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Report of an inspection of a
Designated Centre for Disabilities
(Adults)
Name of designated
centre:
Kennington
Name of provider:
St Michael's House
Address of centre:
Dublin 6w
Type of inspection:
Unannounced
Date of inspection:
17 April 2018
Centre ID:
OSV-0002405
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide.
Kennington provides full-time residential care to male and female adults with an intellectual disability, as well as additional physical, sensory, health and mental health needs. Care and support provided at Kennington aims to provide a holistic approach to residents’ needs based on the social care approach model. Kennington is located in a city and is close to local amenities such as shops and leisure facilities. The centre is in walking distance to public transport links which enable residents to access further facilities in the surrounding area. The centre is a two-storey seven bedded house in a residential area. The house comprises two sitting rooms, a kitchen/dining room, utility room and seven bedrooms of which six are used by residents. The centre's seventh bedroom is used as an office and for staff overnight accommodation. The centre further offers two communal bathrooms, with the downstairs facility including a fully accessible walk-in shower. The centre has a back patio garden area which includes a seating area and outside storage facilities.
Residents with mobility needs are further assisted at the centre through the provision of a ramp leading to the front door entrance. Residents are supported by a team of social care workers. On weekdays, two social care workers are available at key times during the day such as in the morning and evening times to support residents. However, staffing levels reduce to one worker during times when residents are at day services or engaged in part-time employment. On weekends, two staff members are available throughout the day to meet residents’ assessed needs. At night-time, an overnight staff member is available at Kennington to provide assistance to
residents if required. In addition, the provider has arrangements in place to provide if required, management and nursing support outside of office hours and at
weekends.
The following information outlines some additional data on this centre.
Current registration end
date:
04/11/2018
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
17 April 2018 08:45hrs to
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Views of people who use the service
The inspector had the opportunity to meet all six residents who lived at
Kennington. Residents told the inspector that they were happy at the centre and had lived there for a long time. Residents said that they got on well with the staff and they were supported to achieve their personal goals as well as being involved in day-to-day activities such as cooking meals.
Residents told the inspector that they were involved in decision making on how the centre was run through their regular house meetings. Residents said that during these meetings, they decided the menu and planned activities they wish to do for the week. Residents said that they would raise any complaints they had about the care and support during the meetings and were happy with how their complaints had been addressed. Residents further told the inspector that if they had any complaints outside of the meeting, they would have no reservations in speaking to either the staff on duty or the centre's management team.
Residents told the inspector that they felt safe at the centre and had been involved in regular fire drills and knew how to evacuate from the house in an emergency.
Some residents showed the inspector their bedrooms. Residents told the inspector that they had chosen the wallpaper and curtains for their rooms. The inspector observed that residents' bedrooms were individualised and reflected their personal interests.
Residents said they were supported to keep in contact with their families and friends, and relatives could visit them anytime at the centre if they wished.
Throughout the inspection, residents appeared both comfortable and relaxed with all supports provided by staff. With support being provided in a timely and dignified manner, which reflected residents' assessed needs.
Capacity and capability
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Management audits conducted by the person in charge regularly monitored and reviewed all aspects of the centre's operations. Where areas for improvement were identified such as the centre's decoration and resident access to the Internet, these had been addressed in a timely manner and in-line with any agreed time frames. However, although the provider ensured that residents' needs were met and they were safe, governance arrangements had not identified gaps in areas such as residents' personal planning arrangements and the assessment of fire
safety procedures at the centre.
Staffing arrangements ensured that residents were supported in a timely manner with their assessed needs and to achieve their personal goals. Where individual resident's needs had increased, the person in charge had ensured that staffing levels were reviewed and altered to ensure continuity of care for the resident.
Following the previous inspection, the person in charge had put measures in place to improve staff access to training. Staff had received training which reflected
residents' health care needs, as well as the centre's risk management arrangements. Training ensured that staff knowledge reflected both residents' assessed needs and current developments in health and social care practices. Staff also attended team meetings and received regular management supervision which ensured they were kept up-to-date on changes to residents’ needs, the centre's operations and organisational policies and procedures.
The provider had arrangements in place which ensured the effective response to adverse incidents such as accidents and residents were protected from harm at the centre. Staff who spoke to the inspector were knowledgeable about the
management of risks specifically in relation to resident's health care needs and fire safety, and had received regular training to ensure their practice was up-to-date .
