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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Birch Services
Name of provider:
Brothers of Charity Services
Ireland
Address of centre:
Roscommon
Type of inspection:
Unannounced
Date of inspection:
16 April 2018
Centre ID:
OSV-0004467
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
Birch Services is a residential service, which is run by the Brothers of Charity Services. The centre provides accommodation and support for twelve male and female adults over the age of 18 years, with an intellectual disability, including those with a diagnosis of dementia. The centre comprises of two bungalows and both are located on the outskirts of two separate towns in Co. Roscommon. Both bungalows comprise of residents' bedrooms and en-suites, shared bathrooms, office spaces, kitchen and dining areas, utility areas and sitting rooms. Residents also have access to garden areas. Staff are on duty both day and night to support residents availing of this service.
The following information outlines some additional data on this centre.
Current registration end
date:
14/02/2019
Number of residents on the
date of inspection:
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How we inspect
To prepare for this inspection the inspector or inspectors reviewed all information about this centre. This included any previous inspection findings, registration information, information submitted by the provider or person in charge and other unsolicited information since the last inspection.
As part of our inspection, where possible, we:
speak with residents and the people who visit them to find out their experience of the service,
talk with staff and management to find out how they plan, deliver and monitor
the care and support services that are provided to people who live in the centre,
observe practice and daily life to see if it reflects what people tell us,
review documents to see if appropriate records are kept and that they reflect practice and what people tell us.
In order to summarise our inspection findings and to describe how well a service is doing, we group and report on the regulations under two dimensions of:
1. Capacity and capability of the service:
This section describes the leadership and management of the centre and how effective it is in ensuring that a good quality and safe service is being provided. It outlines how people who work in the centre are recruited and trained and whether there are appropriate systems and processes in place to underpin the safe delivery and oversight of the service.
2. Quality and safety of the service:
This section describes the care and support people receive and if it was of a good quality and ensured people were safe. It includes information about the care and supports available for people and the environment in which they live.
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This inspection was carried out during the following times:
Date
Times of
Inspection
Inspector
Role
16 April 2018 10:30hrs to
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Views of people who use the service
The inspector met with six residents who live in this centre, with four speaking directly with the inspector. During the inspection, one resident requested to speak with the inspector in private and this was facilitated.
Residents spoke with the inspector about the care and support they receive and said they were happy with the staff working in the centre and with their bedroom as it gave them privacy and sufficient storage for their personal items. Residents told the inspector about the activities that staff support them to engage in and told of their plans to attend up-coming events in the local town. Residents also told the inspector of their involvement in the running of the centre through regular meetings with staff and that they are supported to complete daily chores in the centre. Overall,
residents stated they were happy with the social opportunities available to them; however, some residents told the inspector that they would like to have the support available to engage in more activities of interest to them.
Capacity and capability
The provider had arrangements in place to ensure the service received by residents was regularly monitored and reviewed. Although the provider had satisfactorily completed some actions arising from the last inspection, improvements were still required to ensure adequate staffing levels were in place to support the needs of residents living in the centre.
Staff told the inspector that they were regularly kept informed of changes occurring within the organisation through team meetings. These meetings also gave staff an opportunity to raise any concerns relating to the care and welfare of residents. The provider ensured that staff were kept up-to-date on their roles and responsibilities and that they received regular supervision from the person in charge. Training and development arrangements ensured that all staff received mandatory training as required by the regulations. Where staff requested or required additional training to support them in their role, this training was provided. Staff who spoke with the inspector were very familiar with each resident's needs and of their role in supporting these residents, especially in relation to the management of specific health care needs.
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provider had systems available that supported the person in charge to escalate concerns relating to the centre. At the time of inspection, the person in charge was aware of the specific improvements required within the service, had escalated these in line with the organisations' procedures and was regularly updated on the work the provider had made towards addressing these concerns.
