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

St. John of God Kildare Services - DC7

Name of provider: St John of God Community Services Company Limited By Guarantee

Address of centre: Kildare

Type of inspection: Announced

Date of inspection:

14 January 2020

Centre ID: OSV-0002944

Fieldwork ID: MON-0022498

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About the designated centre

The following information has been submitted by the registered provider and describes the service they provide. Designated Centre 7 supports 23 individuals, both male and female, living across five terraced homes and one apartment located in a large town in Co. Kildare. Each resident has their own bedroom and share common areas with other residents. Residents with an intellectual disability and mental health issues are supported by social care workers, nursing staff and a healthcare assistant. Some residents attend various day programmes provided by St. John of God Kildare services and some residents are supported to participate in activities in their local community or stay at home on days that they choose. Residents have access through a referral system for the following multi-disciplinary supports psychology, psychiatry and social work. All other clinical support are accessed through community based primary care with a referral from the individuals G.P as the need arises. The centres' registration is subject to a de-congregation plan to reduce the capacity of each house from five adults to a maximum capacity of four residents. The following information outlines some additional data on this centre.

Number of residents on the

date of inspection:

23

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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

09:30hrs to 19:30hrs

Erin Clarke Lead

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What residents told us and what inspectors observed

The inspector met with the residents of all of the houses in the designated centre throughout different times of the day and observed elements of their daily lives. The inspector spent breakfast with a group of residents before they left for their individual day activities. Residents were observed being supported with their needs as detailed in dsyphagia plans later reviewed by the inspector. Residents spoke to the inspector regarding their plans for the day and what they liked about living in their home.

In another house residents wanted the inspector to hold a meeting with them to discuss their views of the service and highlight areas that they have felt had been improved upon. There was a strong ethos of resident involvement and consultation in the running of their homes. For example, residents brought maintenance issues to the attention of staff and the person in charge and were kept up to date on the progress until they were completed. New televisions were also installed, at the request of residents in order to view extra channels.

Residents stated that they felt well supported, safe and well cared for in the centre. Residents informed the inspector that they were very happy with the staff and keyworkers who supported them. The residents spoken with very much identified with the sense of community in this centre and some residents had resided there for many years. All residents spoken with on this inspection were highly complimentary about the service that they received, the management and staff in this designated centre.

All residents had taken part in a recent survey regarding their residential experience as part of the providers annual review process. Residents had identified that they would like additional living space and a bigger house. Overall happiness was expressed with the centre, meals, and staffing support. The majority of residents were clear on who they would speak to if unhappy. Residents who had made complaints were happy with how these had been addressed.

Staff on duty in the centre were observed to interact with residents in a warm and caring manner and the centre was decorated with pictures of the residents enjoying events and engaging in activities with peers or family members and in their local community.

Capacity and capability

The registered provider had ensured that this was a well-run centre which was meeting the residents' individual needs. This was reflected by a good level of

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compliance across the regulations inspected against. The centre had a restrictive condition attached to its registration to ensure that the centre's decongregation plan was implemented, which would afford residents a more comfortable living environment. It was found that the provider had made progress towards this condition by the successful transition of one resident to a community house. The provider updated the inspector on it's future plans to ensure that they met the requirement of this condition.

The person in charge was supported in the effective governance and oversight of the centre by two social care leaders who reported into them. The person in charge reported into the programme manager for the area. There was evidence of regular meetings between the person in charge, the two team leaders and the programme manager. In addition, the inspector reviewed records of audits, quality improvement plans and staff meetings minutes that demonstrated the continuous review of the service provided. It was evident that staff and management were advocates for residents’ rights and ensuring that a good quality of life was provided in line with residents’ wishes.

The provider had conducted an unannounced audit of the care provided in the centre which identified some areas for improvement. There was a system of audits in place which gathered data on various elements of the care provided such as dsyphagia plans and adverse events. An annual review of the service was carried out and an action plan was developed, to address any identified issues. The inspector found that actions generated from these internal audits had been addressed by the person in charge in a prompt manner, which resulted in continuous improvements in the quality of care provided to residents. The person in charge had ensured that all residents were consulted with in relation to their views of the service provided. The inspector found that residents’ wishes influenced action and resources to address these concerns.

