report of an inspection of a designated centre for ... members. residents lived in self contained...

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Report of an inspection of a Designated Centre for Disabilities (Adults) Issued by the Chief Inspector Name of designated centre:

Donegal Cheshire Apartments

Name of provider: The Cheshire Foundation in Ireland

Address of centre: Donegal

Type of inspection: Announced

Date of inspection:

14 and 15 January 2020

Centre ID: OSV-0003440

Fieldwork ID: MON-0022959

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About the designated centre

The following information has been submitted by the registered provider and describes the service they provide.

Donegal Cheshire Apartments provides full-time residential care and support to

adults (male and female) with a disability from the age of 30 years old. The centre is a single storey dwelling that can accommodate up to twelve residents. Each resident has their own self-contained apartment comprising a kitchen, dining and lounge area

and a bedroom with en-suite bathrooms which were accessible to people with mobility issues. There are also communal areas including lounge, two large activity rooms, two conservatories and additional bathroom facilities. The designated centre

is located in a residential area of a town and is close to local amenities. Residents are supported by a team of social care workers along with additional nursing support being provided during the week. Residents are supported with their assessed needs

by between three to four staff during the day and at evening times. Overnight there are two staff, one sleep over staff and one waking staff.

The following information outlines some additional data on this centre.

Number of residents on the

date of inspection:

10

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How we inspect

This inspection was carried out to assess compliance with the Health Act 2007 (as amended), the Health Act 2007 (Care and Support of Residents in Designated Centres for Persons (Children and Adults) with Disabilities) Regulations 2013, and the

Health Act 2007 (Registration of Designated Centres for Persons (Children and Adults with Disabilities) Regulations 2013 - 2015 as amended. To prepare for this inspection the inspector of social services (hereafter referred to as 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.

This inspection was carried out during the following times:

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Date Times of

Inspection

Inspector Role

Tuesday 14

January 2020

14:30hrs to

19:30hrs

Julie Pryce Lead

Wednesday 15 January 2020

10:30hrs to 15:30hrs

Julie Pryce Lead

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What residents told us and what inspectors observed

There were ten residents living in the centre at the time of the inspection. The

inspector met and spent time with five residents, and also met some family members.

Residents lived in self contained apartments in the centre, and some residents invited the inspector into their apartment for to speak with them. Residents had furnished and decorated their apartments according to their own tastes, and had

their personal possessions in their homes. Residents told the inspector that they were happy in their homes and that staff were supportive. They spoke about

occasions where staff had supported them in various ways. Some residents said that they were supported to maintain their independence, while having staff to call on us required. Some residents spoke fondly of staff members, and told the inspector who

they would go to if they had a problem or needed to discuss anything.

Some residents could not communicate verbally, however staff members were very

familiar with the ways in which they communicated, and assisted the inspector to interpret individual ways of answering so that the inspector could communicate with them. Residents indicated that they were happy, had plenty of activities to engage

in and were helped by staff to go about their daily lives.

The inspector also met some relatives of residents, who expressed a high level of

satisfaction with the service. Some families were supported in their homes by staff so that their relatives could visit, for example over the Christmas season. Where relatives had raised any concerns to staff, these had been reviewed in line with the

centres complaints policies and procedures.

Capacity and capability

The centre was effectively managed, with a clearly defined management structure in place and explicit lines of accountability and various governance processes so as

to ensure appropriate safety and quality of care and support was provided to residents.

The provider had made arrangements to ensure that key management and leadership roles were appropriately filled. There was a person in charge in position

at the time of the inspection who was appropriately skilled, experienced and qualified. This person in charge was full time and demonstrated their ability to lead the staff team and to support good practice. They were knowledgeable about the

care and support needs of residents. The person in charge was supported by a nursing manager and by a service co-ordinator, and also had human resource and

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administration support.

The provider had put systems in place to ensure the staff team could effectively meet the needs of residents. The staffing arrangements were appropriate to meet the assessed needs of residents. Staff were in receipt of regular training in

accordance with the needs of residents, and where appropriate this training included competency assessments. Staff demonstrated a detailed knowledge of the support needs of residents, and were observed to be implementing guidance in personal

plans. There was evidenced through discussion with staff and through observation that there was a caring relationship with residents.

A sample of staff files, and files relating to volunteers in the centre were reviewed, and all had the required documentation in place. Staff were supervised by the

person in charge and support managers on a daily basis and supervision conversations were held regularly. Annual performance management was in place. Therefore the provider had ensured a staff team who were knowledgeable and

competent were in place to support the residents.

The provider demonstrated the capacity to identify and address areas for

improvement. Six monthly unannounced visits had been conducted on behalf of the provider. These visits comprised a detailed audit of the care and support offered to residents, and identified actions for improvement. These actions were monitored

locally by the management team, and oversight was provided by the organisation's quality team. An annual review of the care and support offered to residents had also been undertaken. Improvements were again identified, and staff signed to say that

they had read and understood the requirements.

