INSPECTION OF A CHILDREN S RESIDENTIAL CENTRE IN THE HEALTH SERVICE EXECUTIVE DUBLIN MID LEINSTER AREA

Transcription

1 INSPECTION OF A CHILDREN S RESIDENTIAL CENTRE IN THE HEALTH SERVICE EXECUTIVE DUBLIN MID LEINSTER AREA Inspection Report ID Number: 625 Fieldwork Date: 18 April 2013 Centre ID Number: 424 Issue Date: 14/06/2013

2 Contents 1. Introduction 1.1 Methodology 1.2 Acknowledgements 1.3 Management structure 1.4 Data on young people 2. Summary of findings 3. Findings 4. Summary of recommendations Action Plan 2

3 1. Introduction The Health Information and Quality Authority (the Authority or HIQA) Regulation Directorate carried out an unannounced themed inspection of a children s residential centre in the Health Service Executive (HSE) Dublin Mid Leinster Area (DML) under Section 69(2) of the Child Care Act 1991 on 18 April Maureen Burns (lead inspector) and Eimear Short (co-inspector) carried out the inspection. A previous inspection was carried out in February 2012 (report 520) and a follow-up inspection was undertaken in December 2012 (report 607). These reports can be accessed on the Authority s website This themed inspection focused on key components of the following National Standards for Children s Residential Centres (2001): Purpose and function monitoring management and staffing planning for children and young people care of young people safeguarding and child protection premises and safety The centre was located in a six bed-roomed detached house surrounded by attractive countryside, near a small town some miles from the suburbs of Dublin. The centre was established to provide a short-term (12 week) rapid access service to children and young people in DML, aged between 13 and 15 years of age on admission and under 13 in exceptional circumstances. Its purpose was to act as a place of safety for children pending a full social work assessment of risk. It also provided a service for children awaiting foster care, longer term residential care placement or respite care. At the time of this inspection, there were three young people living in the centre. A fourth young person had been discharged two days before the inspection. On the day of this inspection, the centre had scheduled a meeting with professionals at which it was agreed that one of the three young people would be discharged the following day to a more suitable placement. The provider was required to take immediate action to address significant noncompliances in relation to fire safety. Damage had been caused to four of the fire doors at the centre, in the week preceding the inspection and these had not been replaced. This particular action is numbered 23 in the Action Plan at the end of this report with the HSE s response. 3

4 Other findings of the inspection were that the centre staff team were committed and concerned with the young people s welfare and that they endeavoured to provide a safe and nurturing environment. However, inspectors found that over the preceding four week period, the case mix of the young people living in the centre impacted on the young people s interaction with each other and centre staff and ultimately presented challenges for staff in managing their behaviours. Consequently the quality and safety of the service provided to meet these young people s needs had been affected. Considerable infrastructural damage had been caused by the young people over the preceding four week period, which impacted on the ambience of the centre. All referrals were considered by the HSE central admissions committee and were subject to the centres admission criteria, but at the time of this inspection there were two young people living in the centre. However, their placement did not comply with the placement duration requirements of the centres statement and purpose. Key areas of improvement made in this report relate to the management of challenging behaviour, suitable placement and admissions, accommodation, maintenance and fire safety. Recommendations in relation to other areas of practice are outlined further in the report. 1.1 Methodology The judgements of the inspectors in relation to this inspection were based on an analysis of findings verified from a number of sources of evidence gathered through: observation of practice examination of records and documentation, including: o policies and procedures o young people s care plans and care files o details of unauthorised absences o details of physical interventions o staff supervision and training records o administrative records o significant event notifications o fire safety and building control compliance o health and safety documents previous Authority inspection reports (2) During the inspection, inspectors met individually with two young people. The third young person chose not to meet with inspectors. The following people were interviewed, the deputy services director the two centre managers three social care workers 4

