Report of an inspection of a Designated Centre for Disabilities (Adults) Name of designated centre: Name of provider: Address of centre: Acorn Services Brothers of Charity Services Ireland Galway Type of inspection: Announced Date of inspection: 21 August 2018 Centre ID: OSV-0005041 Fieldwork ID: MON-0021939 Page 1 of 13
About the designated centre The following information has been submitted by the registered provider and describes the service they provide. Acorn services provide both full-time residential and respite care and support to adults with a disability. Acorn services comprises of two premises, which include a two-storey house located in a town and a bungalow located outside the same town in a nearby village. Both premises include a one bed self-contained apartment with its own bathroom, kitchen/dining room and living room. Residents in the main part of each premises have their own bedrooms and access to a communal kitchen/dining room and sitting room, along with bathroom and laundry facilities. The design and layout of each premises is fully accessible, with additional aids and adaptations such as overhead hoists being provided to meet residents assessed needs where required. Residents are supported by a team of social care workers in each of the centre's premises. Staffing levels are flexible in nature and dependent on residents' assessed needs and occupancy levels during the week. In one premises, residents are supported by either one to two staff members during the day, with this increasing to two to three in the centre's second premises due to residents' assessed needs. At night, residents in both premises are supported by overnight sleeping staff, who are available to provide assistance if required. In addition, the provider has arrangements in place to provide management support to staff outside of office hours and at weekends. The following information outlines some additional data on this centre. Current registration end date: Number of residents on the date of inspection: 31/01/2019 3 Page 2 of 13
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. A full list of all regulations and the dimension they are reported under can be seen in Appendix 1. Page 3 of 13
This inspection was carried out during the following times: Date Times of Inspection Inspector Role 21 August 2018 09:00hrs to 16:25hrs Stevan Orme Lead Page 4 of 13
Views of people who use the service The inspector met three residents who lived at Acorn services during the inspection. Residents, who spoke the inspector, told them that they liked living at the centre and were supported by staff to do the activities in the local community and achieve their goals. Throughout the inspection, the inspector observed that residents appeared relaxed and comfortable at the centre and with all support provided by staff. The inspector also reviewed three questionnaires completed on behalf of residents by their representatives on the care and support provided at Acorn services. Questionnaires reflected that residents representatives were happy and satisfied with all aspects of the care and support provided at the designated centre. Capacity and capability Governance and management arrangements at Acorn services ensured that residents received a good quality of care and support in-line with their assessed needs. The provider's policies and staff practices ensured that residents were kept safe and protected from harm and supported to achieve their personal goals. The centre had a clearly defined management structure, which incorporated a suitably qualified and experienced person in charge. The person in charge was actively involved in the day-to-day governance of the centre and was knowledgeable on residents' assessed needs. Staffing arrangements at the centre ensured that residents' needs were met in-line with their assessed needs and all associated support interventions. Appropriate staffing levels ensured that residents were able to regularly enjoy activities of their choice, both at the centre and in the local community, and work towards achieving their personal goals such as increased independent living skills. The person in charge ensured that residents were supported by a qualified and knowledgeable staff team. Staff knowledge was kept up-to-date through regular access to training opportunities on both residents assessed needs and current developments in health and social care practices. In addition, staff attended regular team meetings and were supported with their individual professional development through one-to-one formal supervision arrangements. The provider ensured that the quality of residents' care and support was subject to ongoing review through a range of regular management audits on all aspects of Page 5 of 13
the centre's operations. The provider ensured that day-to-day internal checks were carried out by staff as well as unannounced visits by a delegated person within the provider entity. Where audits and visits identified areas for improvement, these were addressed in a responsive manner and reflected both staff knowledge and observed practices at the centre. The provider also conducted an annual review into the care and support provided at Acorn services, which included consultation with both residents and their representatives about their experiences at the centre. The provider s risk management practices were robust in nature, and procedures were in place to effectively respond to adverse incidents which might occur. Staff were knowledgeable on risks identified at the centre and their associated interventions as well as actions to be taken in the event of an emergency. Furthermore, the provider had arrangements in place for both the recording and analysis of accident and incidents, with the findings being discussed with staff and incorporated into practices to effectively support residents' assessed needs. The provider ensured