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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Glen 3
Name of provider:
Daughters of Charity Disability
Support Services Company
Limited by Guarantee
Address of centre:
Dublin 20
Type of inspection:
Unannounced
Date of inspection:
04 April 2018
Centre ID:
OSV-0003727
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
The designated centre consisted of three bungalows located in a campus setting and provided a service to 16 residents who have an intellectual disability and require moderate to high support interventions. The centre was located in a suburb of a large city where taxi, bus and train services were available. A nurse lead service and 24 hour nursing care was provided. Residents were supported to engage in a range of activities which were meaningful to them both in the community and on the campus where the centre was located. Each resident had their own bedroom which was decorated in line with their individual preferences and needs.
The following information outlines some additional data on this centre.
Current registration end
date:
01/11/2018
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
04 April 2018 09:00hrs to
18:30hrs Ivan Cormican Lead 04 April 2018 09:00hrs to
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Views of people who use the service
The inspectors met with 15 residents on the day of inspection. Residents appeared relaxed in the home and staff interacted with them in a kind and caring manner. Staff were also observed to be able to communicate with residents through using sign language and the spoken word. Some residents who were able to communicate verbally indicated that they were happy with the service provided.
Capacity and capability
Overall, the inspector found that residents were supported to be valued members of their local community and participated in activities which were meaningful to them. Residents were observed to be treated in a warm and caring manner and staff on duty had a good understanding of their personal preferences and care needs. However, the governance arrangements of the designated centre failed to ensure that the premises was meeting the needs of all residents, furthermore considerable improvements were required to ensure that dignified living arrangements were in place for one identified resident.
Significant failings were identified on the previous inspection of this centre in
relation to the care provided to a resident. The provider had implemented a range of actions to address this issue; however, on this inspection, inspectors found that a resident continued to live in the centre without free access to bathroom facilities and had restricted access to kitchen facilities. Inspectors found that the individualised area for this resident was not meeting their needs and was not conducive with a dignified living arrangement. This was discussed with local management of the centre and there was evidence that this situation had been escalated to the provider entity; however, no further progress had been made in improving the
accommodation provided for this resident.
The provider had conducted an unannounced audit of the care provided in the centre which identified some areas for improvement. The provider had
also consulted with residents in regards to the annual review of the service; however this review had not been conducted within the required time line. There was a continuous system of audits in place which gathered data on various elements of the care provided such as medications, fire precautions and health and safety.
The provider was found to have supported the development of a
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attending regular staff meetings. However, not all staff members were up-to-date with training needs.
The provider had produced a statement of purpose which outlined the services which would be provided in the centre. This document was recently reviewed and amended to reflect the current capacity of the centre. Inspectors found this capacity was accurate to the centre; however, the centre would be unable to provide a service to the number of residents as stated on the centre's original conditions of registration. The provider was aware of this situation and was currently applying to renew the registration of this centre with a reduced capacity. Inspectors also found that this document did not contain all prescribed information as set on in Schedule 1 of the regulations.
Registration Regulation 5: Application for registration or renewal of
registration
At the time of inspection, the provider was in the process of applying to renew the registration of the centre with a reduced capacity to that of the original conditions of registration.
Judgment: Compliant
Regulation 15: Staffing
Inspectors found that residents received continuity of care from staff members who were familiar to them. Nursing care was provided to meet the assessed needs of the residents and a sample of staff files which were reviewed contained all required information as stated in the Regulations.
Judgment: Compliant
Regulation 16: Training and staff development
While there was a training programme in place. The training records demonstrated that all staff had not completed refresher training as required and staff were
not identified for planned courses.
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Regulation 21: Records
Records as required under Schedule 3 and 4 were maintained in the centre. During the inspection staff were unable to produce documentation for inspectors to review and there was some confusion in regards to the location and presence of some documents in the centre. Inspectors found that some improvements were required in regards to documentation to ensure that important information was readily available to all staff, at all times.
