Report of an inspection of a Designated Centre for Disabilities (Adults) Name of designated centre: Name of provider: Address of centre: Creg Services Brothers of Charity Services Ireland Galway Type of inspection: Unannounced Date of inspection: 08 January 2019 Centre ID: OSV-0005007 Fieldwork ID: MON-0025136 Page 1 of 17
About the designated centre The following information has been submitted by the registered provider and describes the service they provide. The designated centre provides a residential service to adults over the age of 18. Residents of this service have a severe intellectual disability and may also have a diagnosis of autism. Some residents may also use services offered by the mental health team and behavioural support specialists. The centre can also cater for residents with complex medical needs and a combination of nurses, social care workers and care assistants work in this centre. The centre comprises of two houses, which are located on the outskirts of a city where public transport links such as trains, taxis and buses are available. The centre also provides transport for residents to access their local community. Each resident has their own bedroom and an appropriate number of shared bathrooms are available for residents to use. Suitable cooking and kitchen facilities are also available and reception rooms are warm and comfortably furnished. A social model of care is offered to residents in this centre and seven residents are receiving integrated services, with both day and residential supports, provided in the designated centre, three residents attend separate day services. One staff member supports residents, in each house, during night time hours and two-to-three staff members support residents, in each house, during the day. The following information outlines some additional data on this centre. Number of residents on the date of inspection: 10 Page 2 of 17
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 17
This inspection was carried out during the following times: Date Times of Inspection Inspector Role 08 January 2019 09:00hrs to 17:30hrs Ivan Cormican Lead Page 4 of 17
Views of people who use the service The inspector met with seven residents on the day of inspection. These residents interacted with the inspector on their own terms and they appeared relaxed in the centre. Staff in the centre had a good understanding of their care needs and were observed to interact in a warm and caring manner. Staff members could understand residents' wishes through the use of some spoken words and also through the use of some non-verbal communication. Capacity and capability Overall, the inspector found that many aspects of the care which was provided in this centre were maintained to a good standard of care and support; however, some improvements were required in regards to the safeguarding of residents in the centre. The provider had a robust management structure in place for this centre which consisted of a person in charge, team leaders, area manager and sector head. This structure had clear lines of accountability and it was evident that there was good communication pathways between all those who were involved in the management of the centre. There were was also a transparent reporting system which ensured that senior management were kept up-to-date with issues and concerns which may be impacting on the quality and safety of care which was provided to residents. This reporting system had identified incidents within the centre which had negatively impacted on the safety of care which was provided to residents. In response, several reviews of the service had occurred which included safeguarding, behavioural support, psychology and the mental health team. The provider was also beginning to examine compatibility of residents within the centre. The inspector found that this response from the provider had assisted in alleviating some of the issues in the centre; however, incidents within the centre continued to occur which did have a negative impact on the safety of care which was provided to some residents. The person in charge attended the centre on a regular basis had a good understanding of the centre and of the residents' individual care needs. The person in charge and the staff team were also conducting regular reviews of the quality of care which was provided in the centre which assisted in ensuring that residents received a good quality service. The provider had conducted all required reviews and audits as stated in the regulations and the findings of these audits were used to drive improvements within the centre. Page 5 of 17
The staff members who met with the inspector were found to have detailed knowledge of the residents' care needs including both healthcare and behavioural support. There was a schedule of staff meetings in place and staff received regular support and supervision from the person in charge and from team leaders within the service. The inspector found that these arrangements ensured that staff were kept informed of updated care practices and were facilitated to raise concerns in regards to the care which was provided in the centre. The provider had also ensured that a competent workforce supported residents by ensuring that both mandatory and refresher training was offered. A review of a sample of these records indicated that these staff members had completed all required training. Regulation 15: Staffing A review of the staff rota indicated that residents received continuity of care from staff members who were familiar to them. Staff members who met with the inspector were found to interact with residents in a very pleasant manner and also had a good understanding of the residents' care needs. Judgment: Regulation 16: Training and staff development Staff were up-to-date with training needs and received regular support and supervision from the person in charge and team leaders within the centre. Judgment: Regulation 3: Statement of purpose The centre's statement of purpose had been adapted to an accessible format for residents since the last inspection of this centre. The service was also found to be run in accordance with this document. Judgment: Regulation 31: Notification of incidents The person in charge maintained a record of all notifications which had been Page 6 of 17