The centre's rosters, staffing arrangements, staff records, training and development were all reviewed and were found compliant in line with regulatory requirements. On review of the rosters and in discussion with the person in charge it was observed that additional hours had been provided in one house in response to the changing needs of residents in recent months. The provider had identified that the service had to evolve to meet the increased assessed needs of residents. While relief staff were used to address some gaps in staffing levels, business cases had been developed for additional staffing support and funding. The inspector requested that an up to date statement of purpose was submitted to the office of the Chief Inspector of Social Services to reflect the increased staffing arrangements and this was completed.

There was a clear training matrix maintained which indicated that all staff had the required training elements. The person in charge highlighted to the inspector that staff would have access to increased training when new diagnoses or supports presented in the centre. Informal training had also been made available to staff while awaiting results of recent clinical assessments. This demonstrated a responsive approach to any change in need.

Records of all incidents occurring in the centre had been maintained, and

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notifications of any adverse incidents and quarterly returns had been appropriately made within the required time frames as viewed by the inspector.

The registered provider had established and implemented effective systems to address and resolve issues raised by residents or their representatives. Systems were in place, including details of advocacy services, to ensure residents had access to information which would support and encourage them to express any concerns they may have. The inspector saw evidence that the complaints procedure was discussed at residents monthly meetings in a format that was accessible to them. There were no active complaints at the time of inspection.

Improvement was needed in setting out a contract that would fully inform residents of the service they could expect to receive. Fees had not been reviewed in line with the reduction of residents living in one house. Also there was an inequity of charges whereby not all residents within the designated centre were subject to charges. This was discussed at the feedback session and the inspector was informed that a policy was being developed as to how payable charges would be aligned to national guidelines regarding residential fees.

Registration Regulation 5: Application for registration or renewal of registration

The provider had submitted the required documentation for the renewal of the registration of this designated centre.

Judgment: Compliant

Regulation 14: Persons in charge

The inspector found that the person in charge met the requirements of this regulation with regard to their qualifications, background, knowledge and experience. Additionally, it was noted that there were clear systems in operation to facilitate the person in charge's current regulatory responsibilities for two designated centres.

Judgment: Compliant

Regulation 15: Staffing

The staffing compliment in the centre was aligned to the assessed needs of the residents. There was a regular staff team working in the centre which also incorporated a panel of relief staff. The person in charge advised that the centre had

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recently applied for funding approval for additional staff due to recent changes in the needs of residents. The providers recruitment process ensured that staff documentation required under schedule two of the regulations was obtained, as sampled by the inspector. Staff spoken with were familiar with the residents' needs.

Judgment: Compliant

Regulation 16: Training and staff development

The provider ensured that a schedule of mandatory and refresher training was in place which supported the delivery of care to residents. In addition the organisation had started to roll out specific training which reflected the residents' changing needs. Staff team meetings were also being held at regular intervals.

Judgment: Compliant

Regulation 22: Insurance

The registered provider had a contract of insurance against injury to residents and other risks in the designated centre, including loss or damage to property.

Judgment: Compliant

Regulation 23: Governance and management

There were effective governance, leadership and management arrangements in place to govern the centre and to ensure the provision of a good quality and safe service to residents. There was an effective management structure, and there were arrangements in place, such as extensive auditing systems, to ensure that the service provided was safe and in line with residents’ needs.

Judgment: Compliant

Regulation 24: Admissions and contract for the provision of services

There were written agreements for the provision of service in place in the centre. These agreements included the required information and had been agreed with residents or their representatives. However, improvement was required with the

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review of charges and the equity of charges across the designated centre.

Judgment: Substantially compliant

Regulation 31: Notification of incidents

A record of all incidents occurring in the centre were maintained and where required, notified to the Chief Inspector and within the timelines required in the regulations.

Judgment: Compliant

Regulation 34: Complaints procedure

The provider had put in place an effective complaints procedure which was in an accessible format, included an appeals process and was displayed in a prominent position in the centre. There was evidence that the provider had ensured that this policy had been implemented fully within the service.

