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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Avalon
Name of provider:
Health Service Executive
Address of centre:
Meath
Type of inspection:
Announced
Date of inspection:
19 September 2018
Centre ID:
OSV-0003694
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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 designated centre provides 24 hours residential care and currently
accommodates seven adults both male and female with an intellectual disability. The centre is a large detached bungalow a few kilometres outside a town in Co. Meath. The centre comprises of fifteen rooms including two store areas and a lobby area. There is a kitchen, dining room, sitting room, office, utility room, store room and seven bedrooms, all with ensuite facilities. There is one separate bathroom and one wheelchair accessible toilet. The centre has a large garden and patio area at the back of the house. It has its own transport; a wheelchair accessible vehicle and a people carrier. The person in charge works full-time in this centre and there are 6 nurses and 7 health care assistants employed in this centre.
The following information outlines some additional data on this centre.
Current registration end
date:
21/09/2019
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
19 September 2018 11:00hrs to
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Views of people who use the service
The inspector met with a number of the residents 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 HIQA questionnaires, residents’ weekly meeting minutes, the designated centre’s annual review and various other records that endeavoured to voice the resident’s opinion.
Two of the residents showed the inspector around their bedrooms and pointed out where they had been involved in the décor of the room. The residents seemed happy and proud to show the inspector family photographs, memorabilia and personal items contained within their rooms. The inspector observed the residents smiling and appearing enthusiastic when looking a photographs of goals they were supported to achieve.
One of the residents advised the inspector that they were happy living in the house. A family member of one of the residents called in on the day of inspection and informed the inspector that her family member saw the centre as her “home” and enjoyed living there.
One resident noted on a questionnaire that they were happy with the activities they engaged in and happy how they chose to spend their time. Another resident noted that they had ample choice around meals, day trips and daily living activities. A number of residents advised that when they made a complaint, they were happy with the way it was dealt with and were satisfied with the outcome.
The inspectors observed that residents' needs were very well known to staff. The residents appeared very comfortable in their home and relaxed in the company of staff. The inspector observed that staff were kind and respectful towards residents through positive, mindful and caring interactions. All of the residents’ feedback questionnaires relayed positive comments about the staff and in particular how kind and helpful they were.
Capacity and capability
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upheld through care and support that was person-centred and promoted an inclusive environment where each of the residents’ needs, wishes and intrinsic
value were taken in to account. There were clear lines of accountability at individual, team and organisational level so that all staff working in the centre were aware of their responsibilities and who they were accountable to. This was the second inspection of this centre within nine months, with both inspections resulting in high compliance and evidence of good quality of care provided to residents.
Governance and management systems in place ensured residents received positive outcomes in their lives and the delivery of a safe and quality service. The inspector found that there was a comprehensive auditing system in place by the person in charge to evaluate and improve the provision of service and to achieve better outcomes for the residents.
The person in charge had commenced in the role in February 2018. The person in charge was familiar with the residents' needs and ensured that they were met in practice. The inspector found that the person in charge had a clear understanding and vision of the service to be provided and, supported by the provider, fostered a culture that promoted the individual and collective rights of the residents.
The inspector spoke with a number of staff who demonstrated appropriate understanding and knowledge of policies and procedures that ensure safe and effective care of residents. The inspector found that staff had the necessary competencies and skills to support the residents that lived in the centre and had developed therapeutic relationships with the residents.
On the previous inspection in January 2018, the inspector found that there were sufficient numbers of staff with the necessary experience and competencies to meet the needs of the residents living in the centre and that staff mandatory training was up to date.
One to one supervision meetings were taking place every six months 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. Staff informed the inspector that they felt supported by the person in charge and that they could approach them at any time in relation to concerns or matters that arose.
Regulation 23: Governance and management
Unannounced six monthly reviews and annual reviews were being carried out in line with regulation requirements.
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Regulation 24: Admissions and contract for the provision of services
Judgment: Compliant
Regulation 3: Statement of purpose
The service being delivered was in line with the current statement of purpose.
