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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Meadowview Bungalows 3 & 4
Name of provider:
Redwood Neurobehavioural
Services Limited
Address of centre:
Meath
Type of inspection:
Announced
Date of inspection:
09 May 2018
Centre ID:
OSV-0005175
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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 centre provides a residential service for adults both male and female over the age of 18years with intellectual disabilities, autistic spectrum and acquired brain injuries who may also have mental health difficulties and behaviours which challenge. The centre consists of two bungalows that can accommodated five residents in one bungalow and six residents in another.
The following information outlines some additional data on this centre.
Current registration end
date:
21/10/2018
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
09 May 2018 10:30hrs to
19:30hrs Andrew Mooney Lead 09 May 2018 10:30hrs to
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Views of people who use the service
The views of the people who use the service were established by speaking with some residents and observing them at different points throughout the
day. Additionally, documentation such as resident questionnaires and the complaints & compliments folder were reviewed.
The inspectors met and engaged with six residents in line with their assessed needs and preference's. The inspectors observed very positive interactions between
residents and staff. It was clear residents were comfortable in the company of staff. Staff engaged positively with residents and demonstrated that they knew and understood the individual communication needs of residents.
From a review of the residents questionnaires it was clear that residents were happy with staff and they felt safe in the centre.
Capacity and capability
The centre had the capacity and capability to positively support residents in all aspects of their lives.
The residential service had effective leadership, governance and management arrangements in place and clear lines of accountability. The person in charge had a schedule of monthly audits that covered areas such as health and safety, risk management, notifications and medication. These were reviewed during monthly governance and supervision meetings between the person in charge and
the registered provider representative. The provider had complied with the
regulations, by ensuring there was an unannounced inspection of the service every six months and any actions identified were acted upon in a reasonable time frame. There was an annual review of the quality and safety of the centre, which provided for consultation with residents.
The use of available resources were planned and managed to provide person-centred services to the residents within the centre. Staff had the required
competencies to manage and deliver person-centred, effective and safe services to the residents living in the centre. This included the availability of nursing staff on a 24 hour basis and staff being provided with specific training to meet the individual needs of residents.
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displayed in prominent positions within the centre. Each resident had a contract for the provision of services. However, inspectors found that the contents of these contracts were not consistent with the actual practice within the centre and they therefore required review.
Regulation 15: Staffing
There was sufficient staff with the right skills, qualifications and experience to meet the assessed needs of residents at all times.
Judgment: Compliant
Regulation 16: Training and staff development
Staff received ongoing training that was relevant to the needs of residents and staff were supervised appropriate to their role.
Judgment: Compliant
Regulation 23: Governance and management
The management structure was clearly defined and identifies the lines of authority and accountability, specifies roles and details responsibilities for all areas of service provision.
Judgment: Compliant
Regulation 24: Admissions and contract for the provision of services
The contracts for the provision of services did not consistently reflect the practice within the centre.
Judgment: Substantially compliant
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The statement of purpose was in place and included all information set out in the associated schedule.
Judgment: Compliant
Regulation 34: Complaints procedure
Complaints were managed in a timely and proactive manner, and were appropriately recorded by the nominated person. The complaints process was accessible to
residents and displayed prominently.
Judgment: Compliant
Regulation 4: Written policies and procedures
All Schedule 5 written policies and procedures are in place and reviewed within the time frame set out by the Chief Inspector. Written policies and procedures were accessible to staff.
Judgment: Compliant
Quality and safety
The centre provided a quality and safe service to residents which enhanced their quality of life.
Each resident had a personal plan which detailed their needs and outlined the supports they required to maximise their personal development and quality of life. Each resident exercised choice and control in their daily life, in line with their preferences and assessed needs. Residents were proactively supported to pursue meaningful goals and these goals were regularly reviewed with key workers.
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The privacy and dignity of each resident was respected. Residents were not subjected to restrictive procedures unless a restriction was assessed as being required due to a serious risk to safety and welfare. Such restrictions were under regular review with appropriate allied healthcare professionals. Where required residents had access to positive behaviour support and this was utlised to support their assessed needs. The centre had adequate systems in place to manage allegations of abuse and took all necessary steps to ensure residents were safe.
