Fit-person Entry Programme. Reflecting on practice for continuous improvement

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1 Fit-person Entry Programme Reflecting on practice for continuous improvement in designated 04 centres for older people <

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3 Table of Contents Introduction to the Fit-person Entry Programme Background The Fit-person Entry Programme How to use the Fit-person Entry Programme The structure of the Fit-person Entry Programme Self-assessment Section 1: Legislation and regulations The purpose of registration The legislation National Quality Standards for Residential Care Settings for Older People in Ireland The Regulations and the Standards Section 2: Rights Resident involvement and consultation Advocacy Information and communication Consent Privacy Dignity Civil, political and religious rights Complaints Protected disclosure Section 3: Protection Elder abuse Elder abuse in designated centres Elder abuse in people with dementia Indicators of abuse Training staff to deal with and respond to abuse Safeguarding residents financial affairs...037

4 Section 4: Health and social care needs Healthcare needs Assessment Care planning Health promotion Medication management Self-administration of medicines Medication and dementia Alternative therapies End of life care Section 5: Quality of life Quality of life and quality of care Retaining independence and control Choice and risk Routines Fulfilment Social relationships Nutrition Water and ageing Person-centred care Challenging behaviour and older people with dementia Section 6: Staffing Staff and quality of life Staff skills Staff recruitment practices Staff induction Staff training Supporting staff Night staff Agency staff Staffing levels...085

5 Section 7: The care environment The physical environment and its relationship to quality of life Teaghlach model of care The physical environment and dementia Principles of a safe physical environment Section 8: Governance and management The role of the provider The role of the person in charge Leadership and management Quality assurance and continuous improvement Risk management Information management and communication Record Keeping Fit-person Entry Programme Conclusion Next Steps Appendix 1: Acknowledgements Bibliography...112

6 Introduction to the Fit-person Entry Programme Background The Health Information and Quality Authority (the Authority) was established under the Health Act 2007 as the statutory agency with responsibility for developing and monitoring standards for health and social care services (with the exception of services regulated by the Mental Health Act 2001). The Social Services Inspectorate (SSI), one of six directorates within the Authority, has responsibility for regulating social care services. Under the Health Act 2007, the Chief Inspector of Social Services has the power to register and inspect private, voluntary and public designated centres for children, older people and people with a disability and to enforce regulations and standards if required. As per section 50 of the Health Act 2007, the Chief Inspector will only register the centre if satisfied that the registered provider is a fit person as required under the Act. The registered provider is the owner or the person with overall responsibility for the residential service. In the case of a partnership, company, voluntary or statutory body, the provider is a named nominee. This individual must be sufficiently senior to make decisions and implement recommendations and requirements arising from an inspection of the designated centre. The registered provider will be named on the registration certificate. The person in charge of the residential service is the person with responsibility for the day to day running of the centre. This is the person referred to in many centres as the manager or the director. The Fit-person Entry Programme As the provider, you must demonstrate to the satisfaction of SSI that you are suitable or fit to be registered. The Fitperson Entry Programme, based on the National Quality Standards for Residential Care Settings for Older People in Ireland, has been designed as a means for you to self-assess your fitness to run a centre. The purpose of the Fit-person Entry Programme is to assist you in considering the Standards as a guide on how to provide, review and continually improve good care. The Fit-person Entry Programme will help you assess the way you operate your centre, and identify gaps in your services or areas of learning. It will make you aware of changes you need to make to some areas of practice and it will challenge you to think about the way you operate your centre. It will take a participative approach by encouraging you to reflect on and consider your experience, competence and knowledge, together with your staff and residents. The Fit-person Entry Programme is a useful way of analysing the development needs of you and your staff. By assessing your own fitness, and where necessary, developing your practice further, the expected outcome is that each resident in your centre will be enabled to live as full and as independent a life as possible. A fit person is one who can be trusted, in whom one has confidence, who acts according to high principles. It follows that a person is unfit if he or she is untrustworthy or dishonest. A proprietor of a care home be such a fit person since people in [his/ her] care are often frail and vulnerable and the person in control of them is in a powerful position to exploit that frailty. (UK Tribunal Decision no. 76. in Downey, 1999: 45). 001