Judgment: Substantially compliant
Regulation 23: Governance and management
The provider had a suitable management structure in place and all required reviews and audits of the centre had been completed. The provider had also introduced a range of on-going internal audits which promoted the quality of care provided in the centre. However, inspectors found that the provider had not ensured the suitability of the living arrangements for all residents in the centre. Inspectors also found that the annual review had not been completed within the required time line.
Judgment: Not compliant
Regulation 3: Statement of purpose
The provider had produced a statement of purpose which had been recently reviewed; however, inspectors found that this document did not contain all prescribed information as set out in the regulations.
Judgment: Substantially compliant
Regulation 31: Notification of incidents
The provider maintained a record of all notifications which was submitted to the chief inspector and a review of adverse events indicated that some notifications were submitted as required; however, inspectors found that not all restrictive practices were submitted as required.
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Quality and safety
Overall, inspectors found that improvements had occurred for some residents in terms of the quality of care provided in this centre since the previous inspection. Residents were supported to be more engaged in their local community and a combination of campus based and community based activities were in place. However, further improvements were required in terms of the suitability of the premises in meeting the needs of all residents.
The centre comprised three houses which were warm, clean and comfortably furnished. Some residents had additional sitting rooms for their own use and there was also communal areas and a separate visitors room in each house. The majority of residents had free access to all areas of their home; however, a resident did not have free access to all of their home, which included bathroom and kitchen facilities. The resident was supported to access these facilities but had to seek the attention of staff in order to do so. Inspectors found that these arrangements were not supporting the needs of this resident. This issue was discussed at length
with management of the centre and there was evidence that local management had escalated these arrangements to the provider entity but little progress had been made in resolving the situation.
Significant failings were identified on the previous inspection of this centre in relation to the residents' rights and the use of restrictive practices in the centre. Inspectors found that the provider had taken these issues seriously and had introduced a range of measures to monitor and review these arrangements in the centre. Inspectors found that these actions undertaken by the provider had
improved some aspects of the quality of care for some residents in the centre with the introduction as assistive technology and a range of activities which
were meaningful to the each resident. There was regular involvement from allied health professionals such as behavioural support specialists and the mental health team. An advocate had been involved in the centre and a sensory assessment had indicated that a resident may benefit from deep pressure massage and the
introduction of music, all of which were introduced by the staff team. However, these actions had little impact in addressing the fundamental issue in the centre which was the unsuitable living arrangements for one resident.
Restrictive practices in relation to accessing all areas of the premises had been regularly reviewed and substantial input from allied health professionals had occurred since the last inspection of this centre. There was evidence that these reviews had improved the quality of lives of residents with a range of activities introduced which was based on the residents' assessed needs. Some measures had also been taken to reduce these practices and a clear rationale was in place when an practice could not be eliminated. However, some restrictive practices had not been recently reviewed to ensure that these practices were consistently required.
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was in place in relation to supporting residents with certain aspects of their care. Staff had a good knowledge of how to support the residents and a behavioural support specialist was actively involved in the centre. There was also some behavioural guidance in place to support staff in the delivery of care.
The provider had systems and procedures in place to ensure that residents were protected from potential abuse. There were some safeguarding plans in place in the centre which were reviewed on a regular basis. Staff had a good understanding of these plans and could detail the interventions required to ensure that all residents were safe in the centre.
The provider had systems in place for the recording and response to adverse events. Inspectors found that all adverse events had been addressed in a prompt manner by management of the centre and additional measures such as
safeguarding plans had been implemented to address any identified issues. The provider also had suitable arrangements in place for monitoring risk within the centre. All identified risks had been reviewed on a regular basis and appropriate controls were in place which reflected the rating which was applied.
The provider had appropriate medication storage facilities in place and medication prescription sheets contained the required information to promote the safe
administration of medications. The inspector reviewed a sample of associated administration sheets and found that all regular medications had been administered as prescribed.
