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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Brookfield
Name of provider:
Praxis Care
Address of centre:
Co. Dublin
Type of inspection:
Unannounced
Date of inspection:
21 November 2018
Centre ID:
OSV-0005686
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
Brookfield is a community home for up to five adults with an intellectual disability. The service can support both males and females. The house is located in County Dublin and is a two story, six bedroomed detached home. It has been recently renovated to meet the needs of residents residing in the centre. Each resident has their own bedroom with an ensuite bathroom. There is a sitting room, quite room, downstairs toilet and a spacious kitchen/dining/living area. There is also a separate utility room in the back garden. The back garden has been adapted to meet
residents' needs. The house is located in close proximity to public transport and a wide variety of social, recreational, educational and training facilities. The house is social care led and residents are supported 24 hours a day, seven days a week.
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
21 November 2018 09:30hrs to
17:00hrs Marie Byrne Lead 21 November 2018 09:30hrs to
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Views of people who use the service
The centre was newly registered to accommodate five adults with an intellectual disability. There centre was home to four gentlemen on the day of the inspection. These residents had been supported to transition from another centre in the locality in order to better meet their care and support needs. The inspectors had the
opportunity to meet and spent some time with the four residents on the day of the inspection. Each resident who spoke with the inspector said that they were settling in well to the new centre and that they much preferred the new premises. Residents were particularly complimentary towards how much bigger and accessible the new premises was.
The inspectors observed residents transition to and from day services and appointments. They observed staff providing support to them to assist them to make decisions and communicate their needs in line with their wishes. During the inspection each resident appeared relaxed and comfortable with the supports
offered by staff. Each resident who spoke with inspectors said that they were happy and felt safe in their home. Monthly keyworker sessions were capturing how happy residents were with the care and support. During these meetings residents and their keyworkers discussed whether there were any changes they would like to make in the centre.
As the centre was only in operation a number of months an annual review which captured the views of residents and their representatives was not yet due. However, there were systems in place for the residents and their representative to raise any concern regarding the quality and safety of care delivered such as keyworker meetings and the complaints process.
Capacity and capability
Overall, the inspector found that the registered provider and person in charge were ensuring a good quality and safe service. The centre was well managed and this was bringing about positive outcomes for residents.
There were clearly defined management structures in place which identified the lines of authority and accountability. The staff team reported to the person in charge, who in turn reported to the person participating in the management of the designated centre (PPIM). The person in charge and PPIM were meeting regularly to discuss residents' care and support needs and staff meetings were
held regularly. There was evidence that actions following these meetings were positively impacting on residents' day-to-day life.
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quality and safety and the six monthly review by the provider were not yet due.
The inspectors found that the residents were supported by a skilled and competent workforce. Each resident appeared comfortable with the level of support offered by staff. The inspectors spoke with four staff members during the inspection and found that they were knowledgeable in relation to residents' specific care and support needs. Planned and actual rosters were maintained and there was evidence that consistency was maintained by using one regular relief staff to cover the required shifts. The person in charge and PPIM had identified that the number of staff required review in line with residents' changing needs and were in the process of reviewing staff numbers to ensure there were sufficient numbers of staff to meet residents' changing needs.
Staff had completed a suite of training and refreshers in line with the residents' needs and were in receipt of regular formal supervision in line with the
organisations' policy.
Residents' admissions were in line with the statement of purpose. Each resident had a written contract of care which outlined the care, welfare and support to be
provided, the services to be provided, and the fees to be charged including
additional fees if required. One resident had indicated that they would like to leave the service and it was evident that the provider had supported the resident to place their name on the housing list and put the necessary support in place to support them to pursue this.
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. However, there was one open complaint which was not progressing in a timely manner to the satisfaction level of the complainant. In addition the
complainant had indicated that they were not comfortable with the fact that the person who they made the complaint against had approached them to discuss the complaint. The person in charge and PPIM informed the inspectors that they were aware of this and were in the process of working on resolution of the complaint to the satisfaction of the complainant.
Residents were protected by the policies and procedures which were in place such as the policies required by Schedule 5 of the regulations. These policies had been reviewed in line with the timeframe identified in the regulations. Area specific policies and procedures were developed as required.
Regulation 15: Staffing
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meet residents' changing needs.
Judgment: Substantially compliant
Regulation 16: Training and staff development
Staff had access to some training and refreshers in line with residents' needs and were in receipt of regular formal supervision in line with the organisations' policy.
Judgment: Compliant
Regulation 23: Governance and management
The centre had effective governance and management arrangements in place. There were clear lines of authority and accountability and staff had specific roles and responsibilities. Plans were in place to complete the six monthly and annual review of quality and safety of care and support.