7 Fitness will be assessed in accordance with section 50 of the Health Act 2007, which states: (1) Where an application is made under section 48 for the registration or renewal of the registration of a designated centre, the chief inspector, if satisfied that the person who is the registered provider, or intended registered provider, and each other person who will participate in the management of the designated centre (a) is a fit person to be the registered provider of the designated centre and to participate in its management, and (b) if the application is for registration, will comply with, or, if for renewal, is in compliance with (i) standards set by the Authority under section 8(1)(b), (ii) regulations under section 101, and (iii) any other enactment which appears to the chief inspector to be relevant, and is cited to the applicant in writing by the chief inspector, shall grant the application and if not so satisfied shall refuse it. How to use the Fit-person Entry Programme As the provider in the care setting, you are required to complete the Fitperson Entry Programme and the corresponding self-assessment tool. You may wish to complete the Fitperson Entry Programme on your own or with the person in charge. It is also recommended that other people involved in the management of the care setting complete the Fit-person Entry Programme, although they are not required to submit the assessment. The Fit-person Entry Programme is in the format of a distance learning programme, with defined learning outcomes and self-assessment activities. The Fit-person Entry Programme sets out the learning outcomes and guides you, the provider, on how to access useful information. The structure of the Fit-person Entry Programme The Fit-person Entry Programme is designed so that you are in control of your own assessment and each section is similarly structured. The learning outcomes are defined at the start of each section. Within the section, some issues are explored. These issues are related to the Standards but are not exhaustive. Not all of the Standards are addressed. Throughout each section you will be asked to work through a series of activities, designed to promote learning and to enable you to reflect on care practices. Some of the activities will help you evaluate how you run your centre, others will direct you to specific articles or background texts, while others still invite you to think about updating practice in new and sometimes innovative ways. On completion of each activity in the Fit-person Entry Programme you should think carefully about your response, and decide what evidence there is of your knowledge and understanding that you could demonstrate to an outsider. The content is designed to help you reflect on the Standards. It is expected that it will prompt you to think about ways of meeting these Standards and, where possible, improve on care practices. At the end of each section, there will be a short summary of the key points. 002

8 003 Self-assessment Following completion of the Fit-person Entry Programme you will be required to complete a self-assessment evaluation. The self-assessment section of the Fit-person Entry Programme will be sent out to you with the registration application form. As part of the registration process, you will be required to submit this evaluation to SSI within eight weeks of receiving it. Self-assessment allows you to examine the everyday activities, systems and processes within your centre and assess them against the Standards. The Fit-person Entry Programme is seen as a means to assist you in carrying out this assessment. The relevant sections of the self-assessment tool should be completed at the end of each corresponding section of the Fit-person Entry Programme. There are some key steps in the self-assessment process you will need to consider, such as: 1. Having read a particular section, what changes have to be made or will you be making to practice? 2. What are the timeframes you propose to bring about changes in practice? 3. Who is the person within your organisation who will have responsibility for ensuring these changes come about? On completion of the Fit-person Entry Programme and the self-assessment evaluation, we will contact you to arrange an interview with you and an inspection of your centre. We will also interview the person in charge of the centre. The interview will assess your understanding of, and capacity to implement the regulatory requirements and the standards. The size of the service you provide, the statement of purpose and function and the number and needs of the people who will use your service will all be taken into account. In-text references Downey, J. (Ed.) (1999). The Brief Case Handbook. Educational Broadcasting Services Trust on behalf of the UK Department of Health. Health Act publications/health_act_2007.html Health Information and Quality Authority (2009). National Quality Standards for Residential Care Settings for Older People in Ireland. residential_care.asp

9 01 < SECTION 1: LEGISLATION AND REGULATIONS

10 Learning outcomes understand the concept of registration demonstrate understanding of the concept of fitness understand the relationship between the Health Act 2007, the regulations and the National Quality Standards for Residential Care Settings for Older People in Ireland understand the role of the Health Information and Quality Authority as the regulatory Authority identify the role of registration in raising the standards of care. Resources needed to complete this section 1. National Quality Standards for Residential Care Settings for Older People in Ireland. Available at 2. The Health Act Available at: www. dohc.ie/publications/health_act_2007.html 005

