Beechgrove/Acorns, OSV 0004703, 10 October 2018

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Report of an inspection of a

Designated Centre for Disabilities

(Adults)

Name of designated

centre:

Beechgrove/Acorns

Name of provider:

Health Service Executive

Address of centre:

Westmeath

Type of inspection:

Announced

Date of inspection:

10 October 2018

Centre ID:

OSV-0004703

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About the designated centre

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

This centre comprised of two bungalows just on the outskirts of a large town in Co. Westmeath. The centre provides 24 hours care and nursing residential support to both male and female residents over the age of eighteen years with an intellectual disability. One of the houses in the centre comprises of five bedrooms, two

bathrooms, a utility room, a sitting room and kitchen. There is a large garden to the rear of the house with a large outdoor storage shed. Transport is available to

residents living in the house. The other house comprises of four bedrooms with two bathrooms, a utility room and separate toilet area. There is a sitting room, living room, visitors room, and a kitchen and dining area. There is a large garden to the back of the house with a small garden at the front. Currently there is transport available to most of the residents living in this house. There is a full-time person in charge employed in this centre who divides her time between both houses. The centre employs four full-time staff nurses (intellectual disabilities), two part-time staff nurse (mental health), two full time staff nurses (general) and two part-time staff nurses (general). The centre also employs 12 full-time health care assistants.

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

10 October 2018 10:30hrs to

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Views of people who use the service

The inspector met with all of the residents in both houses on the day of the inspection and observed elements of their daily lives. The residents in this centre used verbal and non-verbal communication, so where appropriate their views were relayed through staff advocating on their behalf. Residents’ views were also taken from the designated centre’s annual review and various other records that

endeavoured to voice the residents' opinions.

Most of the residents were happy to show the inspector around their bedroom and seemed proud and content showing off the photos, memorabilia and personal items contained within their room.

One of the residents talked to the inspector about the different activities they enjoyed and in particular how they were supported to follow the local football team through a staff member accompanying them to matches most weekends.

One resident advised the inspector that they were happy living in the house and showed the inspector around communal areas of the house, both indoors and outdoors.

Residents appeared content and relaxed in their environment and the inspector observed that there was an atmosphere of friendliness in both houses and that staff were kind and respectful towards residents through positive, mindful and caring interactions.

Capacity and capability

Overall, the inspector found that the care provided to the residents by the person in charge and staff was of a good standard. However, to fully ensure that

residents received positive outcomes in their lives and the delivery of a safe and quality service, improvements were required to governance and managements systems, recruitment systems and arrangements for when the person in charge was absent.

An annual review of the quality and safety of care and support of the centre was carried out by the person in charge. The inspector found that improvements had been made to the format of the review document since the last inspection. The six month unannounced review had been carried out by the centre's senior

management. However, the inspector was informed that there was no quality assurance system in place to monitor the time-lines and completion of the actions arising from both of these reviews.

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was competent, with appropriate qualification and skills and sufficient practice and management experience to oversee the residential service to meet its stated purpose, aims and objectives. However, due to other organisational commitments and periods of absence, it was evident that additional resources were required to support the person in charge to ensure effective and consistent service delivery.

The inspector found that when the person in charge was absent that there were no clear lines of accountability at organisational level so that all staff working in the centre were aware of who they were accountable to. The inspector spoke with a number of staff who voiced their concerns regarding the lack on-site

leadership when there were periods where the person in charge was absent.

Furthermore, there was evidence to demonstrate that when the person in charge was absent from the centre that the arrangements in place for the running of the designated centre were not satisfactory and had resulted in some specific regulation requirements not being met.

There was an annual auditing schedule in place for the person in charge to evaluate and improve the provision of service and to achieve better outcomes for the

residents however, the inspector found that when the person in charge was absent for a period of time that the audits were not always completed within the planned time-frame.

The inspector found that overall, staff had the necessary competencies and skills to support the specific residents that lived in the centre and had developed therapeutic relationship with residents. The inspectors observed kind, caring and respectful interactions between staff and residents throughout the day. However, the inspector found that the organisation's current agency framework did not ensure continuity of care for the residents and did not always ensure that staff with appropriate skills and experience were employed.

The inspector found evidence that for the most part, staff had received mandatory training. Staff who spoke with the inspector demonstrated good understanding of residents’ needs and were knowledgeable of policies and procedures which related to the general welfare and protection of the residents.

One to one supervision meetings were being provided by the person in charge to support staff perform their duties to the best of their ability. Staff advised the inspector that they found these meetings to be beneficial to their practice.