Judgment: Compliant
Regulation 24: Admissions and contract for the provision of services
Residents had a contract of care in place which contained the information required by the regulations. The inspectors reviewed admissions to the centre and found that they had been completed in line with the residents' needs and wishes and in line with the centres' admissions policy.
Judgment: Compliant
Regulation 3: Statement of purpose
The statement of purpose contained all the information required by Schedule 1 of the regulations and it had been reviewed in line with the timeframe identified in the regulations.
Page 8 of 19 Judgment: Compliant
Regulation 34: Complaints procedure
There were complaints policies and procedures including a user friendly complaints process. There was a local complaints officer and residents and staff who spoke with the inspector could describe this process. However, there were a an open
complaints which was not being progressed in a timely manner or resolved to the complainants satisfaction.
Judgment: Not compliant
Regulation 4: Written policies and procedures
All policies and procedures required by Schedule 5 of the regulations were available and had been reviewed in line with the timeframe identified in the regulations.
Judgment: Compliant
Quality and safety
Overall, the inspector found that the provider and person in charge were striving to ensure that the quality of the service provided for the residents was good. They lived in a caring environment where they had opportunities to make their own choices and decisions.
The premises was purchased by the provider and renovated to meet the specific care and support needs of the residents. It was well designed and laid out and provided plenty of private and communal space for residents. The house was found to be clean throughout and well maintained. Works had been completed prior to residents moving in to ensure it was accessible and meeting residents' needs. Residents indicated their satisfaction with the size and accessibility of the centre. They all indicated that were very happy to have moved house. Each resident had their own bedroom and bathroom and access to the necessary equipment to support them.
Each resident had an assessment of need and care plans and risk assessments were developed as required. The inspectors found that personal plans were clearly
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monthly and discussing a variety of topics such as; visits, outings, transport, wishes, appointments and areas of concern. Monthly everyday living reviews were being completed by keyworkers. These reviews were detailed in nature and reviewed topics such as; residents' health and wellbeing, daily living skills, empowerment, hope and recovery, activities, safety, finances and education and employment. In addition an annual everyday living review meeting was being held with residents, their representatives and staff.
Residents were actively supported and encouraged to connect with their family and friends and to be part of their local community. Residents were supported to
participate in activities in line with their needs and wishes. Since the last inspection a vehicle had been leased to facilitate one resident to access the
community in line with their wishes. The resident told the inspectors that they were very happy with the vehicle and it had made it much easier for them to access activities and their local community. There was a culture of promoting lifelong education and residents were actively encouraged and supported to participate in education and training programmes in line with their interests and aspirations. Residents were also supported to seek employment in line with their wishes.
Residents' healthcare needs were appropriately assessed and care plans
were developed in line with these assessed needs. Each resident had access to appropriate allied health professionals. There were emergency grab sheets in place in case of an emergency which clearly outlined their care and support needs. Residents had a physical wellbeing care plan in place and all appointments with allied health professionals were logged. There was clear evidence that residents healthcare needs were reviewed and updated following appointments with allied health professionals and in line with their changing needs.
Residents had communication support plans in place which outlined how they communicated and how staff could support them to understand. Each resident had a 'this is me' document which outlined important information in relation to that person. In addition residents had an everyday living assessment outlining how they communicate, how they process information, and their ability to communicate pain. Social stories were developed with residents as required.
Residents’ positive behaviour support plans clearly guided staff practice to support them. There was evidence that they were reviewed and updated regularly in line with residents’ changing needs. Residents had empowerment, hope and recovery care plans in place which were person centred, detailed and guiding staff to support residents. Social storied were developed as necessary to support residents to
manage their behaviour.
The inspector found that the provider and person in charge were proactively
protecting residents from abuse. In response to a number of safeguarding concerns in the centre the provider had responded by putting appropriate measures in place to keep residents safe. These measures included safeguarding plans and the person in charge and staff team assisting a number of residents to develop their
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residents in line with their support needs and wishes.
The inspectors reviewed a number of residents' transition plans and found that admission and found that it had been completed in line with residents' needs and wishes and the centres' admissions policy. Transition plans were detailed and outlined each step of the transition process and residents' involvement in decisions. Transition plans were also available in a format accessible to residents.
There were suitable arrangements in place to detect, contain and extinguish fires. Each resident had a personal emergency evacuation procedure in place and there was evidence that these were reviewed regularly and changes made in line with learning from fire drills. The centre was only in operation a number of months and the inspectors discussed the importance of fire drills being completed involving all residents and different scenarios, and area specific fire training for staff as
required. A fire risk assessment had been completed in centre and plans were in place to complete this annually.
