Report of an inspection of a Designated Centre for Disabilities (Adults) Name of designated Grattan Lodge centre: Name of provider: St Michael's House Address of centre: Dublin 13 Type of inspection: Announced Date of inspection: 08 February 2018 Centre ID: OSV-0003599 Fieldwork ID: MON-0020783 Page 1 of 11
About the designated centre The following information has been submitted by the registered provider and describes the service they provide. The designated centre is a community based home with the capacity to provide fulltime residential care and support to six adults both male and female. It is currently home for five residents with varying degrees of intellectual and physical disabilities. Residents in the centre are supported with positive behaviour support needs, augmentative communication needs, emotional support needs, specialised diet and nutritional needs, and physical and intimate care support needs. The house is situated on a quiet cul de sac with a large green area opposite the house. It is in a suburban area of Co. Dublin with access to a variety of local amenities such as a local shopping centre, cinema, bowling alley, dart station, bus routes, and churches. The centre has a vehicle to enable residents to access day services, local amenities and leisure facilities in the surrounding areas. The centre consists of a large twostorey house with seven bedrooms and an accessible front and back garden. Residents in the centre are supported 24 hours a day, seven days a week by a staff team comprising of a person in charge, social care workers, and a care assistant. The following information outlines some additional data on this centre. Current registration end date: Number of residents on the date of inspection: 22/07/2021 5 Page 2 of 11
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 11
This inspection was carried out during the following times: Date Times of Inspection Inspector Role 08 February 2018 09:55hrs to 17:20hrs 08 February 2018 09:55hrs to 17:20hrs Marie Byrne Helen Thompson Lead Support Page 4 of 11
Views of people who use the service The inspectors met and spoke with four residents during the inspection who were complimentary towards the care and support in the centre. They spoke fondly of the staff and stated that they were happy to live in the centre. They told inspectors they were getting the right supports and felt safe. Residents gave positive feedback to the inspectors in relation to the quality of the food, choices in the centre, and the range of activities they were supported to engage in. They told inspectors that they were involved in decision making about the day-to-day running of the house including menu planning, shopping, and cooking. There were similar positive comments in the questionnaires which all five residents in the centre were supported to complete prior to the inspection. Some residents outlined areas for improvement in the centre such as having access to the upstairs of the premises and access to a room to meet with visitors. The inspectors also reviewed a questionnaire completed by a resident's relative which indicated that overall they were satisfied with the care and support provided to their relative in the centre. Inspectors observed staff provide support to residents to engage in activities of their choice on the day of inspection including attending appointments, day services and activities in the local community. Capacity and capability Overall, inspectors found that the registered provider and person in charge were ensuring a good quality and safe service for residents in the centre. Care and support was found to be person-centred and in line with residents choices, needs, and wishes. The provider had put measures in place to complete most of the actions required following the last inspection. There were clearly defined management structures which identified the lines of authority and accountability in the centre. The staff team reported to the person in charge who in turn reported to the service manager. Residents and staff could clearly identify how they would report any concerns about the quality of care and support in the centre. Staff were in receipt of support and supervision to ensure they performed their duties to the best of their abilities. Page 5 of 11
There were arrangements in place to monitor the quality of care and support in the centre including an annual review of the quality and safety in the centre and six monthly visits by the provider or their representative. Learning and improvements were brought about as a result of the findings of these reviews. A number of audits were also completed regularly in the centre. There was evidence that residents and their representatives had been involved in the review of quality of care and supports in the centre. The statement of purpose accurately reflected the facilities and services provided in the centre and contained all the information required in schedule 1 of the regulations. It had been reviewed regularly in line with the time frame identified in the regulations. There were appropriate staff numbers to meet the assessed needs of residents. The inspectors spoke with a number of staff in the centre who could clearly identify the care and support needs of residents. Staff in the centre had access to training and refresher training in line with the statement of purpose but required additional training in line with residents emotional and mental health needs. Staff were observed to treat residents with respect and warmth, and to encourage them to develop their life skills and independence. There were policies and procedures in place to guide staff practices to support residents. A record of all incidents occurring in the centre was maintained. However, there were a number of incidents recorded in the centre which had not been notified to HIQA in line with the regulations. Regulation 16: Training and staff development Improvement was required in relation to staff training to meet residents' needs. Judgment: Substantially compliant Regulation 23: Governance and management There were sufficient resources available in the centre to ensure effective delivery of care and support in line with the statement of purpose. Judgment: Page 6 of 11