Regulation 17: Premises
The premises was warm and clean and residents' communal and personal areas were decorated with items of personal interest and photos of family members. Some residents had free access to all areas of their home and individualised living areas were in place for some residents. However, inspectors found that the premises was not meeting the needs of all residents.
Judgment: Not compliant
Regulation 26: Risk management procedures
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arrangements promoted the safety of care which was provided to residents.
Judgment: Compliant
Regulation 28: Fire precautions
Fire safety was taken seriously by the provider and suitable fire precautions and fire fighting equipment were in place. Fire drills indicated that residents could be
evacuated in a prompt manner and staff were conducting regular checks of fire equipment. However, some fire doors were wedged open on the day of inspection, this was brought to the attention of the provider and these wedges were removed. Furthermore a fire door in a resident's individualised area was held open with an item of furniture and staff stated that this was in place to meet the needs of the resident; however, inspectors found that this arrangements compromised the fire safety features of this centre.
Judgment: Substantially compliant
Regulation 29: Medicines and pharmaceutical services
The provider had appropriate medication storage facilities in place and medication prescription sheets contained the required information to promote the safe
administration of medications.
Judgment: Compliant
Regulation 5: Individual assessment and personal plan
Each resident had a personal plan in place, there was evidence
of an annual multidisciplinary review of the personal plans. Residents had access to their personal plans in a format that was accessible to them. Residents' social care goals had improved since the last inspection, there were more community based activities identified for residents.
Judgment: Compliant
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Some residents in the centre required interventions from behavioural support and staff who met with the inspector had a good understanding of supporting their needs. There were some restrictive practices in place; however, some of these practices had not been recently reviewed to ensure that they were consistently required.
Judgment: Substantially compliant
Regulation 8: Protection
The provider had a policy on safeguarding residents from abuse and staff members had a good understanding of safeguarding procedures used within the centre. Staff were also found to engage with resident in a warm and caring manner.
Judgment: Compliant
Regulation 9: Residents' rights
There was evidence that residents participated in decisions affecting their daily lives and there was evidence that residents were consulted in regards to meals choice; however, residents' meals were provided from a centralised kitchen which did not ensure that residents maintained full control over all aspects of their daily lives. Inspectors also found that improvements were required to ensure that residents’ privacy was protected in communications within the centre.
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Appendix 1 - Full list of regulations considered under each dimension
Regulation Title
Judgment
Capacity and capability
Registration Regulation 5: Application for registration or
renewal of registration Compliant
Regulation 15: Staffing Compliant
Regulation 16: Training and staff development Substantially compliant
Regulation 21: Records Substantially
compliant Regulation 23: Governance and management Not compliant Regulation 3: Statement of purpose Substantially
compliant Regulation 31: Notification of incidents Substantially
compliant
Quality and safety
Regulation 17: Premises Not compliant
Regulation 26: Risk management procedures Compliant Regulation 28: Fire precautions Substantially
compliant Regulation 29: Medicines and pharmaceutical services Compliant Regulation 5: Individual assessment and personal plan Compliant Regulation 7: Positive behavioural support Substantially
compliant
Regulation 8: Protection Compliant
Regulation 9: Residents' rights Substantially compliant
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Compliance Plan for Glen 3 OSV-0003727
Inspection ID: MON-0023732
Date of inspection: 04/04/2018
Introduction and instruction
This document sets out the regulations where it has been assessed that the provider or person in charge are not compliant with the Health Act 2007 (Care and Support of Residents in Designated Centres for Persons (Children And Adults) With Disabilities) Regulations 2013, Health Act 2007 (Registration of Designated Centres for Persons (Children and Adults with Disabilities) Regulations 2013 and the National Standards for Residential Services for Children and Adults with Disabilities.
This document is divided into two sections:
Section 1 is the compliance plan. It outlines which regulations the provider or person in charge must take action on to comply. In this section the provider or person in charge must consider the overall regulation when responding and not just the individual non compliances as listed section 2.
