Health Information and Quality Authority Fit-Person Entry Programme Self-assessment Centre name: Centre address: Centre ID: Name of provider The Health Information and Quality Authority's Social Services Inspectorate (SSI), referred to in the Health Act 2007 as the Office of the Chief Inspector, was established to regulate the quality of residential care in designated centres for children, dependent people, and people with disabilities. The Chief Inspector will only register the centre if satisfied, inter alia, that the registered provider is a fit person as required under the Health Act 2007. As the provider you must demonstrate to the satisfaction of the chief inspector that you are suitable or fit to be registered. Fitness will be assessed in accordance with section 50 of the Health Act 2007, which states: (1) Where an application is made under section 48 for the registration or renewal of the registration of a designated centre, the Chief Inspector, if satisfied that the person who is the registered provider, or intended registered provider, and each other person who will participate in the management of the designated centre (a) is a fit person to be the registered provider of the designated centre and to participate in its management, and (b) if the application is for registration, will comply with, or, if for renewal, is in compliance with (i) standards set by the Authority under section 8(1)(b), (ii) regulations under section 101, and RF11 Version1.1 16062011 1
(iii) any other enactment which appears to the chief inspector to be relevant, and is cited to the applicant in writing by the chief inspector, shall grant the application and if not so satisfied shall refuse it. This self-assessment tool has been developed as part of the registration process to enable you to assess the everyday activities, systems and processes within your centre. The Fitperson Entry Programme is seen as a means to assist you in carrying out this assessment. You may wish to complete the self-assessment on your own or with the person in charge. However, as the provider of the care setting you are responsible to ensure it is satisfactorily completed and that it accurately reflects the systems and practices within your centre. Section A of the self-assessment should be completed at the end of each corresponding section of the Fit-person entry programme. On completion of the Fit-person entry programme and the self-assessment evaluation you may have identified areas for quality improvements. Please use Section B of the selfassessment to highlight the areas you have prioritised for improvement over the next six months and include the manner in which you intend to do this. Following submission of your registration application and self-assessment, Fit-person interviews with the provider and person in charge will take place. The interview will assess your understanding of, and capacity to implement the regulatory requirements and the standards. The size of the service you provide, the statement of purpose and function and the number and needs of the people who will use your service will all be taken into account. There will also be an inspection of your centre to assess your compliance with regulations and standards. RF11 Version1.1 16062011 2
Section A: Self-Assessment Name of the person(s) who completed the self-assessment Section 1. Legislation and Regulations (Please one box) 1. The provider is familiar with his/her statutory obligations as set out in the Health Act 2007 and the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) 2. The person in charge is familiar with his/her statutory obligations as set out in the Health Act 2007 and the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) 3. The provider and person in charge are fully aware of, and adhere to, notification requirements as per Regulation 36 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) 4. Staff are familiar with the Health Act 2007 and the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) RF11 Version1.1 16062011 3
Section 2. Rights (Please one box) 1. Our communication systems meet the diverse needs of all our residents (e.g. people with dementia, people with speech difficulties, people with poor eyesight) 2. We have both formal and informal ways of consulting with residents and including them in the decision making process 3. We ensure that the views and experiences of all residents inform the service provided 4. We manage the centre in a way that maximises residents capacity to exercise personal autonomy and choice 5. We enable residents to make informed decisions about the management of their care, including decisions to accept or refuse treatment 6. We ensure that residents receive care in a dignified way that respects their privacy at all times 7. We make all residents aware of the complaints process and what to do if they are dissatisfied with the response they receive 8. The complaints process is user-friendly and accessible to all residents 9. All complaints are fully investigated and the outcome communicated to the complainant RF11 Version1.1 16062011 4
Section 3. Protection (Please one box) 1. There are no barriers to staff disclosing suspected abuse 2. We have a range of measures in place to safeguard and protect all residents, including those with a cognitive impairment or difficulty communicating 3. Staff have received training in understanding protection of vulnerable adults and implementing the centre s policy on responding to suspicions, allegations and disclosures of abuse, including who to report it to 4. The provider and person in charge rigorously monitor the systems in place to protect residents 5. Each resident s finances and personal possessions are safeguarded RF11 Version1.1 16062011 5
