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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Rossmore
Name of provider:
St Michael's House
Address of centre:
Dublin 6w
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
Rossmore provides full-time residential support to male and female adults. Rossmore is based on the social care model and aims to support residents to live as
independently as possible. This service is located in a residential area, and within walking distance of local amenities such as shops and leisure facilities. The centre is close to public transport which enables residents to access additional facilities in their local community. The centre comprises one large two-storey dwelling. Residents have access to a communal sitting room, kitchen/dining room, utility room with laundry facilities and another small sitting room. In addition, there is two communal bathrooms provided, located on the ground floor and first floor of the centre. There were gardens to the front and rear of the centre, which residents had access to. The staff team are assigned throughout day based on the assessed needs of residents'. In addition, at night, an over-night staff is available to provide assistance to residents if required.
The following information outlines some additional data on this centre.
Current registration end
date:
01/10/2018
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
01 May 2018 09:15hrs to
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Views of people who use the service
The inspector met with six residents who used this service. Residents, who spoke with the inspector, stated they were happy with the service and care provided. They also confirmed that they had good access to the local community and enjoyed living in the centre. Residents were also offered choice with their day services and some were supported to enjoy a home based programme. All residents appeared
comfortable and relaxed in the company of each other and with staff, throughout the inspection.
Feedback forms were received by the inspector and these confirmed the satisfaction with the service at this time.
Capacity and capability
Overall, governance and management arrangements ensured that a good quality and safe service was provided for residents living at this centre.
The provider ensured that the service was subject to ongoing monitoring, review and development. This had resulted in an improved standard of care, support and safety being provided to residents living at the centre. For example, residents were provided individualised daily programmes where required, which reflected a person centred approach. Six-monthly audits of the centre’s practices were being carried out by the management team and staff carried out regular audits of areas such as, medication management and residents' finances. Records showed that the provider had identified areas of non-compliance, however, no clear plan or time frames were in place to clearly address the identified risks in a report dated March 2017.
The person in charge was based in the centre and worked closely with staff. She was, therefore, well known to the residents and was very familiar with their up-to-date care and support needs. There were suitable cover arrangements in place to ensure that staff were adequately supported when the person in charge was off duty.
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residents.
The management team ensured that safe and effective recruitment practices were in place so that staff had the required skills, experience and competencies to carry out their roles and responsibilities. They ensured that all staff had undergone Garda Síochána vetting as a primary safeguarding measure for ensuring that residents were safe and protected from abuse.
Rosters, and discussions with staff, showed that there were sufficient numbers of suitably qualified staff to support residents’ assessed needs and especially their daily activities programme. The inspector observed, and staff confirmed,
that staffing arrangements ensured that residents were able to take part in activities of their choice in the centre and the local community.
The provider had measures in place to review and evaluate risks, and for the recording and reviewing of adverse incidents and complaints. There had been a low level of accidents, incidents and complaints and there had been no serious accidents involving residents.
Regulation 14: Persons in charge
The role of the person in charge was full time and the person who filled this role had the required qualifications and experience. The person in charge was very
knowledgeable regarding the individual needs of each resident.
Judgment: Compliant
Regulation 15: Staffing
Planned staffing rosters had been developed and these were accurate at the time of inspection. Staffing levels and skill-mixes provided, reflected the assessed needs of all residents in the centre.
Judgment: Compliant
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Staff who worked in the centre had received training in all mandatory courses as required by the organisation. In addition, a training needs analysis had also been completed to identify specialised training required in the service.
Judgment: Compliant
Regulation 19: Directory of residents
The person in charge had maintained a directory of all residents in the centre and this contained the information required by the regulations. It also reflected any nights when residents did not reside in the centre.
Judgment: Compliant
Regulation 22: Insurance
The provider had ensured and maintained up-to-date insurance for the centre as required by the regulations.