The provider ensured that residents received continuity of care and support from the staff working in the centre. There was a planned and actual roster in place and this clearly identified the staff on duty during the day and night. Since the last
inspection, the provider had allocated additional support hours to the service, which meant that residents had extra staff support available to them to engage in activities of interest to them. Staff told the inspector that this additional support had a
positive impact on the quality of service received by residents. At the time of inspection, the provider was preparing a business case to request additional social care support for the service. In the interim, the inspector observed that due to a lack of social support available to residents at weekends, this meant residents could only engage in social opportunities on Saturdays, with insufficient support in place for residents to engage in social activities on Sundays. In addition, although nursing care was provided in the centre, the provider had not assessed residents' nursing care needs to ensure the current allocation of nursing care adequately met the nursing care needs of the residents.
Regulation 15: Staffing
The provider had failed to ensure that the skill mix and number of staff was based on the assessed nursing needs of the residents.
There was a lack of sufficient staffing to support resident access social care support at weekends.
The provider failed to ensure that where nursing care was required, it was provided subject to the statement of purpose.
Judgment: Not compliant
Regulation 16: Training and staff development
Staff had up-to-date training in areas such as manual handling, safeguarding, fire safety, management of behaviours that challenge and safe administration of medications. Additional training was also available to staff as-required. Staff received regular supervision and copies of the regulations and standards were available in the centre for staff to reference.
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Judgment: Compliant
Regulation 23: Governance and management
The provider had governance systems and processes in place to assess the quality and safety of the service. in addition, the person in charge was ensuring that regular meetings were held with staff to discuss service improvements and residents'
experience.
Judgment: Compliant
Regulation 3: Statement of purpose
At the time of inspection, the provider was in the process of reviewing the
Statement of Purpose. However, the current statement of purpose did not include all the requirements of schedule 1.
Judgment: Substantially compliant
Quality and safety
Although generally residents received the care and support that they required and were facilitated to spend their time as they wished, improvements were required to how the provider assessed and put in arrangements to meet the needs of residents.
Since the last inspection, the provider Had made improvements to the arrangements in place for healthcare and personal planning. However, improvements were still required to the fire safety and risk management arrangements.
Improved personal planning arrangements ensured that residents had personal plans in place to guide staff on the care and support they required. Personal goals were developed with residents and their families and clear records were in place demonstrating the progress residents had made towards achieving their goals. Improvements were also observed to healthcare arrangements, ensuring staff had access to clear guidance on the daily support required by residents with specific healthcare needs. Residents also had regular reviews with allied health care professionals.
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modifications recently completed to meet the changing mobility needs of residents. However, some gaps were observed to the system in place to assess residents' specific needs.
Systems were in place to support staff to know how to detect, respond to and manage safeguarding concerns. Where residents presented with behaviour that challenges, arrangements were in place to support these residents. Comprehensive guidance was in place to guide staff on the appropriate application of restrictive practices. However, improvements were required to the risk assessment of these practices to ensure they supported the safety and welfare of residents while these were in use.
The provider had some fire precautions in place including fire fighting equipment, clear fire exits, regular checks of the fire systems and emergency lighting. Staff had received up-to-date training in fire safety and staff who spoke with the inspector knew their role and responsibility in the event of a fire in the centre. Although fire drills were occurring on a regular basis, a fire drill with minimum staffing levels had not been conducted with the current residents living in the centre. This was brought to the attention of the person in charge who scheduled a fire drill to be completed in the days subsequent to the inspection. Following the inspection the person in charge assured the inspector that this drill had been completed.
A fire safety assessment of the centre was completed by a competent person in 2017, which identified improvements were required to the centre's fire containment arrangements and fire detection systems. However, the provider had failed to address these improvements and had no plan in place for when these works would be completed.
To mitigate against the risk of fire spreading within the centre, procedures were in place to guide staff on the containment measures to be adhered to at night.
However, procedures were not in place to guide staff on containment measures to be adhered to during the day when residents were present in the centre. This was rectified by the person in charge by the close of the inspection. Although clear fire procedures were displayed in the centre, these procedures did not guide staff on how to access support when the providers' out-of-hours services were not available during the night.
