made to ensure compliance by 9/11/18.

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guidance re complaints, safeguarding, and behaviours that challenge for PIC and staff to ensuire procedures are clear relating to definitions, notifiables and follow up plans

30/11/18.

Regulation 15: Staffing Not Compliant

Outline how you are going to come into compliance with Regulation 15: Staffing:

The rostered hours for the centre has been reviewed by the PIC and Residential Manager and rosters have been implemented to 11pm effective November Roster.

Regulation 16: Training and staff

development Not Compliant

Outline how you are going to come into compliance with Regulation 16: Training and staff development:

A training plan has been put in place, all training updates are scheduled for completion by December 18.

Regulation 23: Governance and

management Not Compliant

Outline how you are going to come into compliance with Regulation 23: Governance and management:

Staff Supervision one to one has been implemented in this centre commencing

6/10/2018 and will be twice annually. There is one staff member outstanding who carries out relief work. Her supervision meeting will be completed by 30/11/18. This will be carried out by the Person in Charge. Monthly team supervision meetings will continue to be held.

Regulation 3: Statement of purpose Not Compliant

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

The Statement of Purpose and Function has been revised and sent to RST on 7/11/18

Regulation 12: Personal possessions Not Compliant

Outline how you are going to come into compliance with Regulation 12: Personal possessions:

This has been completed 6/11/18.

Regulation 26: Risk management

procedures Not Compliant

Outline how you are going to come into compliance with Regulation 26: Risk management procedures:

All the Risk Assessments have been reviewed to ensure details of risk and control measures include the actual practices in place. Completed 06/11/18.

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Outline how you are going to come into compliance with Regulation 28: Fire precautions: All the requirements of the Fire Authority have been met by the provider and signed off by a competent person in 2013. The additional aid for evacuation is for Fire Officer use and not for staff use (See attached report re compliance)

All PEEPS reviewed and updated 6/11/18

A simulated night drill has been completed 6/11/18.

Regulation 9: Residents' rights Not Compliant

Outline how you are going to come into compliance with Regulation 9: Residents' rights: The Statement of purpose will be updated and circulated. The fixed closures for the home are circulated every Dec/Jan of the year ahead, Any issues are discussed and worked out in advance with families. This has always been the practice. Closures circulated by 20/12/18

Regulation 5: Individual assessment

and personal plan Not Compliant

Outline how you are going to come into compliance with Regulation 5: Individual assessment and personal plan:

All families have receive a letter outlining the requirements for Annual Health Assessment All annual health, personal & social care plans have been reviewed and updated. All PCP review meetings with families and individuals have been held to assess social, personal supports and set goals 18/10/18. Where additional needs or observations have been identified i.e eating or swallow referrals for assessment and future care planning are now being requested and followed up. The Nurse for service will review health needs and up-dated care plan to ensure they are meeting needs of resident 5/12/18.

Regulation 6: Health care Not Compliant

Outline how you are going to come into compliance with Regulation 6: Health care: Al l families have received a letter outlining the requirements for Annual Health Assessement and the PIC has ensured all Annual Health Personal Plans have been reviewed and up-dated. The follow on care required will be put into care plan and reviewed by the Nurse for Services to ensure it meets needs identified Health Professional ( to be completed by 5/12/18).

Regulation 8: Protection Not Compliant

Outline how you are going to come into compliance with Regulation 8: Protection: The Procedures for dealing with Incidents will be reviewed with Designated Officers and Guidance issues to PIC re procedures 30/11/18.

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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

12(1) The person in charge shall ensure that, as far as reasonably practicable, each resident has access to and retains control of personal property and possessions and, where necessary, support is provided to manage their financial affairs.

Not

Compliant Orange 06/11/2018

Regulation

14(4) A person may be appointed as person in charge of more than one designated centre if the chief inspector is satisfied that he or she can ensure the effective governance,

operational management and administration of the designated centres concerned.

Not

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.

Not

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.

Not

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16(1)(a) ensure that staff have access to appropriate training, including refresher training, as part of a continuous professional

development programme.

Compliant

Regulation

16(1)(b) The person in charge shall ensure that staff are appropriately supervised.