In addition a suite of audits had been undertaken, within the areas of quality,

clinical and health and safety. All actions from these processes were monitored, and those marked as complete were observed by the inspector to have been implemented.

There were systems in place to ensure communication between staff and

management, and to ensure oversight of the care and support in the centre. Regular meetings were held with staff, and although the minutes of these meetings were sometimes unclear, there were various other ways of communicating with staff,

including a daily 'update folder' which all staff read and signed at the start of each shift.

There was regular review and monitoring of any accidents and incidents. Any accidents and incidents had been recorded and reported. The records included information about the incident, and any actions taken or required. The person in

charge monitored any required actions, and the process was overseen by the national risk manager.

The provider had put systems in place to receive and respond to feedback about the service. There was a complaints procedure in place which was clearly available, and any complaints were reviewed and recorded. Any steps taken to rectify any issues

raised in a complaint were recorded, and the satisfaction of the complainant was also noted. The record of steps taken was overseen by the complaints officer.

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Residents knew who they would approach if they had a complaint. It was therefore clear that feedback on the service was responded to in a timely manner, and that all

steps were taken to resolve any identified issues.

Regulation 14: Persons in charge

The person in charge was appropriately skilled, experienced and qualified, and had

clear oversight of the centre.

Judgment: Compliant

Regulation 15: Staffing

There were sufficient staff to meet the needs of residents, and consistency of care and continuity of staff was maintained.

Judgment: Compliant

Regulation 16: Training and staff development

Staff were in receipt of all mandatory training, and additional training had been

provided in accordance with the specific needs of residents.

Judgment: Compliant

Regulation 19: Directory of residents

The directory of residents included all the required information.

Judgment: Compliant

Regulation 22: Insurance

There was appropriate insurance in place.

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Judgment: Compliant

Regulation 23: Governance and management

There was a clear management structure in place and robust systems to monitor the

quality of care delivered to residents.

Judgment: Compliant

Regulation 24: Admissions and contract for the provision of services

There were contracts in place which clearly laid out the services offered to residents and any charges incurred.

Judgment: Compliant

Regulation 3: Statement of purpose

The statement of purpose contained all the information required by the regulations, and accurately described the service provided.

Judgment: Compliant

Regulation 31: Notification of incidents

All required notifications were made to HIQA within the required time frames.

Judgment: Compliant

Regulation 34: Complaints procedure

There was a clear complaints procedure which was available in an accessible

version, and residents knew who to approach if they had a complaint.

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Judgment: Compliant

Quality and safety

The provider had arrangements in place to ensure that residents were supported in making their own choices, led meaningful lives based on their interests and had as required access to a ranges of allied healthcare services.

There was an effective personal planning system in place which included detailed assessment and regular review. Each resident had a personal plan in place based

on a detailed assessment of their needs and abilities, including both social and healthcare needs. Residents were involved in the personal planning process, and had an accessible version of the personal plan in their possession if they chose.

There was guidance for staff in various sections of the personal plans, including communication, and staff were observed to be implementing the plans. There were

sections relating to maintaining independence, and on maximising the potential of each individual and it was evident that the personal planning system was driving improved outcomes for residents.

Residents were supported to have positive healthcare outcomes, and to gain

independence in maintaining good health. They had access to members of the multi-disciplinary team as required, and a record was kept of any prescribed healthcare interventions. Healthcare plans were in place where needed, and residents were

closely monitored so that any changes in healthcare needs were responded to immediately. Staff had received training in specific healthcare areas in order to support residents, and supplementary training in response to any changes in

national policy.

Where residents required support with behaviours of concern there were clear

positive behaviour support plans in place, based on detailed assessments. These plans were regularly reviewed, progress was monitored and included detailed guidance for staff. Where there were restrictions in place, there was clear rationale

for the necessity of the practices. Residents were involved in the decision making process around restrictions and had consented to their use. Daily records were kept of the implementation of restrictions, and any interventions were the least restrictive

possible to manage the identified risk.

There were structures and processes in place in relation to risk management which

were effective for the most part. Detailed risk assessments were in place, both environmental and individual. Each identified individual risk assessment had an

associated risk management plan. There was a detailed risk register maintained and regularly reviewed, and oversight of risk throughout the centre by the organisation's national risk manager. However, there were aspects of the premises which

presented a significant risk to the vulnerable adults living in this centre, and while

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the risk had been identified it had not been mitigated.