submitted to the chief inspector; however a review of practices in the centre indicated that not all restrictive practices had been submitted as required. Judgment: Substantially compliant Regulation 23: Governance and management The provider had completed all required audits and reviews as stated in the regulations and the person in charge had a schedule of internal audits in place which assisted in ensuring that the quality and safety of care which was provided was maintained to a good standard. These systems had highlighted a safety concern in the centre and the response from the provider assisted in reducing the frequency of incidents; however, incidents continued to occur within the centre which compromised the safety of some residents. Judgment: Substantially compliant Quality and safety Residents had good access to a range of medical personal such as general practitioners, consultants and allied health professionals. A review of appointment details indicated that all recommended follow-ups had been completed as required and additional care planning had been implemented to support the delivery of care for residents. Staff who met with the inspector had detailed knowledge in regards to complex medical needs, such as diabetes which required robust monitoring. An associated insulin regime was also in place which gave clear guidance in regards to the medicinal management of this condition. There was one active safeguarding plan in the centre which was effectively implemented and subject to on-going review by the safeguarding officer and the staff team. The inspector reviewed a sample of adverse events in the centre and found that the these had been responded to in a prompt manner by the person in charge. Additional input had also been sought from the designated officer, psychology, behavioral support specialists and the mental health team following a number of incidents which had affected the safety of care which was provided in the centre. Following this input, the inspector found that some improvements had resulted for residents; however, incidents within the centre continued to occur and further improvements were required to ensure the safety of residents was maintained at all times. There were number of restrictive practices in place in this centre and a review of documentation indicated that the least restrictive option was trialled and Page 7 of 17
implemented if possible. There was good oversight of these practices with family representatives and multi-disciplinary support involved in their ongoing review. However, the inspector found that not all restrictive practices in the centre had been identified and as a result, these practices were not subject the review process which was present in the centre. The inspector reviewed a sample of positive behavioural support plans which provided comprehensive guidance to the staff team in a form which could be easily understood. This plan also gave clear guidance in the use of chemical interventions which was regularly reviewed by both the mental health team and general practitioner. The person in charge had a good understanding of risks in the centre and comprehensive risk management plans were in place for those risks which would have a direct impact on the care which was provided to residents. These plans had robust control measures in place and a further review of risk ratings within the centre, occurred on the day of inspection. This review reflected the detailed measures which the staff team and provider had implemented to reduce the likelihood of these risks occurring, and the impact which they may have on residents. Each resident had a personal plan in place and a review of a sample of these plans indicated that residents engaged in activities which were meaningful to them and based on their assessed needs. Residents had good access to their local community and additional transport and staffing hours were planned for this centre to further promote the social inclusion of residents in their local community. Residents were also supported to identify personal goals through a planning process which which also involved their own representatives. The inspector reviewed a sample of these goals and found that some had been progressed and achieved. However, some improvements were required, as some goals lacked clarity, for example, one resident wished to pursue an interest in music but no further detail was available in regards to what aspects of music they wished to pursue and how they would achieve this. One resident wished to go on a holiday but this goal had not been progressed and there were no updates available as to why this goal had not been achieved. The inspector found that the arrangements which were in place to support residents with their goals, required further review to ensure that residents were fully supported throughout this process. Regulation 26: Risk management procedures The person in charge had a good understanding of risks in the centre and comprehensive risk management plans were in place for those risks which would have a direct impact on the care which was provided to residents. Judgment: Page 8 of 17
Regulation 28: Fire precautions The provider had fire safety systems in place which were serviced as required by competent people and reviewed by the staff team on a regular basis. The staff team were also conducting regular fire drills with residents and records of these drills indicated that all residents could be effectively evacuated at all times of the day and night. Judgment: Regulation 6: Health care Residents had good access to a range of medical personal such as general practitioners, consultants and allied health professionals. A review of appointment details indicated that all recommended follow-ups had been completed as required and additional care planning had been implemented to support the delivery of care for residents. Judgment: Regulation 8: Protection The provider had been responsive to incidents in the centre and additional measures had been implemented to address these issues. The inspector found that the implementation of these measures had some positive effects on the care which was provided; however, further improvements were required as incidents continued to occur in this centre, which had a negative impact on the safety of care which was provided to some residents. Judgment: Not compliant Regulation 5: Individual assessment and personal plan Residents had good access to their local communities and their personal plans were formally reviewed on a annual basis. Residents were also supported to identify and achieve personal goals. However, the inspector found that the arrangements which were in place to support residents with their goals, required further review to ensure Page 9 of 17
that residents were fully supported throughout this process. Judgment: Substantially compliant Regulation 7: Positive behavioural support There were number of restrictive practices in place in this centre and a review of documentation indicated that the least restrictive option was trialled and implemented if possible. There was good oversight of these practices with family representatives and multi-disciplinary support involved in their ongoing review. However, the inspector found that not all restrictive practices in the centre had been identified and as a result, these practices were not subject to regular review to ensure that the least restrictive practice was employed in the centre. Judgment: Substantially compliant Page 10 of 17