Regulation 3: Statement of purpose The statement of purpose contained all the information required by the regulations. Judgment: Regulation 31: Notification of incidents While there was a log of all accidents and incidents occurring in the centre, some were not reported to HIQA in line with the regulations. Judgment: Not compliant Regulation 4: Written policies and procedures All schedule 5 policies and procedures were in place in the centre and reviewed in line with time frame identified in the regulations. Judgment: Quality and safety Inspectors found for the most part there were systems and procedures in place to protect residents, promote their welfare, and recognise and effectively manage the service when things go wrong. Improvements were required in a number of areas including safeguarding and the layout of the premises to ensure residents could receive visitors in private. There was an assessment of the health, personal, social care and support needs of each resident in the centre. Care plans were developed in line with residents' identified needs. There was evidence that the centre worked together with the resident and their representative to identify their strengths, needs and goals. However, some plans had not been evaluated or reviewed. Residents had opportunities to engage in meaningful activities in line with their wishes and preferences. Activities were discussed at residents' meetings and then discussed daily and changes made in line with residents' wishes on that day. There was a vehicle in the centre to support residents to engage in meaningful activities. Page 7 of 11
Residents reported to the inspectors that they were involved in their local community and supported to access community facilities in line with their wishes. Residents were observed to be supported with day-to-day decisions such as what household tasks' they would take part in and how they wished to spend their day. This was facilitated through the use of pictures and easy read information for some residents. Residents were supported to achieve and enjoy best possible health and had access to allied health professionals in line with their assessed needs. There was evidence of appropriate assessments and care plans in place. Residents were supported and actively encouraged to take responsibility for their own medicines. Each resident had guidelines in place to guide staff on what supports if any they required in relation to administering their medicines. Medicines management practices were reviewed and monitored in the centre. Audits were completed and all medicines errors and incidents were reported and followed up on. The health and safety of residents, visitors and staff was promoted and protected in the centre. There were policies and procedures in place for risk management and emergency planning. There was evidence of evaluation of risk management procedures to ensure they were effective and promoted positive outcomes for residents. Suitable arrangements were in place for the detection and containment of fire in the centre. There were some measures in place to protect residents from being harmed or suffering abuse including staff training. However, the inspector reviewed a number of incidents in the centre which had not been reported or followed up on in line with national guidance or the organisation's policy. There were policies and person-centred procedures in place in relation to intimate care. Residents had access to an advocate or advocacy services if they so wish. Residents were supported to buy, prepare and cook their meals in line with their wishes and preferences. The centre was homely, spacious, clean and comfortable. However, there were some areas in need of maintenance and repair. Also in line with residents' wishes and findings on the day of inspection there was an absence of a designated space for residents to meet their friends and visitors. Suitable storage was in place for residents some of which had been adapted to ensure accessibility. Inspectors found that residents were supported to develop and maintain personal relationships and links with the wider community. Staff in the centre were observed to communicate with residents in a respectful manner, and to listen and respond to each resident. Residents' information was stored in their bedroom and there was a written agreement in place signed Page 8 of 11
by residents in relation to who could access their personal information. Regulation 11: Visits A designated private area for residents to meet visitors was not available. Judgment: Substantially compliant Regulation 17: Premises Improvements were required in relation to maintenance and upkeep in the centre. Judgment: Substantially compliant Regulation 26: Risk management procedures The health and safety of residents, staff and visitors was promoted in the centre. Judgment: Regulation 28: Fire precautions There were appropriate systems in place for the prevention and detection and containment of fire. Judgment: Regulation 29: Medicines and pharmaceutical services There were appropriate systems in place in relation to medicines management in the centre. Judgment: Page 9 of 11