Regulation 14: Persons in charge
The person in charge was employed in a full-time capacity and had the experience and management qualifications required for the post.
Judgment: Compliant
Regulation 15: Staffing
Staffing arrangements ensured that residents were able to participate in activities of their choice, achieve their personal goals and have their needs met in a timely and dignified manner.
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Judgment: Compliant
Regulation 16: Training and staff development
Training provided to staff was up-to-date and reflected residents' needs, the provider's policies and current developments in health and social care practice.
Judgment: Compliant
Regulation 23: Governance and management
Governance and management arrangements ensured that residents were protected from harm and received a good quality of care. However, further action was
required to address identified gaps which related to residents' personal planning and fire safety arrangements.
Judgment: Substantially compliant
Regulation 3: Statement of purpose
The statement of purpose was subject to regular review, reflected the services and facilities provided and contained all information required under Schedule 1 of the regulations.
Judgment: Compliant
Regulation 34: Complaints procedure
Residents were aware of their right to make a complaint and the provider ensured that all received complaints were appropriately recorded and investigated.
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Regulation 4: Written policies and procedures
Policies required under the regulations were subject to regular review and made available to staff at the centre by the provider.
Judgment: Compliant
Quality and safety
During the inspection, residents told the inspector that they were both happy living at the centre and with the care and support they received. Support arrangements at the centre ensured that residents' needs were met and they were supported to both maintain and develop independent living skills. However, improvements
were required to ensure that all aspects of residents' personal planning needs were met and the effectiveness of the centre's fire safety arrangements were assessed.
The centre's premises was maintained to a good standard of repair and decoration. The design and layout of the centre further ensured that it was accessible
to residents with identified mobility needs. Residents told the inspector that they liked living at the centre and staff had supported them to personalise their bedrooms in-line with their interests and tastes.
Residents accessed a range of activities both at the centre and in the local community which reflected their assessed needs, with some residents telling the inspector about part-time jobs they had in the local community. Other residents spoke to the inspector about the day service they attended during the week and local leisure facilities they enjoyed such as being members of a local bowling team. Residents were supported to develop their independent living skills and were encouraged with support to cook meals and do their personal laundry. Residents were also encouraged to engage in positive risk taking, with supports in place to enable them to independently travel on public transport, remain unsupervised at the centre and self-administer some medications.
Since the last inspection, arrangements had been put in place to ensure that residents' personal plans were updated to reflect annual review meeting outcomes and recommendations from multi-disciplinary professionals. However, although resident's needs assessments were comprehensive and reflected the supports provided, one resident's assessment had not been subject to an annual review to ensure its effectiveness. Furthermore, where annual personal plan reviews had been undertaken, minutes did not show that the effectiveness of all supports provided to individual residents had been assessed to ensure they met their needs.
Residents were aware of their rights through involvement in regular house
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the support they received as well as plan the weekly menu and social
activities. Residents were further made aware of their rights and the care they would receive at the centre through the provision of accessible information such as easy read organisational policies and the centre's residents' guide.
The provider ensured that residents were kept safe while at the centre
and arrangements were in place such as a fire evacuation plan and appropriate fire fighting equipment. Residents and staff were regularly involved in simulated fire drills and were knowledgeable on how to evacuate the centre safely in an
emergency. However, the provider's records did not show that the effectiveness of the evacuation plan had been assessed in all circumstances such as under minimal staffing conditions.
Regulation 10: Communication
The provider had ensured that residents had access to the Internet following the last inspection.
Judgment: Compliant
Regulation 13: General welfare and development
Residents were supported to participate in a range of activities which reflected their assessed needs, leisure interests and assisted them to achieve their personal goals.
Judgment: Compliant
Regulation 17: Premises
The centre’s premises were well-maintained and facilities were provided to ensure it was accessible to residents and met their assessed needs.
Judgment: Compliant
Regulation 20: Information for residents
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an easy read 'resident's guide' at the centre.
Judgment: Compliant
Regulation 26: Risk management procedures
Risk management arrangements kept residents safe from harm as well
as supporting them to develop independence skills through positive risk taking.
Judgment: Compliant
Regulation 27: Protection against infection
The provider's policies and staff practices ensured that residents were protected from the risk of infection.