Appendix 1 - Full list of regulations considered under each dimension Regulation Title Capacity and capability Regulation 15: Staffing Regulation 16: Training and staff development Regulation 3: Statement of purpose Regulation 31: Notification of incidents Regulation 23: Governance and management Quality and safety Regulation 26: Risk management procedures Regulation 28: Fire precautions Regulation 6: Health care Regulation 8: Protection Regulation 5: Individual assessment and personal plan Regulation 7: Positive behavioural support Judgment Substantially compliant Substantially compliant Not compliant Substantially compliant Substantially compliant Page 11 of 17
Compliance Plan for Creg Services OSV-0005007 Inspection ID: MON-0025136 Date of inspection: 08/01/2019 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 12 of 17
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 31: Notification of incidents Judgment Substantially Outline how you are going to come into compliance with Regulation 31: Notification of incidents: The PIC has further reviewed all restrictive practices in use in the Designated Centre, and will ensure that all restrictive practices are identified and reviewed by the frontline staff and MDT, will be documented and are forwarded to the Organisations Human Rights Committee for consideration and oversight purposes. The PIC will also ensure that a full list of restrictions will be compiled, with the report being provided to the chief inspector at the end of each quarter of each calendar year, as required by legislation. Regulation 23: Governance and management Substantially Outline how you are going to come into compliance with Regulation 23: Governance and management: The PIC will meet with the Team Leader on a weekly basis to review any and all incidents, in an effort to identify any emerging trends, while ensuring greater governance over the situation. Further to this, individual review meetings will be scheduled with the wider MDT and Designated Officer on an ongoing basis in order to evaluate the effectiveness of steps taken to alleviate the situation, with the next meeting scheduled for March 8th 2019. Additionally to this, training with regard to the completion of AIRS forms has been scheduled for the staff team to ensure greater clarity with regard to the specifics of each incident. Page 13 of 17
Regulation 8: Protection Not Outline how you are going to come into compliance with Regulation 8: Protection: As noted by the inspector, the PIC had initiated a review of incidents that had occurred in the designated centre with frontline staff, MDT, and the Organisations Designated Officer with additional support measures commenced being successful in reducing the frequency of incidents. Following the inspection, all incidents from 1/01/2018 to date were reviewed in detail at a meeting with the PIC, Team Leader, MDT and the Designated Officer on February 1st 2019. It was noted that the incidents arose due to a number of factors which actions agreed aim to address, namely, the provision of an additional 0.6wte Support Worker hours, the provision of an additional vehicle, and the provision of a specific base for day activities being made available to the group as a whole, to facilitate further separation of the group at key times. Behavioural review and further input by the MDT will be ongoing, with further review of behavioural protocols in place. The meeting concluded that a safeguarding referral would not be appropriate at this time due to the fact there was no targeting of any individual involved, that incidents were quite minor in nature with no injuries caused, and incidents have not appeared to have caused any obvious fear in others or significant emotional impact. When clarification was sought on a number of the particular incidents it was also noted that the language used in the incident reports did not accurately reflect the incident that occurred and this will be addressed through upcoming incident report training. The issues involved in this situation were also raised by the Designated Officer with the HSE Safeguarding team at the recent BOCG Management and Monitoring Safeguarding group on January 22nd 2019 and it was agreed that a safeguarding referral at this point would not be an appropriate response to the issues being raised. The Designated Officer will continue to review this situation with a further review meeting scheduled for March 8th 2019. Further to this the person in charge will meet with the local team leader to review any and all incidents on a weekly basis to ensure full governance of the situation. Regulation 5: Individual assessment and personal plan Substantially Outline how you are going to come into compliance with Regulation 5: Individual assessment and personal plan: The PIC will ensure that all aspects of documentation relating to the individuals personal plan is subject to review on a quarterly basis during the year, and includes a review of the effectiveness, progress, and any changes that are required to assist in the achievement of the individuals annual goals. Page 14 of 17
Regulation 7: Positive behavioural support Substantially Outline how you are going to come into compliance with Regulation 7: Positive behavioural support: The PIC has further reviewed all restrictive practices in use in the Designated Centre, and will ensure that all restrictive practices are identified and reviewed by the frontline staff and MDT, are fully documented and are forwarded to the Organisations Human Rights Committee for consideration and oversight purposes. The PIC will also ensure that a full list of restrictions is compiled, with the report being provided to the chief inspector at the end of each quarter of each calendar year, as required by legislation. Page 15 of 17
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 23(1)(c) Regulation 31(3)(a) Regulatory requirement 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. The person in charge shall ensure that a written report is provided to the chief inspector at the end of each quarter of each calendar year in relation to and of the following incidents occurring in the designated centre: any occasion on which a restrictive procedure Judgment Substantially Substantially Risk rating Date to be complied with Yellow 28/03/2019 Yellow 31/01/2019 Page 16 of 17
Regulation 05(6)(c) Regulation 07(5)(c) Regulation 08(2) including physical, chemical or environmental restraint was used. 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 assess the effectiveness of the plan. The person in charge shall ensure that, where a resident s behaviour necessitates intervention under this Regulation the least restrictive procedure, for the shortest duration necessary, is used. The registered provider shall protect residents from all forms of abuse. Substantially Substantially Yellow 21/02/2019 Yellow 31/01/2019 Not Orange 09/03/2019 Page 17 of 17