11 1.1 The purpose of registration The purpose of regulation in the context of care is to raise standards and to protect vulnerable people who are in receipt of services from care providers. Registering designated centres protects vulnerable adults through application of the law. Registration specifies and secures compliance to the legal requirements. As a result of the process people using these services can be assured that the service meets required standards. The registration process effectively commences the regulatory relationship between you, the provider, and the Authority, as the regulator. It sets down clear expectations about quality standards and legal requirements. The registration process sets the benchmark against which enforcement activity can be initiated directly by the Authority in situations where it is deemed necessary. All providers, and other stakeholders, need to be absolutely clear about the significance of this aspect of regulation and that the awarding of registration is a major undertaking. Ultimately, if legal requirements (i.e. regulations) and required standards are not met, registration can be refused or cancelled. Activity 1.1 Registration and inspection Consider the purpose of registration and subsequent inspection, and together with your staff discuss the positive impact regulating centres has for residents. Activity 1.2 The Fit-person Entry Programme In addition to assisting Health Information and Quality Authority to assess your fitness to run a centre, think about how the Fit-person Entry Programme might benefit you, the provider. List some of the benefits: 006

12 1.2 The legislation The Health Act 2007 sets out the powers and duties of the Office of the Chief Inspector of Social Services relating to the registration and inspection of designated centres. The Act introduced a significant change to how designated centres for older people are inspected and registered. Prior to this, only nursing homes operated by private and voluntary providers were inspected by the Health Service Executive (HSE). The new Health Act 2007 requires that all designated centres, including residential care settings for older people, must be inspected and registered whether run by the HSE, private providers or voluntary organisations. This ensures equity of treatment across the whole sector and supports the aim of delivering consistent standards of service to residents regardless of the provider of the service. A designated centre is defined in the Act as an institution at which residential services are provided by the HSE or other service provider. As the provider of a designated centre there are certain things you have to do by law. As previously mentioned your centre will not be registered unless you meet the required standard of fitness. In addition registration will only continue on the basis that you continue to be fit to fulfil these roles. Your responsibilities under the Health Act 2007 are as follows: you cannot carry on or manage a designated centre unless the centre is registered (section 46) it is an offence to give misleading or false information (section 47). In addition, as per section 48 of the Act, you must include with the registration application: (a) the prescribed information about prescribed matters (b) any other information which the Chief Inspector reasonably requires you to include, and (c) the prescribed application fee. In granting an application under the Act, the Chief Inspector may attach to the registration conditions that the Chief Inspector thinks fit in relation to the designated centre concerned. Furthermore at any time, the Chief Inspector may, on one or more grounds specified in the Act, (a) cancel the registration of a designated centre (b) vary or remove any condition of the registration of a designated centre, or (c) attach an additional condition to the registration of a designated centre. 007

13 Activity 1.3 The Health Act 2007 Familiarise yourself with the relevant sections of the Health Act 2007 and the regulations so that you understand the legal requirements involved in providing care. List some of the key responsibilities you have as a provider: Tips: You will also have to operate under other legislation. For example, the Safety, Health and Welfare at Work Act, food safety legislation, Data Protection Act. You should be familiar with the appropriate parts of these, and other relevant Acts. 008

14 1.3 The National Quality Standards for Residential Care Settings for Older People in Ireland The National Quality Standards for Residential Care Settings for Older People in Ireland set out in detail the required outcomes for the provision of care in residential care settings for older people. The National Quality Standards for Residential Care Settings for Older People in Ireland have been developed based on legislation, standards in other jurisdictions, research findings and best practice. There are 32 Standards, which are made up of standard statements and criteria. The standard statements set out the expectations of the service provided to the resident. The criteria are the supporting statements that indicate how a service can be judged as to whether the standard is being met or not. It should be noted that the criteria are not meant to be prescriptive and there may be several ways in which any standard can be met. The Standards are grouped into seven sections to reflect the dimensions of a quality service. Thus, there are sections on the rights of older people; protection; health and social care needs; quality of life; staffing; the care environment; and management and governance. The Standards provide a baseline for those with the responsibility for providing care to assure the quality of care provision. They also provide very clear statements for residents and their families/representatives as to what people living in a designated centre can expect. Some of the Standards focus on outcomes for residents while others focus on the management systems and processes of the care setting. The principal intention of the Standards is to ensure the safety of residents and improve their quality of life. To provide the best service you can, you should not just meet the minimum standards, rather you have to look at how your service affects the lives of the people who use it and what the outcomes are for them. As a provider you should always strive for continuous improvement. 1.4 The Regulations and the Standards All designated centres must be registered to operate within the law. In order to be registered, the centre must comply with the regulations. The Standards are supported by the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations Regulations differ from the Standards in that they are based on primary legislation and are designed to give effect to it; i.e. a regulation sets out the detail of what the legislation intends. If the provider is not in compliance with the regulations, registration may be refused or he/she may lose the registration status. In the case of those standards which are not regulatory standards, nor linked to regulations, failure to comply will not lead to refusal to be registered or loss of registration, but they are designed to encourage continuous improvement. The statutory regulations which give effect to the relevant sections of the Health Act 2007, and underpin the Standards, cover the legal requirements of what you have to do to run a centre. The areas covered under these regulations include the following: maintenance, care, welfare and wellbeing of persons resident in a designated centre These are also known as Statutory Instruments S.I. No. 236 of 2009 Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 and Statutory Instruments S.I. No. 245 Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2009.