5 Telephone interviews were conducted with two social workers and the HSE monitoring officer. 1.2 Acknowledgements Inspectors wish to acknowledge the hospitality and cooperation of the young people, staff members and other professionals involved in this inspection. 1.3 Management structure The centre was managed by two centre managers who reported to the deputy services manager, who in turn, reported to the service manager. There were 16 other care staff members who reported to the centre managers. 1.4 Data on young people During the fieldwork the following young people were living in the centre: Listed in order of length of placement Young person Age Legal Status Length of Placement Number of previous placements #1 14years Full Care Order 6 weeks 3 foster placements #2 10 years Voluntary Care 17 weeks #3 15 years Full Care Order 29 weeks 4 foster placements 1 residential placement 4 foster placements, 1 residential placement 5

6 2. Summary of Findings Practices that met the required Notification of significant events This was met. The centre had a clear system for the notification of positive and negative significant events and records of these events had been maintained. The deputy services manager, social workers, HSE monitoring officers and other relevant parties reported that notifications were made in a prompt manner. In the preceding four weeks, there had been a significant escalation in the number of notifications made. Register This was met. The centre had a register which contained up to date and accurate information as required in the Child Care (Placement of Children in Residential Care) Regulations 1995 Part IV Article 21. Absence without authority This was met. There were two unauthorised absences in the preceding four month period, each of which were well managed, of short duration, assessed as low risk and suitably notified to the relevant individuals. The centre had a policy on unauthorised absences and held a record of all absences without authority. All absences without authority were managed in accordance with Children Missing from Care: A Joint Protocol between An Garda Síochána and the Health Service Executive. There was evidence that all relevant external professionals were notified promptly. Safeguarding and child protection The was met. Care staff had a good awareness and understanding of safe care practices, child protection and Children First: National Guidance for the Protection and Welfare of Children (2011) and Children First (2011). There was a child protection policy in place which complied with the National Guidance and there was evidence that staff had attended training on Children First (2011) since the last full inspection. 6

7 Practices that partly met the required Management This was met in part. The centre was managed by two appropriately qualified centre managers who had joint responsibility and accountability for the management of the centre. The centre managers reported that they delegated each other responsibilities on a day-to-day basis. The centre mangers reported that the deputy service manager maintained a good level of contact with the centre and they identified him/her as a strong source of support to them. While staff within the centre identified that the two centre mangers complemented each other, inspectors were unclear how the centre managers could be held to account as each of their roles and responsibilities had not been clearly defined. Inspectors recommend that the HSE DML ensure that each of the centre managers have clear lines of responsibility and accountability. Inspectors found some evidence that the centre managers reviewed records and reports prepared by staff (e.g. young people s daily logs and shift planners) and providing guidance to both staff and young people. However, this had not been consistent in the preceding three week period. Inspectors recommend that the centre reviews how they assess the quality and effectiveness of services provided, particularly outcomes for the young people. In previous inspections, inspectors had found that the centre was well managed. There was evidence that admission s to the centre since the last inspection and preceding the admission of the young people currently residing in the centre were managed by staff. However, in the four weeks prior to the inspection inspectors found that the management team had not adequately supported the work of the centre and satisfied themselves that appropriate and suitable care practices were in place and that operational policies were being implemented to meet the needs of the children living in the centre. Inspectors recommend that the management team support the work of the centre and satisfy themselves that appropriate and suitable care practices are in place to meet the needs of the children living in the centre. Staff reported that due to work demands over the preceding four week period, that the quality of handover information provided to staff changing shift was sometimes poor. As referred to under the section on managing behaviour, there had been a recent incident, whereby staff had not complied with safety plan in place for the young people. It was identified that staff coming on shift had not received an adequate handover of information on shift change and had not had an opportunity to read the safety plan. Inspectors recommend that the HSE DML review the arrangements in place for the handover of information to staff at shift change and of the quality of that shared information. 7