Section 2 is the list of all regulations where it has been assessed the provider or person in charge is not compliant. Each regulation is risk assessed as to the impact of the non-compliance on the safety, health and welfare of residents using the service.
A finding of:
Substantially compliant - A judgment of substantially compliant means that the provider or person in charge has generally met the requirements of the regulation but some action is required to be fully compliant. This finding will have a risk rating of yellow which is low risk.
Not compliant - A judgment of not compliant means the provider or person
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Section 1
The provider and or the person in charge is required to set out what action they have taken or intend to take to comply with the regulation in order to bring the centre back into compliance. The plan should be SMART in nature. Specific to that regulation, Measurable so that they can monitor progress, Achievable and Realistic, and Time bound. The response must consider the details and risk rating of each regulation set out in section 2 when making the response. It is the provider’s responsibility to ensure they implement the actions within the timeframe.
Compliance plan provider’s response:
Regulation Heading Judgment
Regulation 15: Staffing Compliant
Outline how you are going to come into compliance with Regulation 15: Staffing:
(See Feedback form)
Each house in the designated center has an updated roster and any changes are communicated directly to the house by the PIC or Nurse Manager on Duty. A similar copy is held in the nurse manager office for planning reasons.
Regulation 16: Training and staff
development Substantially Compliant
Outline how you are going to come into compliance with Regulation 16: Training and staff development:
Dates have been arranged for staff due for refresher training. PIC will continue to liaise with training department and keep up to date records.
A training needs analysis is in place. Staff will be scheduled for upcoming training
Regulation 21: Records Substantially Compliant
Outline how you are going to come into compliance with Regulation 21: Records:
A new index system has been developed and disseminated to designated centre to improve organisation of documents. A recent registration visit on 10th May in another
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Regulation 23: Governance and
management Not Compliant
Outline how you are going to come into compliance with Regulation 23: Governance and management:
In relation to the suitability of the living arrangements for one resident; the following is copied from an email sent by CEO Liz Reynolds to service manager and PIC for intention to share to HIQA:
In relation to the extension in the house in the designated centre, I can confirm that this has been approved and that there is funding allocated for this project.
The following is the projected programme for the extension to the above Bungalow:- Please note the Design will be carried out by our in-house design team. (Only Q.S. services will be outsourced)
Sketch Scheme Drawings are completed and attached (with 3 Options for selection/ approval)
29th May 2018 Design Review (all parties)
8th June 2018 Finalised Design with changes to address observations from Design Review(if Any).
6th July 2018 Submit Planning Application
August & September Prepare Tender Drawings & Specification & Tender to Contractors October 2018 Grant of Planning (Subject to planning process going smoothly) November 2018 Appoint Contractor & Commence On Site
31st March 2019 Complete Works (Ready for Occupation)
On the 14th May there was an MDT review with the family of the resident. Current
restrictive practices were discussed. Family was also shown samples of plans of extension and given assurances that this building work will be carried out. The family were very satisfied with this.
In relation to the Annual Review, a date has been set for 11.6.18.
Regulation 3: Statement of purpose Substantially Compliant
Outline how you are going to come into compliance with Regulation 3: Statement of purpose:
The statement of purpose was updated and submitted to HIQA on 1.5.18 for regulation purposes. It is in place in the designated centre and the PIC will ensure that it is
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Regulation 31: Notification of incidents Substantially Compliant
Outline how you are going to come into compliance with Regulation 31: Notification of incidents:
The PIC will ensure that all sensor mats and audio devices are reviewed regularly by the relevant team member or specialist if prescribed for a reason such as epilepsy. The PIC will then ensure that any restrictive practices are then reviewed through restrictive practice meetings and notified through quarterly NF39.
The PIC will ensure that all audio devices are switched off when not required and this will be reflected in residents’ epilepsy action plan. The PIC will ensure this through regular communication with staff and regular checks.