The provider had a system in place to ensure organisational risks were regularly reviewed and that residents were kept safe from identified risks. Although some improvements had been made to this system since the last inspection, some risk assessments still did not describe the measures in place to manage specific risks. For instance, the fire risk assessment for the centre did not accurately describe the measures in place to prevent the occurrence of fire in the centre. Furthermore, although the provider had arrangements in place for the assessment of residents' specific risks, the provider had failed to ensure guidance was available to ensure staff were aware of how to respond to the occurrence of adverse events.
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Regulation 10: Communication
Radio, television and Internet was available in this centre. Where residents
presented with communication needs, arrangements were in place to support these residents to communicate their wishes. Comprehensive personal plans were in place to guide staff on how to communicate with these residents and communication tools were available to residents also.
Judgment: Compliant
Regulation 26: Risk management procedures
The provider failed to ensure risk assessments adequately described the control measures in place to mitigate risks.
The provider failed to ensure risk assessments were in place to ensure safe manual handling practices for residents in use of hoists.
The provider failed to ensure a procedure was in place to guide staff on what to do where such an incident occurs to ensure a timely response to the review of
residents' safety and welfare.
Judgment: Not compliant
Regulation 28: Fire precautions
Personal evacuation plans were in place for each resident; however, some required revision to ensure they provided clear guidance on the supports required by
residents in the event of a fire.
The provider failed to complete works to the centre's fire containment and fire detection systems, as required from a competent persons report.
The fire procedures did not guide staff on the out-of-hours arrangements available to support them in the event of an evacuation.
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Regulation 5: Individual assessment and personal plan
The person in charge failed to assess the nursing care needs of residents to determine the level of nursing care each resident required. In addition, although some assessments were being completed on residents needs such as
communication, these did not take in to account the specific communication needs for residents with dementia.
Judgment: Not compliant
Regulation 6: Health care
Where assessments of residents' specific healthcare needs had been completed there were comprehensive plans in place to guide staff on how to support these residents. Residents had access to various allied health care professionals, including, speech and language therapists, physiotherapists, behavioural specialists and
general practitioners. Staff who spoke with the inspector were very familiar with residents' healthcare needs and how they were required to support these residents.
Judgment: Compliant
Regulation 7: Positive behavioural support
Where residents presented with behaviour that challenges, arrangements were in place to ensure these residents were supported. All staff had up-to-date training in the management of behaviour that challenges. Where restrictive practices were in place there were clear protocols to guide staff in their application. However, some of these practices such as the use of bed rails did not have an adequate risk
assessment or control measures in place to ensure that the resident remained safe while they were in use.
Judgment: Substantially compliant
Regulation 8: Protection
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manage safeguarding concerns. All staff working in the centre had received up-to-date training in safeguarding.
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Appendix 1 - Full list of regulations considered under each dimension
Regulation Title
Judgment
Capacity and capability
Regulation 15: Staffing Not compliant
Regulation 16: Training and staff development Compliant Regulation 23: Governance and management Compliant Regulation 3: Statement of purpose Substantially
compliant
Quality and safety
Regulation 10: Communication Compliant
Regulation 26: Risk management procedures Not compliant Regulation 28: Fire precautions Not compliant Regulation 5: Individual assessment and personal plan Not compliant
Regulation 6: Health care Compliant
Regulation 7: Positive behavioural support Substantially compliant
Regulation 8: Protection Compliant
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Compliance Plan for Birch Services OSV-0004467
Inspection ID: MON-0020995
Date of inspection: 16/04/2018
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 Not Compliant
Outline how you are going to come into compliance with Regulation 15: Staffing:
A business case have been prepared and forwarded to the Funders highlighting the increasing needs and the need for additional staffing at weekends 17/5/2018
There is a nurse led service in one house and the clinical needs of the people supported have been assessed. There are clear guidelines and protocols in place to guide all staff in supporting people.
The statement of purpose is being reviewed to clarify where a nurse led service is in place and the skill mix is clearly identified on the roster.