Judgment: Compliant

Quality and safety

The inspector found that the resident’s well-being and welfare was maintained to a high standard and that there was a strong and visible person-centred culture within the centre. It was evident that the person in charge and staff were aware of each resident's needs and were knowledgeable in the person-centred care practices required to meet those needs. One area for improvement noted by the inspector related to the support provided for all residents to manage their financial affairs.

The designated centre consisted of five terraced houses and one separate apartment. The houses due to their limited communal spaces were subject to a condition of registration that ensured no more than four residents resided in each house. At the time of the inspection, two houses were not meeting this requirement. The provider discussed the transition plans of some residents that were subject to funding approval external to the organisation. The inspector found that the provider had, in the interim, made renovations to one bathroom and detailed plans to enhance spare rooms to ensure residents were afforded adequate living space, while transitions where underway. Outstanding maintenance issues identified on the

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previous inspection had since been addressed.

Each resident had an individual personal plan in place. The inspector reviewed a sample of these plans and found that they had been informed by detailed assessments. The plans outlined the needs of residents and the supports to be provided to residents to meet these needs. Staff members present during this inspection demonstrated a good understanding of such needs and supports. Staff were observed by the inspector to provide appropriate support to residents when required. There was also a focus on the long term needs of the residents in terms of different and changing needs and these were reviewed via the multidisciplinary review process.

Support was provided to residents to enjoy the best possible health. Residents had annual assessments carried out and where necessary healthcare plans were put in place outlining the supports needed for residents. Staff spoken to were aware of the healthcare needs of residents and how best to support them with these. Staff were also recording and noting signs of cognitive decline as part of dementia assessments carried out by the psychology team ensuring that accurate information was being provided.

The inspector found that the fire management systems had been improved upon since the previous inspection with the fitting of magnetic fire door closures. This enabled the free access of residents to navigate their living environment without compromising fire containment measures. Personal emergency evacuation plans had been updated to reflect any issues experienced in a fire evacuation drill. The inspector viewed additional safety measures that were put in place in the event that a resident refused to evacuate in the event of a fire.

Residents did at times present with behaviours of concern and risk. The inspector reviewed the behaviour support plan and saw that it clearly outlined the behaviours, their origin and the purpose of them. There was guidance in the plan as to how staff should respond, record and report specific behaviours. The person in charge discussed with the inspector that the risk of resident absconding had increased in the previous months due to cognitive decline. The inspector found that risk management policies and procedures and risk assessments were in place for dealing with situations where resident safety may have been compromised. The approach to risk management was dynamic, individualised and supported responsible risk-taking as a means of enhancing quality of life while keeping residents safe from harm.

Effective behaviour support systems ensured that residents with behaviours that challenge received the care and support they required. Staff who spoke with the inspectors were found to be knowledgeable in how they were to support these residents. Safeguarding arrangements ensured that residents were safeguarded from abuse and the provider had systems in place to support staff to identify and report any concerns they had regarding the safety and welfare of residents. Some environmental restrictive practices were in use in the designated centre and these were found to be appropriately assessed, monitored and reviewed in line with best practice.

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The provider had ensured that residents retained control of their personal property; residents had their own items in their homes and these were recorded in a log of personal possessions. The vast majority of residents were found to have access to their own funds in individual bank and post office accounts. Financial support plans in place required review to ensure an assessment of need was completed that determined the level of support required by residents for the safekeeping, budgeting, saving, spending and record keeping to the greatest extent possible. For remaining residents whose finances were managed by someone outside of the organisation, there lacked a capacity assessment and oversight mechanism to ensure monies where used in the best interest of the resident.

Regulation 12: Personal possessions

Practices relating to the management and oversight of all resident finances in the centre required review and strengthening. It was also unclear to the inspector, in the absence of an financial assessment, the level of support that residents required and areas where they had capacity in managing their own monies.

Judgment: Substantially compliant

Regulation 17: Premises

The living area of some of the houses were cramped and did not provide adequate communal space. Maintenance works identified on the previous inspection had been completed.

Judgment: Not compliant

Regulation 26: Risk management procedures

There were arrangements in place to manage risk, including a risk management policy and associated procedures. Risks to residents were identified and managed, to promote the safety and autonomy of residents.

Judgment: Compliant

Regulation 28: Fire precautions

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There were appropriate fire precaution measures in place for the prevention, detection and response to fire. Appropriate equipment, emergency lighting and fire evacuation drill were evident. Actions identified on the previous inspection had been completed.