15 the numbers, qualifications and availability of persons employed in a designated centre the design, maintenance, repair, cleaning and cleanliness, ventilation, heating and lighting of and the accommodation provided in a designated centre the food provided for persons while resident in a designated centre the records to be kept in a designated centre the effecting by registered providers of designated centres of contracts of insurance the management and control of the operations of a designated centre the notification of incidents occurring in designated centres. the notification of periods when the person in charge is absent from the designated centre the notification of the procedures and arrangements for periods when the person in charge is absent from the designated centre arrangements for dealing with complaints made by or on behalf of persons seeking, receiving or having received any of the services provided through the designated centres, and to publicise the arrangements. The relationship between the Health Act 2007, the Regulations and the Standards is demonstrated in Figure 1 below. Figure 1: The regulatory framework The Regulatory Framework The Health Act 2007 The Regulations National Quality Standards for Residential Care Settings for Older People in Ireland Activity 1.4 The Standards and the regulations Consider the Standards and the regulations. What do you consider to be some of the key differences between the two? 010

16 Key points from section 1: Legislation and Regulations 1. The purpose of regulation in the context of care is both to raise standards, and to protect vulnerable people who are in receipt of services from care providers. 2. All residential care settings must be registered to operate within the law. 3. Your residential service will not be registered unless you meet the required standard of fitness, and registration will only continue on the basis that you continue to be fit. 4. The Standards provide a framework for those with the responsibility for providing care to assess the quality of service provided. 5. The Standards provide very clear criterion for residents and their families/ representatives as to the rights of a resident living in a residential care setting. 6. Regulations differ from Standards in that they are based on primary legislation and are designed to give effect to it. 011

17 02 < SECTION 2: RIGHTS

18 Key points from the National Quality Standards for Residential Care Settings for Older People in Ireland: Standard 1 Information: Each resident has access to information, in an accessible format, appropriate to his/her individual needs, to assist in decision making. Standard 2 Consultation and Participation: Each resident s rights to consultation and participation in the organisation of the residential care setting, and his/her life within it, are reflected in all policies and practices. Standard 3 Consent: Each resident s consent to treatment and care is obtained in accordance with legislation and current best practice guidelines. Standard 4 Privacy and Dignity: Each resident s right to privacy and dignity is respected. Standard 5 Civil, Political and Religious Rights: Each resident is facilitated to exercise his/her civil, political and religious rights in accordance with his/her wishes. Standard 6 Complaints: The complaints of each resident, his/her family, advocate or representative, and visitors are listened to and acted upon and there is an effective appeals procedure. Standard 7 Contract/Statement of Terms and Conditions: Each resident has a written contract/statement of terms and conditions. Learning outcomes At the end of this section you will be able to: identify the rights of residents examine ways of keeping residents informed identify methods of involving residents in decision-making appreciate residents right to consultation and participation identify methods of ensuring residents privacy and dignity are respected demonstrate commitment to accommodating each resident s right to exercise his/her civil, political and religious rights identify methods of effectively dealing with complaints. 013