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 is being updated to include all the requirements of schedule 1
Regulation 26: Risk management
procedures Not Compliant
Outline how you are going to come into compliance with Regulation 26: Risk management procedures:
All risk assessments have been updated and control measures put in place to mitigate against risk.
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Risk assessments have been reviewed in consultation with the physiotherapist to ensure safe manual handling practices for people who require the use of a hoist.
Guidance is now available to ensure staff are aware of how to respond to an occurrence of adverse events.
Regulation 28: Fire precautions Not Compliant
Outline how you are going to come into compliance with Regulation 28: Fire precautions:
Personal evacuation plans have been updated to ensure they provide clear guidance on the supports required by people supported in the event of a fire.
An updated funding request has been forwarded to the funding provider on receipt on this report requesting funding in order that required works are completed by 1st June 2018.
Out of hours arrangements in the event of a fire have been updated to guide staff in the event of an evacuation.
Regulation 5: Individual assessment
and personal plan Not Compliant
Outline how you are going to come into compliance with Regulation 5: Individual assessment and personal plan:
The person in charge has assessed the nursing needs of the people supported. There are now clear guidelines and protocols for the management of each medical condition. This is a nurse led service, supported by Social Care Workers and Care staff.
In consultation with the Speech and Language Therapist a dementia specific communication assessment has been carried out as required.
Regulation 7: Positive behavioural
support Substantially Compliant
Outline how you are going to come into compliance with Regulation 7: Positive behavioural support:
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Section 2:
Regulations to be complied with
The provider or person in charge must consider the details and risk rating of the following regulations when completing the compliance plan in section 1. Where a regulation has been risk rated red (high risk) the inspector has set out the date by which the provider or person in charge must comply. Where a regulation has been risk rated yellow (low risk) or orange (moderate risk) the provider must include a date (DD Month YY) of when they will be compliant.
The registered provider or person in charge has failed to comply with the following regulation(s).
Regulation Regulatory
requirement Judgment Risk rating Date to be complied with
Regulation 15(1) The registered provider shall ensure that the number,
qualifications and skill mix of staff is appropriate to the number and assessed needs of the residents, the statement of purpose and the size and layout of the designated centre.
Not Compliant Orange This compliance plan response from the registered provider did not adequately assure the office of the chief inspector that the actions will result in compliance with the
regulations.
Regulation 15(2) The registered provider shall ensure that where nursing care is required, subject to the statement of purpose and the assessed needs of residents, it is provided.
Substantially
Compliant Yellow 18/5/18
Regulation 26(2) The registered provider shall ensure that there are systems in place in the designated centre
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for the assessment, management and ongoing review of risk, including a system for responding to emergencies. Regulation 28(1) The registered
provider shall ensure that
effective fire safety management systems are in place.
Substantially
Compliant Yellow 16/5/18
Regulation
28(3)(a) The registered provider shall make adequate arrangements for detecting,
containing and extinguishing fires.
Not Compliant Red 01 June 2018
Regulation
28(3)(d) The registered provider shall make adequate arrangements for evacuating, where necessary in the event of fire, all persons in the designated centre and bringing them to safe locations.
Substantially
Compliant Yellow 25/4/18
Regulation 28(5) The person in charge shall ensure that the procedures to be followed in the event of fire are displayed in a prominent place and/or are readily available as appropriate in the designated centre.
Substantially
Compliant Yellow 18/5/18
Regulation 03(1) The registered provider shall prepare in writing a statement of
Substantially
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purpose containing the information set out in Schedule 1. Regulation
05(1)(b) The person in charge shall ensure that a comprehensive assessment, by an appropriate health care professional, of the health, personal and social care needs of each resident is carried out subsequently as required to reflect changes in need and
circumstances, but no less frequently than on an annual basis.
Not Compliant
Orange 30/6/18
Regulation 07(4) The registered provider shall ensure that, where restrictive
procedures
including physical, chemical or
environmental restraint are used, such procedures are applied in accordance with national policy and evidence based practice.
Substantially