Judgment: Compliant
Regulation 23: Governance and management
Governance and management arrangements in place had ensured that there was a high standard of care provided in the centre. This was regularly monitored and residents were supported in-line with their assessed needs. The provider had completed all actions identified from the last inspection; however, they had no plan in place to complete issues identified in a fire risk report completed in March 2017.
Judgment: Substantially compliant
Regulation 24: Admissions and contract for the provision of services
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Judgment: Substantially compliant
Regulation 3: Statement of purpose
There was a statement of purpose that described the service being provided to residents and met most of the requirements of the regulations. However, further improvement was required as it did not clearly state some of the information required be regulations. The provider reviewed the statement of purpose on an annual basis.
Judgment: Substantially compliant
Regulation 31: Notification of incidents
The provider had arrangements in place to ensure that notifiable events under regulations were submitted to the Chief Inspector.
Judgment: Compliant
Regulation 34: Complaints procedure
Residents were aware of their right to make a complaint and the provider had arrangements in place to ensure that all complaints were recorded and investigated in-line with the organisational policy
Judgment: Compliant
Regulation 4: Written policies and procedures
All policies required by Schedule 5 of the regulations were available to guide staff. However, the guidance provided in the recruitment policy did not clearly inform staff about vetting procedures that were required, in-line with national policy.
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Quality and safety
The inspector found that support arrangements in place at the centre ensured that residents were both protected from harm and supported in accordance with their assessed needs. Support arrangements at the centre also assisted residents to develop greater independence through a range of interventions which supported individuals to take positive risks in their day-to-day lives. Residents told the inspector that they felt safe at the centre and got on well with the staff who supported them.
The provider had ensured that some measures were in place to protect residents and staff from the risk of fire. These included up to date servicing of fire fighting extinguishers, the central heating boiler and the fire alarm system. Staff also carried out a range of fire safety checks. The fire evacuation procedure was displayed, staff had received formal fire safety training and effective fire evacuation drills involving residents and staff were carried out. Further improvement was required throughout the centre as identified in a fire report completed in March 2017. This report listed a range of fire measures that required improvement, which included: self closing devices on all doors, fire rated glass where required, gaps were noted on several doors and emergency lighting required improvement. However, the provider had not identified a time frame for completion of all work required and there was no clear plan in place at the time of inspection. Residents were engaging and completing fire drills and also had evacuation plans in place to ensure staff knew how to support all residents in the event of a fire.
The management team had taken measures to safeguard residents from being harmed or suffering abuse. There was a policy and all staff had received training in safeguarding. This ensured that they had the knowledge and skills to treat each resident with respect and dignity and to recognise the signs of abuse and or neglect.
Residents accessed a range of activities during the day both at the centre and in the local community which reflected their assessed needs. Residents told the inspector about holidays and activities they enjoyed during the week as well as the day service placements they attended. Residents also told the inspector that they were able to independently get to work, but if they required staff support this was readily available . Where residents were less independent than their peers, appropriate supports were put in place by staff to ensure their needs were met. Residents also told the inspector that they enjoyed social activities such as going to the
visiting family and having a drink in local pubs and restaurants. At the time of the inspection, several residents were also planning holidays in Ireland and aboard. Furthermore, the person in charge also ensured that the aging needs were
supported as assessed and residents had choice to actively retire in the centre. As a result individualised programmes were in place which reflected the assessed needs of residents.
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regarding appropriate storage, had been suitably addressed by the person in charge. Staff were observed to complete weekly audits of the medication stored in the centre. On review of the medication files, the inspector found that they were through and comprehensive, however, no assessments were completed to identify residents ability to self medicate.
The design and layout of the centre ensured that it was fully accessible and residents told the inspector that they liked living at the centre. Residents had personalised their bedrooms which reflected their personal choice. There were adequate storage facilities in place for their personal possessions. Overall, the inspector found that the centre was in a good state of repair and decoration throughout.
Regulation 13: General welfare and development
Residents were supported to participate in a range of activities which reflected their assessed needs, interests and personal goals. The provider ensured that support was provided in-line with residents' personal plans. This also promoted
their independence at the centre and accessing their local community.