that all risk management arrangements at the centre were subject to regular review to ensure their ongoing effectiveness and residents' safety. Registration Regulation 5: Application for registration or renewal of registration The provider had ensured that all prescribed documentation required for the renewal of the designated centre's registration was submitted to the Chief Inspector as and when required. Judgment: Regulation 14: Persons in charge The person in charge was full-time, suitably qualified and experienced. The person in charge was actively involved in the management of the centre and ensured that care and support provided meet residents' assessed needs as well as regulatory requirements. Judgment: Regulation 15: Staffing The provider had ensured that appropriate staffing arrangements were in place to meet residents' assessed needs in a timely manner and support them to participate in activities of their choice. Page 6 of 13
Judgment: Regulation 16: Training and staff development Staff had access to regular training opportunities which ensured they were equipped with the appropriate skills and knowledge to support residents' needs and practices were in-line with current health and social care developments. Judgment: Regulation 21: Records The provider's recruitment arrangements ensured that staff personnel records contained all information required by the regulations such as national vetting disclosures and references. Judgment: Regulation 23: Governance and management Governance and management arrangements ensured that all practices at the centre were subject to regular monitoring to ensure their effectiveness. Management arrangements ensured that appropriate resources were available at the centre to support residents with their assessed needs, kept them safe from harm and facilitate the achievement of their personal goals. Judgment: Regulation 3: Statement of purpose The provider ensured that the centre s statement of purpose was subject to regular review, reflected the services and facilities provided and contained all information required under the regulations. Judgment: Page 7 of 13
Regulation 34: Complaints procedure Residents and their representative were aware of their right to make a complaint and the provider ensured that all complaints were appropriately recorded and investigated. Judgment: Regulation 4: Written policies and procedures The provider's policies and procedures were available to staff at the centre. However, not all policies required under the regulations had been subject to a review every three years to ensure they were up-to-date and reflected current developments in health and social care practices. Judgment: Substantially compliant Quality and safety During the course of the inspection, the inspector found that residents received a good quality of care in-line with their assessed needs at Acorn services. Practices at the centre ensured that residents were safe from harm, but also supported residents; dependent on their abilities, to undertake positive risk-taking in their daily lives. Residents participated in a range of activities both at the centre and in the local community which reflected their personal choices and assessed needs. Residents were supported to attend day services in the local area during the week which they enjoyed. Where residents required a more bespoke day programme this was provided by the centre s staff team and directed by the individual's interests and personal goals. Arrangements were also in place to support residents to increase and maintain their independent living skills through positive risk taking. Personal planning arrangements for residents were comprehensive in nature and clearly guided staff on how to support residents with their assessed needs. Residents' personal plans were regularly updated when their needs changed to ensure a consistency of approach, and staff were knowledgeable on all aspects of supports required by residents. Furthermore, residents' personal plans were subject to an annual review into their effectiveness attended by the resident, their representatives and associated multi-disciplinary professionals. Residents were also made aware of the supports they would receive at the centre, through key Page 8 of 13
aspects of their personal plan such as annual personal goals, being made available to them in an accessible version. Where residents had behaviours that challenged, the provider had arrangements in place which ensured that individuals were supported through a multi-disciplinary approach. Comprehensive behaviour support plans were developed by qualified behavioural specialists and reviewed regularly to ensure their effectiveness and guide staff. Where residents' assessed needs were supported by the use of a restrictive practice, governance arrangements ensured that a clear rationale was in place for its use which was subject to both approval and frequent review by the provider's Human Rights Committee. Residents were protected from harm at the centre, with arrangements in place to effectively manage an emergency such as an outbreak of fire. Appropriate and wellmaintained fire equipment was installed at the centre, and regular fire drills were carried out to assess the effectiveness of the centre s fire safety arrangements. Regular drills also ensured that both residents and staff were knowledgeable on actions to take in the event of an evacuation which was further reinforced by regular fire safety training for staff. Residents were supported to be involved in making decisions about the running of the centre. Residents participated in regular house meetings were they decided the weekly menu for the centre and planned social activities. The provider also provided accessible information to residents on their rights such as how to make a complaint and access to advocacy services. The centre s premises were well-maintained and decorated to a good standard. The premises' decor was bright and homely in nature, and reflected residents personal interests and tastes. Arrangements were also in place which enabled residents, who accessed respite care, to bring and securely store personal items at the centre to make them feel more relaxed and comfortable during their stay. In addition, the provider had ensured that the design and layout of the premises was fully accessible and, where required, had installed appropriate aids and adaptations to meet residents assessed needs. Regulation 13: General welfare and development Residents were supported to access and participate in a range of activities which reflected their assessed needs and enabled them to achieve their personal goals. Judgment: Regulation 17: Premises Page 9 of 13