Risk management was generally managed appropriately and there was evidence that the service was safe. There were some gaps in documentation as some risks which had presented had not been reviewed and updated contemporaneously.
The centre had medication management policies and procedures in place that complied with legislative and professional regulatory requirements and best practice. However, there were a number of gaps in medication guidance
documentation that led to staff not having adequate guidance in the management of some ''PRN'' medication. These gaps included ensuring that guidance was consistent with the prescribers' instructions and in line with best practice.
Regulation 13: General welfare and development
Residents were provided with support and care to meet the assessed needs, and had access to recreation and activities in accordance with their interests and capacities.
Judgment: Compliant
Regulation 26: Risk management procedures
While there was evidence that the service was safe, by staff attending to general risk management and safe care was practiced, there were gaps in some
documentation.
Judgment: Substantially compliant
Regulation 28: Fire precautions
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Judgment: Compliant
Regulation 29: Medicines and pharmaceutical services
There was insufficient documentation in place to ensure staff practice was guided sufficiently in the administration of some PRN medication.
Judgment: Not compliant
Regulation 5: Individual assessment and personal plan
The centre was suitable for the purposes of meeting the assessed needs of each resident and, where reasonably practicable, arrangements were in place to meet these needs.
Judgment: Compliant
Regulation 6: Health care
Appropriate healthcare was made available for each resident having regard to each residents' personal plan.
Judgment: Compliant
Regulation 7: Positive behavioural support
Were restrictive procedures such as physical, chemical or environmental restraint are used, such procedures are applied in accordance with national policy and evidence based practice.
Judgment: Compliant
Regulation 8: Protection
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any incident, allegation or suspicion of abuse and took appropriate action where a resident was harmed or suffered abuse.
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Appendix 1 - Full list of regulations considered under each dimension
Regulation Title
Judgment
Capacity and capability
Regulation 15: Staffing Compliant
Regulation 16: Training and staff development Compliant Regulation 23: Governance and management Compliant Regulation 24: Admissions and contract for the provision of
services Substantially compliant
Regulation 3: Statement of purpose Compliant Regulation 34: Complaints procedure Compliant Regulation 4: Written policies and procedures Compliant
Quality and safety
Regulation 13: General welfare and development Compliant Regulation 26: Risk management procedures Substantially
compliant
Regulation 28: Fire precautions Compliant
Regulation 29: Medicines and pharmaceutical services Not 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 Meadowview Bungalows 3 &
4 OSV-0005175
Inspection ID: MON-0021963
Date of inspection: 09/05/2018
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.
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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 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:
• Contract of care including the easy read version of the contract of care are being reviewed and updated to ensure that they reflect the current practice in the designated centre.
Regulation 26: Risk management
procedures Substantially Compliant
Outline how you are going to come into compliance with Regulation 26: Risk management procedures:
• Falls risk assessment (FRAT- Fall Risk Assessment Tool) is in place for all service users, these are reviewed annually or if there is any change in the service users presentation.
Regulation 29: Medicines and
pharmaceutical services Not Compliant
Outline how you are going to come into compliance with Regulation 29: Medicines and pharmaceutical services:
• Director of Nursing for Training and Development led a review on the use of
rescue/emergency medication protocols in consultation with MDT members. A new protocol has been developed following this review to ensure clear instructions are in place for all staff administering rescue/emergency medication.
• In the instance of a service user being prescribed two or more of the same
category of PRN medication, a protocol will be developed to give clear guidance to staff in the administration of the appropriate PRN medication to use for the
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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
24(4)(a) The agreement referred to in paragraph (3) shall include the
support, care and welfare of the resident in the designated centre and details of the services to be provided for that resident and, where appropriate, the fees to be charged.
Substantially
Compliant Yellow 31/08/2018
Regulation 26(2) The registered provider shall ensure that there are systems in place in the designated centre for the
assessment, management and ongoing review of risk, including a system for responding to emergencies.
Substantially
Compliant Yellow 31/08/2018
Regulation
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ensure that the designated centre has appropriate and suitable practices relating to the ordering, receipt,
prescribing, storing, disposal and administration of medicines to ensure that medicine which is prescribed is administered as prescribed to the resident for whom it is prescribed and to no other