The registered provider had established and implemented satisfactory systems to address and resolve issues raised by residents or their representatives. Systems were in place, including an advocacy services, to ensure residents had access to information which would support and encourage them express any concerns they may have.

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A sample of staff files were reviewed and met the requirements specified in Schedule 2.

Organisational systems in place to recruit agency staff meant that the continuity of person centred care was not always maintained. The inspector found evidence of several occasions where agency staff employed were not familiar to the residents or their needs and in one case did not have the right skills set to support the residents' needs.

The inspector found that the roster in place did not convey accurate information relating to the person in charge's on-site hours.

Judgment: Substantially compliant

Regulation 16: Training and staff development

The education and training provided to staff enabled them to provide care that reflected up-to-date, evidence-based practice.

On the day of inspection the inspector found that not all staff training was up to date however, where this was the case, training courses had been booked within a months time or sooner in some cases.

Regulation 19: Directory of residents

The directory of residents was made available, was up to date and contained all the required information.

Judgment: Compliant

Regulation 23: Governance and management

The inspector found evidence that there was insufficient supports in place for the person in charge to ensure the effective governance, operational management and administration of the designated centre at all times.

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absent.

Judgment: Not compliant

Regulation 24: Admissions and contract for the provision of services

Residents' agreements had not been updated or signed by residents or family since 2015.

Regulation 3: Statement of purpose

Overall, the statement of purpose was in line with service being delivered however, some of the services listed as provided to residents were not actually in place in practice. For example ;

- The statement of purpose states there there is an accessible vehicle available to residents however, this vehicle is not accessible to one of the residents. (See residents' rights for more details)

- Arrangements in place if the person in charge is off site states that a nurse is assigned to be in charge in each house and this is highlighted on the roster. The inspector was informed that this is currently not the case. (See governance and management for more details)

- Use of information - states all residents' files secured in locked cupboard in house - this inspector found files were not always locked away or in secure cupboards. (See residents' rights for more detail)

Regulation 31: Notification of incidents

For the most part the centre complied with notification requirements however, the inspector found that a notification relating to an alleged incident had not

been submitted to the Health Information Quality Authority within the three day time period as necessary. Furthermore, two restrictive practices had not been included on the quarterly notifications.

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Page 9 of 26 Judgment: Not compliant

Regulation 34: Complaints procedure

Complaints procedures and protocols were evident and appropriately displayed and available to residents and families.

Judgment: Compliant

Quality and safety

The inspector found that the person in charge and staff were aware of each

residents’ needs and knowledgeable in the person-centred care practices required to meet those needs. Overall, care and support provided to residents was of good quality. However, the inspector found that in relation to fire precautions, premises and residents rights, a number of improvements were required.

The residents' personal care plans reflected the residents continued assessed needs and outlined the support required to maximise their personal development in

accordance with their wishes, individual needs and choices. The inspector found that the residents’ personal plans demonstrated that the residents were facilitated to exercise choice across a range of daily activities and for the most part to have their choices and decisions respected.

The inspector looked at a sample of personal plans and found them to be up-to-date and reviewed on a regular basis. However, the inspector found that residents'

personal plans in one of the houses required improvements around the

documentation of the progress and achievement of residents' goals. Furthermore, the inspector found that these plans were not available in a format that was accessible to the residents.

Residents were supported to be involved in their community through attendance of local day activation services but also through other community activities such as horse riding, gardening activities, attending mass services, local dog and horse racing events, overnight trips away in hotels and dining out in local restaurants and cafés. In one of the houses a local holistic practitioner came to the house and provided individual relaxation, aromatherapy and beauty treatments for residents.

Residents who did not attend an activation service were engaged in an

individualised service within the house which had been assessed and personalised to better meet the needs of the resident. The residents enjoyed activities such

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to take part in the music session. Staff informed the inspector that the residents appeared to enjoy these sessions.

Staff facilitated a supportive environment which enabled the residents to feel safe and protected from abuse. The culture in the house espoused one of openness and transparency where residents could raise and discuss any issues without prejudice. There was documentation to show that staff recognised the importance of empathy and compassion and actively listened to the concerns of residents. Overall, the inspector found that the residents were protected by practices that promoted their safety.

The inspector found that staff treated residents with respect and that personal care practices respected residents' privacy and dignity. Furthermore, residents in both houses had access to advocacy services and information about their rights. However, on the day of inspection the inspector found a number of poor and inappropriate practices relating to the storage and filing of residents' individual personal records.

The inspector found that the design and layout of the of the premises did not always ensure that all residents could enjoy living in an accessible, safe, comfortable and homely environment. Overall, the centre was clean however, both houses required many improvements relating to decorative and structural repairs.