Residents were protected by appropriated risk management procedures and practices. There was a system for keeping residents safe while responding to emergencies and there was a local risk register in place. Risk assessments were developed as necessary and were reviewed and updated regularly. Incident review was completed regularly. However, the organisations' risk management policy required review to ensure it included all the information by the regulations. This included the measures and actions to control the unexpected absence of any resident, accidental injury to residents visitors and staff, aggression and violence, and self-harm.
Residents were protected by policies, procedures and practices in relation to medication management. Records were maintained of all medicines ordered, delivered and received, Medication audits were being completed regularly. Staff were in receipt of training and competency assessments as required in line with the organisations' policy.
Regulation 10: Communication
Residents were supported to communicate using their preferred methods. Their communication needs and support are clearly outlined in their personal plans.
Judgment: Compliant
Regulation 13: General welfare and development
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maintain relationships and links in their local community.
Judgment: Compliant
Regulation 17: Premises
The premises was newly renovated to meet residents' needs prior to them moving in. Residents who spoke with the inspector stated they were very happy with the design and layout of the premises.
Judgment: Compliant
Regulation 25: Temporary absence, transition and discharge of residents
Resident had recently transitioned to the centre and the inspectors found that their transition plans were detailed and that transitions had been completed in line with residents' needs and wishes, and the centres' admissions policy.
Judgment: Compliant
Regulation 26: Risk management procedures
Residents were protected by appropriate risk management procedures and practices in the centre. There was a risk register in place and general and individual risk assessments developed as required. There was evidence that these documents were reviewed and updated regularly. There were systems in place to keep residents safe during emergencies. However the organisations risk management policy required review to ensure it contained all the information required by the regulations.
Judgment: Substantially compliant
Regulation 28: Fire precautions
Suitable fire equipment was provided and serviced as required. There were
adequate means of escape and emergency lighting. Residents had evacuation plans in place and there were plans to complete regular fire drills.
Page 12 of 19 Judgment: Compliant
Regulation 29: Medicines and pharmaceutical services
Residents were protected by appropriate policies, procedures and practices in
relation to medication management. All medicine errors and incidents were recorded and reported and followed up on. Learning was discussed to improve residents safety and to protect reoccurance.
Judgment: Compliant
Regulation 5: Individual assessment and personal plan
Residents' personal plans were found to be person-centred and each resident had access to a keyworker to support them to develop their goals. They had an
assessment of need and care plans in place in line with their identified need. There was evidence that these were reviewed as necessary in line with residents' changing needs and to ensure they were effective.
Judgment: Compliant
Regulation 6: Health care
Residents healthcare needs were appropriately assessed and they had access to allied health professionals in line with their assessed needs. Residents were being supported to develop their knowledge and skills around health promotion.
Judgment: Compliant
Regulation 7: Positive behavioural support
Residents who required them had positive behaviour support plans which outlined proactive and reactive strategies. There was evidence that they were reviewed and updated regularly in line with residents’ changing needs.
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Regulation 8: Protection
Residents were protected by safeguarding polices, procedures and practices. A number of previous safeguarding issue were managed appropriately. Safeguarding plans were put in place as required and all staff had all completed safeguarding training.
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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 23: Governance and management Compliant Regulation 24: Admissions and contract for the provision of
services Compliant
Regulation 3: Statement of purpose Compliant Regulation 34: Complaints procedure Not compliant Regulation 4: Written policies and procedures Compliant
Quality and safety
Regulation 10: Communication Compliant
Regulation 13: General welfare and development Compliant
Regulation 17: Premises Compliant
Regulation 25: Temporary absence, transition and discharge
of residents Compliant
Regulation 26: Risk management procedures Substantially compliant Regulation 28: Fire precautions Compliant Regulation 29: Medicines and pharmaceutical services Compliant Regulation 5: Individual assessment and personal plan Compliant
Regulation 6: Health care Compliant
Regulation 7: Positive behavioural support Compliant
Regulation 8: Protection Compliant
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Compliance Plan for Brookfield OSV-0005686
Inspection ID: MON-0024225
Date of inspection: 21/11/2018
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 15: Staffing Substantially Compliant
Outline how you are going to come into compliance with Regulation 15: Staffing:
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 by:
Increasing the WTE support worker posts in the designated centre from 4.2 WTE posts to 6.2 WTE posts which is required to meet the increased and changing need of service users. This was approved by funding agents as of the 29.11.18
The Registered Provider has ensured that the planned and actual rotas have been amended to reflect the increase in WTE support worker posts in the designated centre. (01.12.18)
The Registered Provider has ensured that the Statement of Purpose for the designated centre has been amended to capture the increase in WTE support worker posts required to meet the assessed needs of the residents. This will be completed by the 05.01.2019
Regulation 34: Complaints procedure Not Compliant
Outline how you are going to come into compliance with Regulation 34: Complaints procedure:
34 (2) (b) The Registered Provider shall ensure that all complaints are investigated promptly by ensuring all complaints are managed in line with the organisations complaints policy.