Regulation 5: Individual assessment and personal plan Improvement was required in the review and evaluation of personal plans. Judgment: Substantially compliant Regulation 6: Health care Residents' healthcare needs were assessed and they had access to allied health professionals in line with their assessed needs. Judgment: Regulation 8: Protection Improvement was required in relation to the prevention, detection and response to abuse in the centre. Judgment: Not compliant Regulation 9: Residents' rights Residents' privacy and dignity was respected in the centre. Judgment: Page 10 of 11
Appendix 1 - Full list of regulations considered under each dimension Regulation Title Capacity and capability Regulation 16: Training and staff development Regulation 23: Governance and management Regulation 3: Statement of purpose Regulation 31: Notification of incidents Regulation 4: Written policies and procedures Quality and safety Regulation 11: Visits Regulation 17: Premises 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 8: Protection Regulation 9: Residents' rights Judgment Substantially compliant Not compliant Substantially compliant Substantially compliant Substantially compliant Not compliant Page 11 of 11
Compliance Plan for Grattan Lodge OSV-0003599 Inspection ID: MON-0020783 Date of inspection: 08/02/2018 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 5
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 16: Training and staff development Judgment Substantially Outline how you are going to come into compliance with Regulation 16: Training and staff development: St Michaels House provides training for all staff which is appropriate to their position. Additional training to support staff with residents emotional and mental health has been arrange with our Mental Health Intellectual Disability Team and will be completed by 30th June 2018. Supervision meeting between the PIC and staff are held at least four times throughout the year. Copies of all relevant information including the Health Act, regulations, guidance documents are present in the designated centre. Regulation 31: Notification of incidents Not Outline how you are going to come into compliance with Regulation 31: Notification of incidents: The PIC will ensure that all required notification will be given in writing, following any adverse incidents to the authority within the required timeframe. Regulation 11: Visits Substantially Outline how you are going to come into compliance with Regulation 11: Visits: There is a policy in the designated centre in relation to visitors. A suitable area within the designated centre had been determined, this area will be refurbished to provide a private area for residents to receive visitors. Visits will be facilitated in accordance with the residents wishes Page 2 of 5
Regulation 17: Premises Substantially Outline how you are going to come into compliance with Regulation 17: Premises: The PIC with the organizations Technical Services will ensure the designated centre is kept in a good state of repair. A Daily cleaning schedule has been reviewed to include all requirements to ensure a clean environment Regulation 5: Individual assessment Substantially and personal plan Outline how you are going to come into compliance with Regulation 5: Individual assessment and personal plan: The PIC will organize a review of all residents personal plans within the designated centre to assess the effectiveness of each plan. Within this review the personal plan will be evaluated to ensure the plan was developed arising from the residents goals and wishes. There is a comprehensive assessment of need for each resident living in the designated centre, this is reviewed annually or as required with multi disciplinary input as appropriate. Assessable format of each residents personal plan are available to each resident and where appropriate their representative in a format that is meaningful to the resident. Regulation 8: Protection Not Outline how you are going to come into compliance with Regulation 8: Protection: Safeguarding training for all staff has been completed. Each resident is supported to develop skills so that they have knowledge and skills to promote their personal self care and protection. Where there are any incidents, allegations or suspicion of abuse, the PIC will ensure this is reported to the Designated Officer and notifications are made to the authority. 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. Page 3 of 5
The registered provider or person in charge has failed to comply with the following regulation(s). Regulation Regulation 11(3)(b) Regulation 16(1)(a) Regulation 17(1)(c) Regulation 31(1)(f) Regulatory requirement The person in charge shall ensure that having regard to the number of residents and needs of each resident; a suitable private area, which is not the resident s room, is available to a resident in which to receive a visitor if required. The person in charge shall ensure that staff have access to appropriate training, including refresher training, as part of a continuous professional development programme. The registered provider shall ensure the premises of the designated centre are clean and suitably decorated. The person in charge shall give the chief inspector notice in writing within 3 working days of the following adverse incidents occurring Judgment Substantially Substantially Substantially Risk Date to be rating complied with Yellow 30/11/2018 Yellow 30/06/18 Yellow 30/06/18 Not Orange 09/02/18 Page 4 of 5
Regulation 05(6)(c) Regulation 08(3) in the designated centre: any allegation, suspected or confirmed, of abuse of any resident. 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 initiate and put in place an Investigation in relation to any incident, allegation or suspicion of abuse and take appropriate action where a resident is harmed or suffers abuse. Substantially Yellow 31/05/18 Not Orange 09/02/18 Page 5 of 5