Judgment: Compliant
Regulation 17: Premises
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Judgment: Compliant
Regulation 18: Food and nutrition
Residents' nutritional needs were well met. Residents chose, and took part, in
shopping for their own food. Suitable foods were provided to suit any special dietary needs of residents.
Judgment: Compliant
Regulation 20: Information for residents
The person in charge and provider had ensured that all information as required by the regulations were available in the designated centre at the time if inspection.
Judgment: Compliant
Regulation 26: Risk management procedures
Risk management arrangements ensured that risks were identified, monitored and regularly reviewed and reflected staff practices and knowledge. Personal emergency evacuation plans had been developed for each resident, which provided sufficient guidance on how to ensure resident safety.
Judgment: Compliant
Regulation 27: Protection against infection
There were measures in place to protect residents from the spread of infection. These included an up-to-date infection control policy, and effective cleaning systems and procedures for food safety management.
Judgment: Compliant
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While the person in charge had ensured that measures were in place to assist and support residents with fire precautions. Further improvement was required as significant work was evident throughout the centre. This included: fire
doors, intumescent seals, self closures, fire glass and emergency lighting. The provider was aware of all required works but had no clear plan in place at the time of inspection. The provider had a report completed in 2017 identifying all the required fire safety measures needed, however, none of these had been addressed and no clear plan was in place to complete this work.
Judgment: Not compliant
Regulation 29: Medicines and pharmaceutical services
There were safe medication management practices in the centre and there was an up-to-date policy to guide staff. Residents' medication was securely stored at the centre and staff who administered medication had received training in safe administration of medication. Issues identified in the last inspection had been completed satisfactorily. However, self assessments for administration of medications, had not been completed for all residents in the centre.
Judgment: Substantially compliant
Regulation 5: Individual assessment and personal plan
All residents' had personal plans developed and included their assessed needs. Annual personal planning meetings, which included the resident and their
representatives, were held as scheduled. Residents' personal goals were agreed at these meetings and reviewed as scheduled. These plans were also provided in a user-friendly format.
Judgment: Compliant
Regulation 6: Health care
The health needs of residents were assessed and they had good access to a range of healthcare services. This included, general practitioners, healthcare professionals and consultants. Plans of care for good health were developed for residents and reflected their assessed needs.
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Judgment: Compliant
Regulation 7: Positive behavioural support
The provider had measures in place to support all residents with behaviours that challenge. Behaviour support plans had been developed where required with input from a psychologist or behaviour support specialist. Plans were implemented and the occurrences of incidents arising from behaviours that challenge were minimal at the time of inspection. All staff had completed training in relation to management of behaviours that challenge.
Judgment: Compliant
Regulation 8: Protection
Arrangements were in place to ensure that all residents were safeguarded from harm or abuse in the centre. All staff had received training in-line with national and local policies. All staff had received training in safeguarding and there was an up-to-date policy in place to guide staff. The management team were clear about what constituted abuse and demonstrated proactive measures that would be taken in response to a suspicion of abuse.
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Appendix 1 - Full list of regulations considered under each dimension
Regulation Title
Judgment
Capacity and capability
Regulation 14: Persons in charge Compliant
Regulation 15: Staffing Compliant
Regulation 16: Training and staff development Compliant Regulation 19: Directory of residents Compliant
Regulation 22: Insurance Compliant
Regulation 23: Governance and management Substantially 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 Compliant Regulation 34: Complaints procedure Compliant Regulation 4: Written policies and procedures Substantially
compliant
Quality and safety
Regulation 13: General welfare and development Compliant
Regulation 17: Premises Compliant
Regulation 18: Food and nutrition Compliant Regulation 20: Information for residents Compliant Regulation 26: Risk management procedures Compliant Regulation 27: Protection against infection Compliant Regulation 28: Fire precautions Not compliant Regulation 29: Medicines and pharmaceutical services Substantially
compliant Regulation 5: Individual assessment and personal plan Compliant
Regulation 6: Health care Compliant
Regulation 7: Positive behavioural support Compliant
Regulation 8: Protection Compliant
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Compliance Plan for Rossmore OSV-0002404
Inspection ID: MON-0023738
Date of inspection: 01/05/2018
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 23: Governance and
management Substantially Compliant
Outline how you are going to come into compliance with Regulation 23: Governance and management:
The registered provider has a plan in place for the completion of the works required as identified in the fire risk report. Plan as follows