Regulation 17: Premises Not Compliant
Outline how you are going to come into compliance with Regulation 17: Premises:
In relation to premises deemed unsuitable, the following is copied from an email sent by CEO Liz Reynolds to service manager and PIC for intention to share to HIQA:
In relation to the extension in the house in the designated centre, I can confirm that this has been approved and that there funding allocated for this project.
The following is the projected programme for the extension to the above Bungalow:- Please note the Design will be carried out by our in-house design team. (Only Q.S. services will be outsourced)
Sketch Scheme Drawings are completed and attached (with 3 Options for selection/ approval)
29th May 2018 Design Review (all parties)
8th June 2018 Finalised Design with changes to address observations from Design Review(if Any).
6th July 2018 Submit Planning Application
August & September Prepare Tender Drawings & Specification & Tender to Contractors October 2018 Grant of Planning (Subject to planning process going smoothly) November 2018 Appoint Contractor & Commence On Site
31st March 2019 Complete Works (Ready for Occupation)
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Also in relation restrictive practices the PIC will ensure that all sensor mats and audio devices are reviewed regularly by the relevant team member or specialist if prescribed for a reason such as epilepsy. The PIC will then ensure that any restrictive practices are then reviewed through restrictive practice meetings and notified through quarterly NF39.
The PIC will ensure that all audio devices are switched off when not required and this will be reflected in residents’ epilepsy action plan. The PIC will ensure this through regular communication and checks.
Regulation 28: Fire precautions Substantially Compliant
Outline how you are going to come into compliance with Regulation 28: Fire precautions:
It has been clearly communicated to staff that cannot wedge open any fire door. New magnet release system installed for resident’s room on 12.4.18
Regulation 29: Medicines and
pharmaceutical services Compliant
Outline how you are going to come into compliance with Regulation 29: Medicines and pharmaceutical services:
See feedback form
Regulation 7: Positive behavioural
support Substantially Compliant
Outline how you are going to come into compliance with Regulation 7: Positive behavioural support:
(See feedback form)
The PIC is going to include index form on care plan which clearly shows the integrated behavior support plan.
CNS in positive behavior support will update existing support interventions to ensure that all strategies developed by CNS are clearly visible within the relevant sections of the care plan
PIC to arrange for all new staff to have individual training with CNS behavior in the behavior support plan as part of their induction.
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Regulation 9: Residents' rights Substantially Compliant
Outline how you are going to come into compliance with Regulation 9: Residents' rights:
Resident meals are provided from a centralized kitchen however, residents can choose from two options the week before. However on the day if they change their mind, the kitchen can provide another option. Each house also has a range of other options to offer the resident if chooses. Breakfast and snack times are provided in the house and again a wide range of choices are available.
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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
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.
Not Compliant Orange 1.5.18
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.
Not Compliant
Orange March 2019
Regulation
23(1)(c) The registered provider shall ensure that management systems are in
Not Compliant
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place in the designated centre to ensure that the service provided is safe, appropriate to residents’ needs, consistent and effectively monitored. Regulation
23(1)(d) The registered provider shall ensure that there is an annual review of the quality and safety of care and support in the designated centre and that such care and support is in accordance with standards.
Substantially
Compliant Yellow 11.6.18
Regulation
28(3)(a) The registered provider shall make adequate arrangements for detecting, containing and extinguishing fires. Substantially
Compliant Yellow Completed 12.4.18
Regulation 03(1) The registered provider shall prepare in writing a statement of purpose containing the information set out in Schedule 1.
Substantially
Compliant Yellow Completed 1.5.18
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
Substantially
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occasion on which a restrictive
procedure
including physical, chemical or
environmental restraint was used. Regulation
07(5)(c) The person in charge shall ensure that, where a resident’s
behaviour necessitates intervention under this Regulation the least restrictive procedure, for the shortest duration necessary, is used.
Substantially
Compliant Yellow 30.05.18
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.
Substantially
Compliant Yellow 1.5.18
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 Substantially
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