The centre s premises were well-maintained and its design and layout met residents assessed needs. Judgment: Regulation 20: Information for residents The provider ensured that both residents and their representatives were made aware of the services and facilities provided at the centre through access to its residents' guide. Judgment: Regulation 26: Risk management procedures Risk management arrangements ensured that possible risks to residents were identified, assessed and control measures implemented. Review arrangements ensured that all agreed interventions were regularly monitored to ensure their effectiveness and residents were kept safe from harm, as well as being supported to undertake positive risk taking in their daily lives. Judgment: Regulation 28: Fire precautions Suitable fire safety equipment and arrangements were in place at the centre, with regular fire drills being carried out to assess the effectiveness of agreed protocols and ensure that staff and residents knew what to do in the event of a fire. Judgment: Regulation 29: Medicines and pharmaceutical services The provider's medication practices ensured that medication was securely stored and administered as prescribed to residents by suitably qualified staff. Page 10 of 13
Judgment: Regulation 5: Individual assessment and personal plan Personal plans clearly described residents assessed needs and associated support interventions, with accessible information on key aspects such as personal goals being made available to residents. The provider ensured that personal plans were reviewed regularly to ensure they effectively supported resident s assessed needs. Judgment: Regulation 6: Health care Residents were supported to access healthcare professionals as and when required, with all provided supports being subject to regular review and reflecting up-to-date recommendations from healthcare professionals. Judgment: Regulation 7: Positive behavioural support The provider ensured that staff training and positive behaviour supports were in place to both support the individual and reduce any risk to others. Judgment: Regulation 8: Protection The provider's safeguarding arrangements ensured that residents were protected from possible abuse and regular training opportunities kept staff knowledge up-to-date and in-line with current developments in health and social care practices. Judgment: Page 11 of 13
Regulation 9: Residents' rights Residents were supported to make decisions about the running of the centre and had access to information which informed them about their rights at the centre. Judgment: Page 12 of 13
Appendix 1 - Full list of regulations considered under each dimension Regulation Title Capacity and capability Registration Regulation 5: Application for registration or renewal of registration Regulation 14: Persons in charge Regulation 15: Staffing Regulation 16: Training and staff development Regulation 21: Records Regulation 23: Governance and management Regulation 3: Statement of purpose Regulation 34: Complaints procedure Regulation 4: Written policies and procedures Quality and safety Regulation 13: General welfare and development Regulation 17: Premises Regulation 20: Information for residents Regulation 26: Risk management procedures Regulation 28: Fire precautions Regulation 29: Medicines and pharmaceutical services Regulation 5: Individual assessment and personal plan Regulation 6: Health care Regulation 7: Positive behavioural support Regulation 8: Protection Regulation 9: Residents' rights Judgment Substantially compliant Page 13 of 13
Compliance Plan for Acorn Services OSV-0005041 Inspection ID: MON-0021939 Date of inspection: 21/08/2018 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 in charge has not complied with a regulation and considerable action is required to come into compliance. Continued non-compliance or where the non-compliance poses a significant risk to the safety, health and welfare of residents using the service will be risk rated red (high risk) and the inspector have identified the date by which the provider must comply. Where the noncompliance does not pose a risk to the safety, health and welfare of residents using the service it is risk rated orange (moderate risk) and the provider must take action within a reasonable timeframe to come into compliance. Page 1 of 3
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 Regulation 4: Written policies and procedures Judgment Substantially Outline how you are going to come into compliance with Regulation 4: Written policies and procedures: Currently within the organisation there is a policy group that are updating all of the required polices. All policies required under the regulations will be subject to a review every three years to ensure they are up-to-date and reflect current developments in health and social care practices. Page 2 of 3
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 Regulation 04(3) Regulatory requirement 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. Judgment Substantially Risk Date to be rating complied with Yellow 31/12/2018 Page 3 of 3