Judgment: Compliant
Regulation 31: Notification of incidents
Overall, the inspector found that effective information governance arrangements were in place to ensure that the designated centre complied with notification requirements however, on the day of inspection a small number of notifications either required submission or additional information. On the day after the inspection, all outstanding notifications were submitted.
Judgment: Substantially compliant
Regulation 4: Written policies and procedures
The Schedule 5 policies and procedures were adopted, implemented and made available to staff.
Judgment: Compliant
Quality and safety
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The inspector looked at a sample of personal plans and found that residents had up to date personal plans which were continuously developed and reviewed in
consultation with the resident, relevant keyworker, and where appropriate, allied health care professionals and family members.
The 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. Where appropriate, residents were provided with an accessible format of their personal plan.
The residents’ personal plans promoted meaningfulness and independence in their lives and recognised the intrinsic value of the person by respecting their uniqueness. Four of the residents attended a local day service and three of the residents chose to be involved in a New Directions type programme which provided person-centred support that was tailored to meet their individual needs. Overall, the inspector found that the residents were supported to live a life of their choosing in accordance with their own wishes, needs and aspirations.
Residents were assisted to exercise their right to experience a full range of relationships, including friendships, community links as well as personal
relationships. One resident's goal involved maintaining a relationship with a friend who they had previously attended day service with. The resident was supported by staff to plan and organise an overnight holiday away with their friend.
Residents were facilitated and empowered to exercise choice and control across a range of daily activities and to have their choices and decisions respected. Regular house meetings occurred with the agenda including matters such as complaints, health and safety, person centred planning, news and upcoming activities on offer.
The inspector found that the residents were protected by practices that promoted their safety. Staff facilitated a supportive environment which enabled the residents to feel safe and protected from abuse. There was an atmosphere of openness, and the resident's modesty and privacy was observed to be respected. Residents were supported to develop their knowledge, self-awareness, understanding and skills required for self care and protection through accessible information and residents' meetings promoting safeguarding information
On the day of inspection, in relation to an unexplained incident, the inspector sought further clarification around the follow up actions in response to this incident. The person in charge immediately followed up and commenced an enquiry in to the incident and of the oversight of certain procedures not being followed up on.
The provider and person in charge promoted a positive approach in responding to behaviours that challenge and ensured evidence-based specialist and therapeutic interventions were implemented. The inspector saw evidence that there was clear, correct and positive communications which helped residents understand their own behaviour and how to behave in a manner that respects the rights of others and supports their development. Systems were in place to ensure that where
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required.
Behaviour support plans for two of the residents had recently been reviewed and updated. The inspector was advised that staff training had been arranged to ensure consistency of delivery of the plans, which in turn would ensure better outcomes for the residents whom the plans supported and in turn, for other residents living in the house.
The inspector found that there were good systems in place for the prevention and detection of fire. The audit and inspection requirements set out in the safety statement included monthly and weekly checks ensuring precautions implemented reflected current best practice. However, on the day of inspection the inspector found that improvements were needed to the simulated evacuation procedure.
The physical environment of the house was clean and overall, in good decorative and structural repair. The environment in both houses provided appropriate stimulation and opportunity for the residents to rest, relax and engage in
recreational activities. On the day of inspection a number of rooms in the house were being painted. Residents advised the inspector that they had chosen the colour of paint for their own individual rooms and for communal areas in the house.
Regulation 17: Premises
The premises met the needs of the residents and the design and layout promoted resident's safety, dignity, independence and well-being.
Judgment: Compliant
Regulation 28: Fire precautions
There were systems in place for the prevention and detection of fire.however, the procedure for safe evacuation required improvements so that simulated fire drills included all procedures on residents personal evacuation plans.
The inspector found that one of the resident's personal evacuation plan did not provide clear direction on how to support them evacuate however, on the day of inspection this was updated so that the plan provided full clarification of support required for the resident.