Section 4. Health and social care needs (Please one box) 1. Residents health, personal and social care needs are comprehensively assessed and updated on a three-monthly basis 2. The residents assessment considers their physical, psychological and social care needs 3. Residents are encouraged and enabled to be actively involved in developing their individualised plan of care 4. The care planning process reflect changes to memory, behaviour and personality of those with cognitive impairment and identifies appropriate interventions to respond to those changes 5. Staff are familiar with, and provide care, in accordance with residents care plans. Deviations from planned care is easily identified 6. Staff administer and record medicines in line with a comprehensive policy based on best practice 7. Self-administration of medication is supported and monitored 8. We have a system for reviewing and monitoring safe medication management practices 9. Residents have timely access to GP services and appropriate therapies 10. The specialist services/allied health care services available to residents reflect their diverse care needs 11. We have practices and facilities in place so that residents receive end of life care in a way that meets their individual needs and preferences and respects their dignity and autonomy RF11 Version1.1 16062011 6
Section 5. Quality of Life (Please one box) 1. Daily routines take account of residents individual needs and preferences and are continuously reviewed 2. We find ways to promote autonomy and independence even though some residents may be very dependent 3. Residents have access to advocacy services 4. We ensure that staff communicate effectively with residents 5. Residents have opportunities to participate in activities appropriate to their interests 6. Practices, interventions or therapies assist residents with a cognitive impairment to function at their highest possible level 7. Residents are supported and encouraged to maintain relationships with family and friends 8. We are committed to a restraint-free environment 9. Meals times are unhurried social occasions that provide opportunities for residents to communicate and interact with each other and staff. RF11 Version1.1 16062011 7
Section 6. Staffing (Please one box) 1. There is an appropriate number and skill mix of staff on each shift to respond in a person-centred way to residents needs 2. The service retains staff through a proactive retention strategy that promotes continuity of care for residents 3. We have an in-service training programme that reflects the diverse needs of residents 4. Staff have received training in evidence based principles of dementia care 5. Staff meetings and handover meetings take place regularly to facilitate good communication and consistency among staff 6. All staff receive supervision pertinent to their role, the details of which are recorded 7. Garda vetting and 3 references have been obtained and are on file for all staff 8. Staff have received training in moving and handling and fire safety training takes place on an annual basis RF11 Version1.1 16062011 8
Section 7. The Care Environment (Please one box) 1. The design and layout of the centre reflects and accommodates the diverse needs of residents as outlined in the statement of purpose and function 2. A safe outdoor space with seating is accessible to all residents 3. The centre has a lift or chair lift (for premises with more than one floor) 4. Residents, including those with physical, sensory or cognitive impairment, can access communal areas through the provision of ramps, grab rails, and other aids, and appropriate signage and colour schemes to assist safe mobility 5. There are facilities for residents to meet with visitors in private 6. Each resident has a lockable storage space 7. Procedures consistent with national guidelines on infection prevention and control are implemented by staff on a daily basis 8. Environmental health and safety risks are regularly assessed and monitored, the details of which are recorded RF11 Version1.1 16062011 9
Section 8. Governance and Management (Please one box) 1. The statement of purpose and function meets the requirements of Article 5 and Schedule 1 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) 2. All records required by the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) are readily available and up to date 3. A directory of residents is maintained that includes the information specified in Schedule 3 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) 4. All of the operational policies as required by Schedule 5 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) are available and reviewed at least every 3 years 5. There are arrangements in place for the management of the centre in the absence of the person in charge 6. There are arrangements in place for the identification, assessment and management of all risks, including clinical risks, to residents 7. There is a process for reviewing the quality of and safety of care and quality of life of residents 8. There are processes in place to implement learning from complaints or any serious incidents or adverse events involving residents RF11 Version1.1 16062011 10
Section B. Quality Improvement Plan Area identified for improvement Proposed action to improve practice Time scale RF11 Version1.1 16062011 11
Declaration to be completed by the provider I declare that, to the best of my knowledge and belief, all of the information that I have given in connection with this self-assessment is full and correct. I am aware that it is an offence under the Health Act 2007 to provide false or misleading information. Signed: Date: / / Name: (Please print BLOCK CAPITALS) RF11 Version1.1 16062011 12