Fire safety practices and equipment were in place to ensure risks relating to fire were mitigated. Fire safety equipment including fire doors, extinguishers, fire blankets and emergency lighting were in place and were regularly maintained and

there were fire doors throughout. There was a personal evacuation plan in place for each resident, including any residents who had recently been admitted. While regular fire drills had been undertaken, there had been no fire drill under night

time circumstances so that the provider had not demonstrated that residents could be evacuated in the event of an emergency at night.

There were structures and processes in place in relation to the safeguarding of residents. All staff had had appropriate training and demonstrated knowledge of

their role in the safeguarding of residents. Issues that had arisen relating to safeguarding residents had been addressed immediately by the person in charge, and appropriate action had been taken. Residents' personal money was managed in

a robust manner, and it was clear that measures had been taken to ensure that residents were protected from any form of abuse.

There were contracts of care in place, in which the services offered to residents were outlined, together with any charged incurred. These contracts had been signed by either the residents or their representatives. There was also a transition process

in place fro the admission of any new residents to the centre, which were overseen by the organisation's admissions committee. The person in charge was overseeing the admission of new residents, and was involved in ensuring that the appropriate

supports were in place.

There was an emphasis in the centre and among the staff on upholding the rights of

residents. Residents were supported in choice making, and were included in decisions about their lives. Regular meetings were held with residents to ensure consultation, both as a group and individually. Residents’ dignity was upheld, and all

interactions observed between staff and residents were respectful, appropriate and caring. there had been occasions where staff had advocated for the rights of

residents, and their interventions had improved the quality of life for residents. In addition residents had access to external advocacy services, who had also been involved in ensuring that residents' rights were upheld.

Overall, this inspection found that each resident was supported to have a good quality of life, and to maintain their independence.

Regulation 10: Communication

Residents were supported in communication so that their voices were heard, and that information was available to them.

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Judgment: Compliant

Regulation 13: General welfare and development

Residents were provided with appropriate care and support in accordance with their assessed needs and preferences.

Judgment: Compliant

Regulation 26: Risk management procedures

There was a risk register in place including risk ratings, and a detailed risk

assessment for each risk identified. However a significant risk in the centre had not been mitigated.

Judgment: Not compliant

Regulation 5: Individual assessment and personal plan

There was a personal plan in place for each resident in sufficient detail as to guide practice, including detailed healthcare plans, which had been regularly reviewed

with the involvement of the residents

Judgment: Compliant

Regulation 6: Health care

There was a high standard of healthcare, and there was a prompt and appropriate response to any changing conditions.

Judgment: Compliant

Regulation 7: Positive behavioural support

There were effective behaviour support programmes in place for those residents

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who required support in this area. There were very few restrictive interventions in the centre, and those in place had been assessed appropriately, and residents had

consented to their use.

Judgment: Compliant

Regulation 8: Protection

There were systems in place to ensure that residents were protected from all forms of abuse.

Judgment: Compliant

Regulation 9: Residents' rights

Residents rights were upheld, and no rights restrictions were identified.

Judgment: Compliant

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Appendix 1 - Full list of regulations considered under each dimension

This inspection was carried out to assess compliance with the Health Act 2007 (as amended), the Health Act 2007 (Care and Support of Residents in Designated Centres for Persons (Children and Adults) with Disabilities) Regulations 2013, and the

Health Act 2007 (Registration of Designated Centres for Persons (Children and Adults with Disabilities) Regulations 2013 - 2015 as amended and the regulations considered on this inspection were:

Regulation Title Judgment

Capacity and capability

Regulation 14: Persons in charge Compliant

Regulation 15: Staffing Compliant

Regulation 16: Training and staff development Compliant

Regulation 19: Directory of residents Compliant

Regulation 22: Insurance Compliant

Regulation 23: Governance and management Compliant

Regulation 24: Admissions and contract for the provision of

services

Compliant

Regulation 3: Statement of purpose Compliant

Regulation 31: Notification of incidents Compliant

Regulation 34: Complaints procedure Compliant

Quality and safety

Regulation 10: Communication Compliant

Regulation 13: General welfare and development Compliant

Regulation 26: Risk management procedures Not compliant

Regulation 5: Individual assessment and personal plan 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 Donegal Cheshire Apartments OSV-0003440 Inspection ID: MON-0022959

Date of inspection: 14 and 15/01/2020

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 non-compliance 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.

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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 26: Risk management

procedures

Not Compliant

Outline how you are going to come into compliance with Regulation 26: Risk

management procedures: The provider is going to provide a fob system for the main front door of the building which will restrict access to people not involved with the centre but will provide open

access for residents and staff of the centre. The distribution of fobs will be controlled and recorded by the PIC and management team.

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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 26(2) The registered

provider shall ensure that there are systems in

place in the designated centre for the

assessment, management and ongoing review of

risk, including a system for responding to

emergencies.

Not Compliant Yellow

15/03/2020

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