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Regulation 5: Individual assessment and personal plan
Residents had an up to date personal plan which reflected their continued assessed needs and outlined the support required to maximise their personal development in accordance with their wishes, individual needs and choices.
Judgment: Compliant
Regulation 7: Positive behavioural support
The inspector found that in relation to consent, there was a gap in the
documentation however, care was delivered to high standard and did not result in a medium to high risk to residents.
Judgment: Substantially compliant
Regulation 8: Protection
Residents were safeguarded because staff understand their role in adult protection and are able to put appropriate procedures into practice when necessary.
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Appendix 1 - Full list of regulations considered under each dimension
Regulation Title
Judgment
Capacity and capability
Regulation 23: Governance and management Compliant Regulation 24: Admissions and contract for the provision of
services Compliant
Regulation 3: Statement of purpose Compliant Regulation 31: Notification of incidents Substantially
compliant Regulation 4: Written policies and procedures Compliant
Quality and safety
Regulation 17: Premises Compliant
Regulation 28: Fire precautions Substantially compliant Regulation 5: Individual assessment and personal plan Compliant Regulation 7: Positive behavioural support Substantially
compliant
Regulation 8: Protection Compliant
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Compliance Plan for Avalon OSV-0003694
Inspection ID: MON-0022546
Date of inspection: 19/09/2018
Introduction and instruction
This document sets out the regulations where it has been assessed that the provider or person in charge are not compliant with the Health Act 2007 (Care and Support of Residents in Designated Centres for Persons (Children And Adults) With Disabilities) Regulations 2013, Health Act 2007 (Registration of Designated Centres for Persons (Children and Adults with Disabilities) Regulations 2013 and the National Standards for Residential Services for Children and Adults with Disabilities.
This document is divided into two sections:
Section 1 is the compliance plan. It outlines which regulations the provider or person in charge must take action on to comply. In this section the provider or person in charge must consider the overall regulation when responding and not just the individual non compliances as listed section 2.
Section 2 is the list of all regulations where it has been assessed the provider or person in charge is not compliant. Each regulation is risk assessed as to the impact of the non-compliance on the safety, health and welfare of residents using the service.
A finding of:
Substantially compliant - A judgment of substantially compliant means that
the provider or person in charge has generally met the requirements of the regulation but some action is required to be fully compliant. This finding will have a risk rating of yellow which is low risk.
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 31: Notification of incidents Substantially Compliant
Outline how you are going to come into compliance with Regulation 31: Notification of incidents:
I have submitted NF06 on 20TH September
NFO6 on 20th September
NF06 on 26th September
NF06 on 26th September
NF06 on 18th September
Regulation 28: Fire precautions Substantially Compliant
Outline how you are going to come into compliance with Regulation 28: Fire precautions:
A simulated night time drill was carried out on 14/10/18. 6 residents were evacuated safely and one resident said they would leave the building if there was a real fire. Fire drill carried out during night duty on 24th October ’18. 6 residents were evacuated safely
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Regulation 7: Positive behavioral
support Substantially Compliant
Outline how you are going to come into compliance with Regulation 7: Positive behavioral support:
A meeting was organized with resident and their representative, regarding informed consent for use of
therapeutic interventions prescribed for resident in their mental health management plan by their psychiatrist. I will make sure that every effort is made to identify and alleviate the cause of the president’s behavior of concern. I will make sure all alternative
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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
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 1
st December
’18
Regulation
31(1)(f) The person in charge shall give the chief inspector notice in writing within 3 working days of the following adverse incidents occurring in the designated centre: any allegation, suspected or confirmed, of abuse of any resident.
Substantially
Compliant Yellow 31
st Oct’18
Regulation
31(3)(a) The person in charge shall ensure that a written report is provided to the
Substantially
Compliant Yellow 25
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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 07(3) The registered
provider shall ensure that where required,
therapeutic interventions are implemented with the informed consent of each resident, or his or her representative, and are reviewed as part of the personal planning process.
Substantially
Compliant Yellow 23