1. Self closing doors installation to be completed by 31st December 2018.
2. Cold smoke seals replace intumescent strip with combined intumescent strip/cold smoke seals by 30th September 2018.
3. Review of doors to dining and sitting room to ensure fire resistant glazing in place and upgrade where needed to be completed by 30th September 2018.
4. Emergency Lighting issue identified in report was addressed and completed in 2017.
5. Fire Alarm detection in hot press to be installed by 31st December 2018.
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:
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Regulation 3: Statement of purpose Substantially Compliant
Outline how you are going to come into compliance with Regulation 3: Statement of purpose:
The PIC reviewed the Statement of purpose and it contains the information required as set out in Schedule 1 (copy of same attached).
Regulation 4: Written policies and
procedures Substantially Compliant
Outline how you are going to come into compliance with Regulation 4: Written policies and procedures:
The registered provider is in the process of updating the recruitment policy in line with the national policy on vetting procedures. This will be completed by 30th November 2018.
Regulation 28: Fire precautions Not Compliant
Outline how you are going to come into compliance with Regulation 28: Fire precautions: The registered provider has a plan in place to address the fire safety measures as
identified in Fire risk report completed in March 2017. Plan as follows
1. Self closing doors installation to be completed by 31st December 2018.
2. Cold smoke seals replace intumescent strip with combined intumescent strip/cold smoke seals by 30th September 2018.
3. Review of doors to dining and sitting room to ensure fire resistant glazing in place and upgrade where needed to be completed by 30th September 2018.
4. Emergency Lighting issue identified in report was addressed and completed in 2017.
5. Fire Alarm detection in hot press to be installed by 31st December 2018.
Regulation 29: Medicines and
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Outline how you are going to come into compliance with Regulation 29: Medicines and pharmaceutical services:
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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
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. Substantially
Compliant Yellow 1. 31/12/2018 2. 30/09/2018 3. 30/09/2018 4. completed 2017
5. 31/12/2018
Regulation 24(3) The registered provider shall, on admission, agree in writing with each resident, their representative where the resident is not capable of giving consent, the terms on which that resident shall reside in the designated centre.
Substantially
Compliant Yellow 31/05/2018
Regulation 28(1) The registered provider shall ensure that
effective fire safety
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management systems are in place.
2017
5. 31/12/2018
Regulation
28(2)(a) The registered provider shall take adequate
precautions
against the risk of fire in the
designated centre, and, in that
regard, provide suitable fire fighting equipment, building services, bedding and furnishings.
Not Compliant Orange 1. 31/12/2018 2. 30/09/2018 3. 30/09/2018 4. completed 2017 5. 31/12/2018 Regulation
28(2)(c) The registered provider shall provide adequate means of escape, including
emergency lighting.
Not Compliant Orange 4. completed 2017
Regulation
28(3)(a) The registered provider shall make adequate arrangements for detecting,
containing and extinguishing fires.
Not Compliant Orange 1. 31/12/2018 2. 30/09/2018 3. 30/09/2018 4. completed 2017
5. 31/12/2018
Regulation 29(5) The person in charge shall ensure that following a risk assessment and assessment of capacity, each resident is
encouraged to take responsibility for his or her own medication, in accordance with his or her wishes and preferences and in line with his or her age and the
Substantially
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nature of his or her disability. 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 31/05/2018
Regulation 04(3) The registered provider shall review the policies and procedures referred to in paragraph (1) as often as the chief inspector may require but in any event at intervals not exceeding 3 years and, where necessary, review and update them in accordance with best practice.
Substantially