Judgment: Compliant

Regulation 5: Individual assessment and personal plan

Residents had personal plans in place which outlined their needs and the supports to be provided to residents to meet these needs. These plans were informed by appropriate assessments and were noted to have been reviewed within the previous 12 months. Reviews of such personal plans had taken place with the involvement of residents and their relatives. Personal plans were noted to have multidisciplinary input.

Judgment: Compliant

Regulation 6: Health care

A sample of personal plans reviewed contained information relating to residents' medical histories along with records of assessments. The inspector saw examples of clear guidance provided to direct care relating to residents' healthcare needs. Nursing staff was available in the centre. As a result the inspector was satisfied that adequate support was provided to residents to experience the best possible health.

Judgment: Compliant

Regulation 7: Positive behavioural support

Staff had a good understanding of behavioural support plans which were in place and restrictive practices which were implemented in the centre were kept under regular review to ensure that the least restrictive practice was implemented at all times.

Judgment: Compliant

Regulation 8: Protection

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The provider had appropriate arrangements in place to safeguard residents from harm or abuse. All staff had received training in safeguarding, and there was a safeguarding policy to guide staff. The services of a designated safeguarding officer were available to support residents and staff.

Judgment: Compliant

Regulation 9: Residents' rights

The provider had ensured that each resident, in accordance with their wishes, participated in decisions about their care and support. Residents also had the freedom to exercise choice and control in their daily lives. Residents were consulted with on their views and their preferences were respected.

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

Registration Regulation 5: Application for registration or renewal of registration

Compliant

Regulation 14: Persons in charge Compliant

Regulation 15: Staffing Compliant

Regulation 16: Training and staff development Compliant

Regulation 22: Insurance Compliant

Regulation 23: Governance and management Compliant

Regulation 24: Admissions and contract for the provision of services

Substantially compliant

Regulation 31: Notification of incidents Compliant

Regulation 34: Complaints procedure Compliant

Quality and safety

Regulation 12: Personal possessions Substantially compliant

Regulation 17: Premises Not compliant

Regulation 26: Risk management procedures Compliant

Regulation 28: Fire precautions 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 St. John of God Kildare Services - DC7 OSV-0002944 Inspection ID: MON-0022498

Date of inspection: 14/01/2020 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 24: Admissions and contract for the provision of services

Substantially Compliant

Outline how you are going to come into compliance with Regulation 24: Admissions and contract for the provision of services: - A RSSMAC assessment will be completed for each resident by the 30th April 2020. - The schedule of charges, which is attached to the contract of care and supports, will be updated in-line with the above RSSMAC assessments by the 30th of June 2020.

Regulation 12: Personal possessions

Substantially Compliant

Outline how you are going to come into compliance with Regulation 12: Personal possessions: - Through the person centered planning process, the issue of two residents identified as having limited access to their finances will be addressed and financial records will be sought to ensure compliance by the 30th of June 2020. - The financial assessment section of the ” Using my environment” assessment tool in the residents personal plans, will be completed with all residents as part of the person centered planning process by 31st Dec 2020.

Regulation 17: Premises

Not Compliant

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Outline how you are going to come into compliance with Regulation 17: Premises: - Two identified houses which house five residents in designated center 7, will be reduced to four residents, with no further admissions to the designated center. Options to reduce the number of residents in these two houses will be explored further by 30th March 2021. - The service will comply with condition No. 4 of the “notice of proposed decision to re-register” designated center 7. Ongoing

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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 12(1) The person in charge shall ensure that, as far as reasonably practicable, each resident has access to and retains control of personal property and possessions and, where necessary, support is provided to manage their financial affairs.

Substantially Compliant

Yellow

30/06/2020

Regulation 17(1)(a)

The registered provider shall ensure the premises of the designated centre are designed and laid out to meet the aims and objectives of the service and the number and needs of residents.

Not Compliant Orange

31/03/2021

Regulation 24(4)(a)

The agreement referred to in paragraph (3) shall include the support, care and

Not Compliant Orange

31/12/2020

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welfare of the resident in the designated centre and details of the services to be provided for that resident and, where appropriate, the fees to be charged.