Judgment: Compliant
Regulation 28: Fire precautions
Suitable fire safety arrangements were in place, however the effectiveness of the centre's fire evacuation plan under all circumstances had not been assessed.
Judgment: Substantially compliant
Regulation 29: Medicines and pharmaceutical services
The provider's medication practices ensured that medication was securely stored and administered by suitably qualified staff.
Judgment: Compliant
Regulation 5: Individual assessment and personal plan
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staff knowledge. However, not all personal plans had been reviewed annually and review meetings did not show an assessment into the effectiveness of all supports provided to residents.
Judgment: Substantially compliant
Regulation 6: Health care
Residents were supported to access health care professionals as and when required, which ensured that they maintained a good quality of health in-line with their
assessed needs.
Judgment: Compliant
Regulation 7: Positive behavioural support
The provider ensured that staff received up-to-date training and their knowledge reflected current developments in the positive management of behaviour.
Judgment: Compliant
Regulation 8: Protection
The provider had arrangements in place to safeguard residents from abuse which included clear reporting protocols and staff access to regular training to ensure their knowledge was in-line with current practice developments.
Judgment: Compliant
Regulation 9: Residents' rights
Residents made decisions about the running of the centre and were aware of their rights such as how to making a complaint about the care and support they
received.
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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 23: Governance and management Substantially
compliant Regulation 3: Statement of purpose Compliant Regulation 34: Complaints procedure Compliant Regulation 4: Written policies and procedures Compliant
Quality and safety
Regulation 10: Communication Compliant
Regulation 13: General welfare and development Compliant
Regulation 17: Premises Compliant
Regulation 20: Information for residents Compliant Regulation 26: Risk management procedures Compliant Regulation 27: Protection against infection Compliant Regulation 28: Fire precautions Substantially
compliant Regulation 29: Medicines and pharmaceutical services Compliant Regulation 5: Individual assessment and personal plan Substantially
compliant
Regulation 6: Health care Compliant
Regulation 7: Positive behavioural support Compliant
Regulation 8: Protection Compliant
Regulation 9: Residents' rights Compliant
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Compliance Plan for Kennington OSV-0002405
Inspection ID: MON-0023730
Date of inspection: 17/04/2018
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 23: Governance and
management Substantially Compliant
Outline how you are going to come into compliance with Regulation 23: Governance and management:
The Registered provider will ensure that annual review meetings will incorporate a review of support plans for each resident. Any amendments required will be agreed at this meeting.
Assessments of Need will be updated annually or sooner if gaps are identified by the resident or keyworker, particular attention will be given to fire safety arrangements This will be on the agenda at each resident’s yearly review.
Regulation 28: Fire precautions Substantially Compliant
Outline how you are going to come into compliance with Regulation 28: Fire precautions:
The register provider will ensure fire drills will be completed as per St Michael’s House policy. Effectiveness of the centre's fire evacuation plan under all circumstances including evacuation using minumium staff support To date one fire drill has been completed with one staff on duty. Report available The remainder of fire drills including walk abouts will be spread throughout the remainder of the year. The Fire evacuation plans and drills will form part of the agenda for staff meetings
Regulation 5: Individual assessment
and personal plan Substantially Compliant
Outline how you are going to come into compliance with Regulation 5: Individual assessment and personal plan:
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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
st September
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 Fire drills and walk abouts will be spread throughout the year.
December 2018
Regulation
05(1)(b) The person in charge shall ensure that a comprehensive assessment, by an appropriate health
Substantially
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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.
Regulation
05(6)(b) The person in charge shall ensure that the personal plan is the subject of a review, carried out annually or more frequently if there is a change in needs or circumstances, which review shall be conducted in a manner that ensures the maximum participation of each resident, and where appropriate his or her
representative, in accordance with the resident’s wishes, age and the nature of his or her disability.
Substantially
Compliant Yellow 1st September 2018
Regulation
05(6)(c) The person in charge shall ensure that the personal plan is the subject of a review, carried out annually or more frequently if there is a change in needs or
Substantially
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circumstances, which review shall assess the
effectiveness of the plan.
Regulation
05(7)(c) The recommendations arising out of a review carried out pursuant to
paragraph (6) shall be recorded and shall include the names of those responsible for pursuing objectives in the plan within agreed timescales.
Substantially
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