Not

Regulation

23(1)(a) The registered provider shall ensure that the designated centre is resourced to ensure the effective delivery of care and support in accordance with the statement of purpose.

Not

Regulation

23(1)(b) The registered provider shall ensure that there is a clearly defined management structure in the designated centre that identifies the lines of authority and accountability, specifies roles, and details responsibilities for all areas of service provision.

Not

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.

Not

Regulation

24(4)(a) The agreement referred to in paragraph (3) shall include the support, care and welfare of the resident in the designated centre and details of the

services to be provided for that resident and, where

appropriate, the fees to be charged.

Not

Regulation

26(1)(d) The registered provider shall ensure that the risk management policy, referred to in paragraph 16 of Schedule 5, includes the following:

arrangements for the

identification, recording and investigation of, and learning from, serious incidents or adverse events involving

Not

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residents. Regulation

26(1)(e) The registered provider shall ensure that the risk management policy, referred to in paragraph 16 of Schedule 5, includes the following:

arrangements to ensure that risk control measures are proportional to the risk

identified, and that any adverse impact such measures might have on the resident’s quality of life have been considered.

Not

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

Regulation

28(1) The registered provider shall ensure that effective fire safety management systems are in place.

Not

Regulation

28(2)(b)(ii) The registered provider shall make adequate arrangements for reviewing fire precautions.

Not

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.

Not

Regulation

28(4)(a) The registered provider shall make arrangements for staff to receive suitable training in fire prevention, emergency

procedures, building layout and escape routes, location of fire alarm call points and first aid fire fighting equipment, fire control techniques and

arrangements for the evacuation of residents.

Not

Regulation

03(1) The registered provider shall prepare in writing a statement of purpose containing the information set out in Schedule

Not

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1. Regulation

31(1)(f) The person in charge shall give the chief inspector notice in writing within 3 working days of the following adverse incidents occurring in the designated centre: any allegation, suspected or confirmed, of abuse of any resident.

Not

Regulation

31(3)(d) The person in charge shall ensure that a written report is provided to the chief inspector at the end of each quarter of each calendar year in relation to and of the following incidents occurring in the designated centre: any injury to a resident not required to be notified under paragraph (1)(d).

Not

Regulation

34(2)(b) The registered provider shall ensure that all complaints are investigated promptly.

Not

Regulation

34(2)(e) The registered provider shall ensure that any measures required for improvement in response to a complaint are put in place.

Not

Regulation

34(2)(f) The registered provider shall ensure that the nominated person maintains a record of all complaints including details of any investigation into a

complaint, outcome of a

complaint, any action taken on foot of a complaint and whether or not the resident was

satisfied.

Not

Regulation

05(1)(b) The person in charge shall ensure that a comprehensive assessment, by an appropriate health care professional, of the health, personal and social care needs of each resident is carried out subsequently as required to reflect changes in need and circumstances, but no less frequently than on an annual basis.

Not

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05(2) ensure, insofar as is reasonably practicable, that arrangements are in place to meet the needs of each resident, as assessed in accordance with paragraph (1).

Compliant

Regulation

06(1) The registered provider shall provide appropriate health care for each resident, having regard to that resident’s personal plan.

Not

Regulation

06(2)(c) The person in charge shall ensure that the resident’s right to refuse medical treatment shall be respected. Such refusal shall be documented and the matter brought to the attention of the resident’s medical

practitioner.

Not

Regulation

06(2)(d) The person in charge shall ensure that when a resident requires services provided by allied health professionals, access to such services is provided by the registered provider or by arrangement with the Executive.

Not

Regulation

08(3) The person in charge shall initiate and put in place an Investigation in relation to any incident, allegation or suspicion of abuse and take appropriate action where a resident is harmed or suffers abuse.

Not

Regulation

08(7) The person in charge shall ensure that all staff receive appropriate training in relation to safeguarding residents and the prevention, detection and response to abuse.

Not

Regulation

09(2)(a) The registered provider shall ensure that each resident, in accordance with his or her wishes, age and the nature of his or her disability participates in and consents, with supports where necessary, to decisions about his or her care and support.

Not