Procedures were in place for the prevention and control of infection. These procedures were ensured by cleaning checks in order to maximise the safety and quality of care delivered to each resident. However, the inspector found that

improvements were required in the centre to fully ensure the prevention and control of infection.

The inspector found that the fire fighting equipment and fire alarm systems were appropriately serviced and checked and that there were satisfactory systems in place for the prevention and detection of fire. However, the inspector found that the mobility and cognitive understanding residents was not always adequately

accounted for in the evacuation procedure or in residents individual personal

evacuation plans. The inspector also found that improvements were required to the evacuation routes in both houses and in the practice, recording and documenting of fire drills.

Regulation 28: Fire precautions

The inspector found that;

There was no fire evacuation plan on the wall of one of the houses.

Residents' personal evacuation plans did not include information regarding specific individual supports required for each resident during day and night-time

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The inspector also found that the centre's emergency response plan and individuals' personal emergency evacuation plans required reviewing to ensure that all external fire exit routes were accessible to all residents during night time fire evacuations; In one of the houses one of the evacuation routes was not suitable for two residents who required extra supports during night-time evacuation.

In one of the houses an evacuation route included uneven grassy surface with no guiding lights.

In one of the houses there was no evidence to demonstrate that the evacuation procedure for simulated fire drills (with least amount of staff and all of the residents) was fit for purpose.

Regulation 5: Individual assessment and personal plan

In one of the houses the recording and documentation of the progress of residents' goals was not clear and achievements of goals was not always documented.

Personal plans had not been audited by the person in charge as per annual schedule in place.

In one house residents' personal plans were not in a format that was accessible to the them.

Regulation 8: Protection

In both houses there was unclear signage as to who the designated officers for the centre were.

Regulation 9: Residents' rights

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2016.

In one of the houses, residents' medical administration records were not stored in locked and secure cupboard.

In one of the houses, 2017 personal records belonging to current and past residents were found in an outside locked shed that was used for storing household supplies and electric appliances. However, by the end of the day these files had been

removed from this location and archived in an appropriate secure location belonging to the organisation.

Regulation 27: Protection against infection

The inspector found that the cleaning process could not ensure complete

disinfection and decontamination due to chipped paint on walls throughout both centres.

Regulation 17: Premises

The premises did not always meet the needs of the residents and overall the design and layout in both houses did not promote the residents' safety, dignity,

independence and well-being.

For the most part, both houses appeared clean inside and on the day of inspection staff were carrying out the scheduled weekly ''deep clean'' in one of the

houses. However, there was a large amount of maintenance and structural work required for both houses;

Both houses had marks and scuffing on the walls of the bedrooms, halls, bathrooms and communal areas;

A number of door frames in both houses were chipped and/or had ingrained scuff marks;

The leather headboard in one of the residents' bedrooms had a rip in the centre of it;

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One house had no appropriate facilities for residents to meet with visitors;

The corridors in one house was very narrow and was limiting for two of the residents who used large comfort type wheelchairs;

There was lack of storage facilities in both houses;

There was office and filing equipment in the residents’ sitting room and dining area of both houses;

The area surrounding the wall of an outdoor pipe required plastering;

Outside one of the houses the walls had chipped paint with layers of cobwebs and dirt along the gutters.

There was paper rubbish on the ground of the front and back garden of one of the houses;

A smoking area, that had been provided for a resident in one of the houses, was dirty inside with most of one wall covered in flaking and chipped paint;

The footpath outside the back of one houses had an uneven surface;

The manhole cover on the same uneven footpath was loose and moved when stood on.

Regulation 11: Visits

There was no suitable space for visitors in one of the houses however, in the other house a new visitors room had been provided

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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 Substantially

compliant Regulation 19: Directory of residents Compliant Regulation 23: Governance and management Not compliant Regulation 24: Admissions and contract for the provision of

services Substantially compliant

Regulation 3: Statement of purpose Substantially compliant Regulation 31: Notification of incidents Not compliant Regulation 34: Complaints procedure Compliant

Quality and safety

Regulation 28: Fire precautions Not compliant Regulation 5: Individual assessment and personal plan Substantially

compliant

Regulation 8: Protection Substantially

compliant Regulation 9: Residents' rights Not compliant Regulation 27: Protection against infection Substantially

compliant

Regulation 17: Premises Not compliant

Regulation 11: Visits Not compliant

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Compliance Plan for Beechgrove/Acorns

OSV-0004703

Inspection ID: MON-0022577

Date of inspection: 10/10/2018

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 15: Staffing Substantially Compliant

Outline how you are going to come into compliance with Regulation 15: Staffing: To ensure continuity of person centred care being maintained, the planned rosters for the designated centre have been completed 4 weeks in advance by the PIC to ensure forward planning of regular agency staff being assigned to the area in the event of planned absences. On occasions where there is an unplanned absence the agency staff will be assigned a regular/familiar staff to work alongside at the commencement of the shift as part of the induction to the area.