The registered Provider will ensure that the complaints process is a standing agenda item at monthly residents meetings.
The Registered Provider has ensured that contact details of both the local and
organizational complaints officers are displayed in the communal area of the designated centre for all residents to access easily.
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policy of the outcome of the complaint and shall also be informed of the appeals process. There is also further processes when a satisfactory resolution cannot be met and the complaint needs to progress to the next stage.
The Complaints policy notes that the complainant will be fully informed of the progress of their complaint, timeframes and any decisions to extend time limits will be notified to the complainant within 5 working days.
The registered Provider has ensured that the complaint which was open at the time of the inspection has now been closed (21.12.18) The complainant has been informed of the outcome of the complaint and the appeals process. The complaint has been resolved to the satisfaction of the complainant.
The local complaints officer is responsible for responding appropriately to all complaints to ensure that they are resolved at the earliest stage. Details of the complaint including the investigation, outcome and responses are all captured on the complaints record form which is maintained both centrally and locally.
Regulation 34(2)(e)
The Registered Provider will ensure that all staff complete training in the management of complaints to ensure that they respond appropriately to any complaints raised within the designated centre.
Records of complaints are maintained locally in a log within the complaints folder. All details relating to the complaint are captured on the Complaints Record Form which is also stored within this folder.
34 (4)
Residents are supported to make complaints and there is transparency in the service in relation to recording and reporting of complaints. The Person in Charge has provided information for residents in relation to the Confidential Recipient and the complaint process. This was last completed on the 30.08.2018.
Regulation 26: Risk management procedures Substantially Compliant
Outline how you are going to come into compliance with Regulation 26: Risk management procedures:
26 (1) (c) The Registered Provider shall ensure that the risk management policy, referred to in paragraph 16 of schedule 5 includes the following: The measures and actions in place to control the following specified risks: accidental injury to residents, visitors and staff, Aggression and Violence and Self-harm.
The Registered Provider will ensure that the risk management policy is reviewed by the Quality and Governance Department to include measures and actions from the
organizations existing policies on
1.The unexpected absence of any resident 2.Accidential injury to residents, visitors or staff 3.Aggression and Violence
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Section 2:
Regulations to be complied with
The provider or person in charge must consider the details and risk rating of the following regulations when completing the compliance plan in section 1. Where a regulation has been risk rated red (high risk) the inspector has set out the date by which the provider or person in charge must comply. Where a regulation has been risk rated yellow (low risk) or orange (moderate risk) the provider must include a date (DD Month YY) of when they will be compliant.
The registered provider or person in charge has failed to comply with the following regulation(s).
Regulation Regulatory requirement Judgment Risk
rating Date to be complied with
Regulation
15(1) The registered provider shall ensure that the number, qualifications and skill mix of staff is appropriate to the number and assessed needs of the residents, the
statement of purpose and the size and layout of the designated centre.
Substantially
Compliant Yellow 04/01/2019
Regulation
26(1)(c)(i) The registered provider shall ensure that the risk management policy,
referred to in paragraph 16 of Schedule 5, includes the following: the measures and actions in place to control the following specified risks: the unexpected absence of any resident.
Substantially
Compliant Yellow 28/02/2019
Regulation
26(1)(c)(ii) The registered provider shall ensure that the risk management policy,
referred to in paragraph 16 of Schedule 5, includes the following: the measures and actions in place to control the following specified risks: accidental injury to
residents, visitors or staff.
Substantially
Compliant Yellow 28/02/2019
Regulation
26(1)(c)(iii) The registered provider shall ensure that the risk management policy,
referred to in paragraph 16
Substantially
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of Schedule 5, includes the following: the measures and actions in place to control the following specified risks: aggression and violence. Regulation
26(1)(c)(iv) The registered provider shall ensure that the risk management policy,
referred to in paragraph 16 of Schedule 5, includes the following: the measures and actions in place to control the following specified risks: self-harm.
Substantially
Compliant Yellow 28/02/2019
Regulation
34(2)(b) The registered provider shall ensure that all complaints are investigated promptly.
Not
Compliant Yellow 21/12/2018
Regulation
34(2)(d) The registered provider shall ensure that the complainant is informed promptly of the outcome of his or her
complaint and details of the appeals process.
Not
Compliant Yellow 21/12/2018
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