19 Resources needed to complete this section 1. Fact sheet on Communication from The Alzheimer s Society of Ireland which can be downloaded at the following link: Dementia/I m-a-carer/alzheimer-and- Communication 2. Age Action Ireland report on Dignity in Healthcare. The report can be accessed on the Age Action website: 2.1 Resident involvement and consultation Older people living in residential settings often feel a loss of autonomy, choice, and decision-making. As the Residential Forum, UK (www.residentialforum.com) points out: Well-being and quality of life for most people is enhanced through meaningful involvement and activity. This is also true for older people in designated centres. It is crucial that older people in residential care have opportunities to be involved in decisions which affect them. There are many ways in which resident involvement can be facilitated and encouraged. It often falls to staff members to identify the extent to which a resident wishes to participate and at what level. Involving older people in the organisation of the centre might mean a change in thinking on the part the provider and this process may require a cultural change within some centres. Resident involvement will depend both on the ability and the interest of each resident, and providers should look at both informal and formal methods of including residents in the decision-making process. Both residents and their representatives are well placed to identify problems and gaps in how a centre is organised. If they are involved they can make constructive suggestions for improvement and their involvement can help ensure that changes to services are meaningful. Providers also need to recognise that there is a big difference between being listened to and being heard. As a provider, if you respect what an individual has said, you must respond to it and act on it. Other staff in the centre should also be equipped to hear and respond to residents. Where there are communication barriers, creative solutions may be required (see section 2.2). The importance of being involved has been summarised by one resident of a care setting who said: No place, no hospital, no nursing home is like your own home, not to me.peace of mind, I think, at home makes you different. You run your home. These people here run the nursing home. At home, you re the overseer. You take care of everything, and I think that makes you more like a whole being. Here, you re just a part. When you re home, you re whole. You re a whole person. You re taking care of everything, and everything comes to you by your means, and it makes you feel more at home. (Gubrium, 1993) 014

20 Activity 2.1 Involvement What do you and your staff do to enable residents to have a say in the running of the centre, if they are deaf, blind or suffering from dementia? Tips: Consultation should involve all residents, not just those who are fit and articulate. Activity 2.2 Consultation If you are an existing provider can you think of examples where the views of the residents were sought and a change was brought about in a policy or process? Describe the most significant change in your centre Advocacy Advocacy has an important role to play in helping centres to meet the needs of residents. In recent years, there has been a growth in advocacy services, and some of these have been placed on a statutory footing. The Comhairle Act 2000 defines advocacy as representing the interests of a person seeking a social service and assisting in securing their entitlements, but not involving legal representation. With the Mental Health Act 2001 there is statutory provision for legal advocacy for people with a mental health disorder, while the Disability Act 2005, provides an entitlement to advocacy for persons with a disability. Older people do not have a statutory entitlement to advocacy services although it is increasingly recognised that many people need such support. The Forum for Older People was established in late 2006 under the HSE s Office of Consumer Affairs. It comprises almost all of the major national organisations with a special interest and expertise in services for older people including:

21 Department of Health and Children Health Service Executive (HSE) National Council for Ageing and Older People Nursing Homes Ireland Irish Hospice Foundation Citizens Information Board Age and Opportunity Age Action Ireland Alzheimer s Society Irish Society for Quality and Safety in Healthcare Irish Advocacy Network Patient Focus Senior Helpline Third Age Irish Patients Association Irish Senior Citizen s Parliament. The Forum for Older People is one of a number of initiatives, which has been developed under the National Strategy for Service User Involvement in the Irish Example of good practice Residents committees Health Service , a national transformation project. The Forum has developed a number of proposals to significantly improve the quality of life of people living in residential units, one of which is for a representative advocacy service for older people in long-stay units. As part of this initiative, Age Action Ireland has started to address advocacy issues in nursing homes through the facilitation of resident councils in care settings. Many centres employ a resident advocate to provide information and assistance to support the rights of residents in centres. Among other things, the advocate will listen and ask questions in order to clarify specific issues of concern, he/she will assist the older person to express his/her wishes and provide strategies to resolve any issues. It is a particularly important role for residents who have no family or friends nearby and those who might be reluctant to bring concerns directly to staff. The use of an advocate can facilitate the involvement of residents in decision-making. Many centres are now establishing residents committees. Residents committees represent the views and wishes of all residents living in a centre, and can bring matters to the attention of management, therefore facilitating them to contribute to and oversee effective changes. Where there are residents who cannot speak for themselves a committee can act as a voice for those residents. They can also serve a social function by promoting relationships between both staff and residents. Providers should be open to feedback from the committee on issues which are important to residents even though they may be difficult for the provider or person in charge to address. 016

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