The PIC roster will convey accurate information relating to the planned hours on-site specific to each house of the designated centre and the actual hours allocated will be reflected on the planned/actual rosters.

Regulation 16: Training and staff

development Substantially Compliant

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

Training courses which had been booked as observed on the day of inspection have now been completed; however there are four outstanding training dates due for completion. Three staff members are due to complete CPR on Thursday 16 November 2018 and one staff member is booked for Safeguarding Vulnerable Adults training on 20 November 2018. To ensure this is maintained and updated, staff training will be a featured topic on all staff supervision meetings and staff are required to provide all updated training

certificates to the PIC and filed in the respective house for inspection.

The training template will be reviewed on the last Monday of every month to ensure same is updated with current training completed by all staff working in the designated centre.

Regulation 23: Governance and

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

In the event of the PIC being on short term leave, the ADON will be present in the houses between the days Monday to Friday and assume the duties of the PIC with immediate effect.

In the event of long term absences a specified purpose contract will be submitted for replacement of PIC.

Regulation 24: Admissions and

contract for the provision of services Substantially Compliant

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

Residential agreements have been updated and communicated to residents and next-of-kin for signing, along with updated RSSMAC forms outlining pay contributions payable to the HSE and or Housing Association.

Regulation 3: Statement of purpose Substantially Compliant

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

An accessible vehicle lease for the centre. A suitable vehicle will be provided.

The statement of purpose will be updated in order to reflect the revised arrangement in place in the absence of the PIC, as outlined under Governance and Management.

All documents relating to residents have been locked away in a designated and secure cupboard. The Policy on Confidentiality has been communicated to all staff.

Regulation 31: Notification of incidents Not Compliant

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

All staff will inform the ADON/RDON on duty/ on call immediately of notifications on day of occurrence. All staff in the designated centre will be informed of HIQA notification requirement at house meetings.

Two quarterly notification forms (NF39) for the period January, February, March and April, May, June will be amended and resubmitted outlining all restrictive practices in place. The period July, August and September have been completed and submitted.

Regulation 28: Fire precautions Not Compliant

Outline how you are going to come into compliance with Regulation 28: Fire precautions: A fire evacuation plan has been made available on the wall of one of the houses as required.

The Fire Officer visited the designated centre to review the regulations in place and ensure effective fire safety management systems are in place. In one house of the designated centre, the exit door at the utility room was reviewed as a fire exit door. A decision was made that this is not to be utilized as an emergency exit for residents in the event of a fire. The exit door is primarily to only be utilized in the event of a staff

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immediate vicinity. This has been highlighted within residents individual PEEP’s updated. All residents PEEP’s have been updated outlining specifically which exit doors are to be utilized for each individual in the event of an emergency evacuation, the equipment to be utilized specific to each individual and specific to time of evacuation (day/night

evacuation), outlining if the individual will evacuate walking aided/unaided, if the individual requires the use of a wheelchair and its location or a ski mat for some residents that are in bed during night evacuation. A copy of PEEP’s is located in each care plan and at the back of the fire folder.

Uneven pathway will be leveled at the rear to one house. Emergency lighting will be provided to the rear of one house.

Simulated night time evacuations’ were conducted to both houses of the designated centre.

Regulation 5: Individual assessment

and personal plan Substantially Compliant

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

PCP’s have been updated and located in individual folders separate to the individual care plan, identifying specific goals to be achieved with identified timelines for completion and a progress notes relating to each goal clearly labeled.

Care Plans and individual assessment plans have been reviewed and updated to ensure each care plan goal is clearly identified with progress notes identified to correspond specifically to each individual goal.

An Audit of PCP’s will be conducted as per yearly audit schedule.

All personal plans will be provided in a format suitable to each individual resident.

Regulation 8: Protection Substantially Compliant

Outline how you are going to come into compliance with Regulation 8: Protection: A clearly identified poster will be implemented to the wall of each house in the

designated centre identifying in picture format the designated officer and the contact details of same.

Regulation 9: Residents' rights Not Compliant

Outline how you are going to come into compliance with Regulation 9: Residents' rights: An accessible vehicle will be provided to one of the houses in the designated centre. Medical administration records have been locked away when not in use, within a designated and secure cupboard for same.

The personal records belonging to residents were removed from the locked shed outside and archived within a designated area of the centre on the day of inspection.

Regulation 27: Protection against

infection Substantially Compliant

Outline how you are going to come into compliance with Regulation 27: Protection against infection:

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completed.

Regulation 17: Premises Not Compliant

Outline how you are going to come into compliance with Regulation 17: Premises: A leather headboard will be replaced in one of the residents’ bedroom.

The tile missing from the bathroom wall will be replaced.

A review will be undertaken in conjunction with the maintenance and OT department in relation to transporting residents in a narrow corridor in one house of the designated centre. Following this review a plan will be devised by the PIC to action the

recommendations of the review.

The gutters in one house of the designated centre will be cleaned.

Internal and external painting works within both houses of the designated will be completed.

A review will be undertaken on the storage of both houses within the designated centre. Following this review a plan will be put in place by the PIC to address the storage

requirements in both houses.

The area surrounding the wall of an outdoor pipe will be plastered. Paper rubbish has been removed from the back garden.

The smoking area has been cleaned. The smoking area will be painted as part of the external painting works.

The uneven surface to the rear of one house in the designated centre will be leveled. The manhole cover will be secured.

Regulation 11: Visits Not Compliant

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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

11(3)(a) The person in charge shall ensure that having regard to the number of residents and needs of each resident; suitable communal facilities are available to receive visitors.

Not Compliant Orange 30/04/2019

Regulation

11(3)(b) The person in charge shall ensure that having regard to the number of residents and needs of each resident; a suitable private area, which is not the

resident’s room, is available to a resident in which to receive a visitor if required.

Regulation 15(3) The registered provider shall ensure that residents receive continuity of care and support,

Substantially

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particularly in circumstances where staff are employed on a less than full-time basis.

Regulation 15(4) The person in charge shall ensure that there is a planned and actual staff rota, showing staff on duty during the day and night and that it is properly maintained.

Substantially

Compliant Yellow 06/11/2018

Regulation

16(1)(a) The person in charge shall ensure that staff have access to appropriate training, including refresher training, as part of a

continuous professional development programme.

Substantially

Regulation

17(1)(a) The registered provider shall ensure the premises of the designated centre are designed and laid out to meet the aims and objectives of the service and the number and needs of residents.

Substantially

Regulation

17(1)(b) The registered provider shall ensure the premises of the designated centre are of sound construction and kept in a good state of repair

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externally and internally. Regulation

17(1)(c) The registered provider shall ensure the premises of the designated centre are clean and suitably decorated.

Substantially

Regulation 17(6) The registered provider shall ensure that the designated centre adheres to best practice in achieving and promoting accessibility. He. she, regularly reviews its accessibility with reference to the statement of purpose and carries out any required

alterations to the premises of the designated centre to ensure it is accessible to all.

Substantially

Regulation 17(7) The registered provider shall make provision for the matters set out in Schedule 6.

Substantially

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.

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23(1)(b) 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.

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.

Regulation

24(4)(b) The agreement referred to in paragraph (3) shall provide for, and be consistent with, the resident’s needs as assessed in accordance with Regulation 5(1) and the statement of purpose.

Regulation 27 The registered provider shall ensure that

residents who may be at risk of a healthcare associated infection are protected by adopting

Substantially

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procedures

consistent with the standards for the prevention and control of healthcare associated infections

published by the Authority.

Regulation 28(1) The registered provider shall ensure that

effective fire safety management systems are in place.

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.

Regulation

28(4)(b) The registered provider shall ensure, by means of fire safety management and fire drills at suitable intervals, that staff and, in so far as is reasonably practicable, residents, are aware of the procedure to be followed in the case of fire.

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

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event of fire are 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

Regulation

31(3)(a) 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

occasion on which a restrictive

procedure

including physical, chemical or

environmental restraint was used.

Regulation 05(5) The person in charge shall make the personal plan available, in an accessible format, to the resident and, where

appropriate, his or her representative.

Substantially

Regulation

05(6)(c) The person in charge shall ensure that the personal plan is the subject of a

Substantially

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review, carried out annually or more frequently if there is a change in needs or circumstances, which review shall assess the

effectiveness of the plan.

Regulation 08(2) The registered provider shall protect residents from all forms of abuse.

Substantially

Regulation

09(2)(b) The registered provider shall ensure that each resident, in accordance with his or her wishes, age and the nature of his or her

disability has the freedom to exercise choice and control in his or her daily life.

Regulation 09(3) The registered provider shall ensure that each resident’s privacy and dignity is respected in

relation to, but not limited to, his or her personal and living space, personal

communications, relationships, intimate and personal care, professional consultations and personal

information.