8 Staffing This was met in part. The staff complement at the centre included 16 staff and two qualified and experienced managers. All staff had the required qualifications and the majority of staff had been working in the centre for a prolonged period. In addition the centre used a small number of agency staff on a regular basis. However, a private company had been recruited to meet the needs of one young person residing in the centre and in the preceding four week period agency staff had been used to enhance the staffing arrangements. Inspectors recommend that the HSE DML ensure that there are sufficient staff, who have the required skills and competencies, on-duty at all times to meet the needs of the young people residing in the centre. Supervision and support The was met in part. Inspectors reviewed a sample of supervision records and found that supervision was of a good quality, well recorded and focused on the care of young people living in the centre. However, within the past three months, supervision had not been undertaken within the timelines specified in the centre s policy and was not consistent for all staff. The centre managers indicated that this was as a direct result of the increased workload in managing the centre within the past few months. Staff reported that they felt well supported and had regular informal supervision. It was reported that formal supervision of centre managers by the deputy services director occurred on a six weekly basis. Inspectors recommend that all staff receive formal supervision in line with the frequency and requirements outlined in their policy. Training and development This was met in part. Inspectors reviewed evidence of some staff being provided with some ongoing training including child protection, crisis intervention, first aid and moving and handling. A small number of staff returning from maternity leave required updated training in child protection and crisis intervention, which the centre manager had identified. However, there was no evidence that a training needs analysis had been undertaken to assess the needs of the service and to inform a training programme. Inspectors recommend that the HSE DML undertake a formal needs assessment to assess the training and development needs of the service. Administrative files The was met in part. Each young person had a care file that was well structured, accessible and securely stored. However, there was a number of items missing from files including care plans for two of the young people, that had not been forwarded to the centre by the young person s social worker. One of these young people had been in the centre for more than six months. In 8

9 addition it was evident that within the past four week period there was a number of pieces of documentation which had not been appropriately filed. Inspectors recommend that the centre managers monitor the quality of all the centre records and take appropriate actions to remedy any deficiencies. Monitoring This was met in part. There was evidence that the HSE monitoring officer visited and met with young people at the centre on a regular basis and that she reviewed and followed up on significant event notifications. However, written reports of the monitoring process had not been completed since The HSE monitoring officer reported that she was not in a position to advise as to whether the centre was in compliance with all of the s and regulations in the absence of a full inspection. Inspectors recommend that in-line with the National Standards for Children s Residential Centres (2001) that written reports of the monitoring process should be made available on an annual basis to senior managers, centre staff and inspectors. In so doing and in accordance with the national s, the monitoring officer should satisfy himself/herself that the centre is in compliance with all the regulations and s. Emotional and specialist support The was met in part. Staff who met with inspectors were aware of the emotional and psychological needs of each of the young people residing in the centre and were committed to providing effective support. However, due to challenging behaviour displayed by a number of the young people, it was evident that staff did not feel equipped to meet each of the young people s emotional needs. There was evidence that each of the children had access to specialist supports as required, although on occasions there was a delay in accessing these services. The HSE had secured a private company to work onsite with one of the children for the purpose of undertaking an assessment of his/her needs and to assist staff to care for the child. The centre managers identified that the assessment report was scheduled to be completed the week after the inspection. However, the young person was transferred to another centre the day after the inspection. The HSE DML should ensure that appropriate emotional and specialist support is made available to the young people in the centre in a timely fashion. Restraint This was met in part. There had been 25 instances of restraint in the four months prior this inspection. Eleven of these had been within the four week period preceding this inspection. Inspectors were informed by staff that they used the HSE adopted crisis intervention method and that they were confident to participate in restraint. There was evidence that staff used other 9

10 methods to try and deescalate the situation before using physical restraint. Staff reported that restraint was never used as a sanction or punishment, but rather to protect children from immediate risk to themselves or others, or serious damage to property. There was limited evidence that the centre over the preceding four week period had consistently reviewed or monitored restraint episodes, in terms of appropriateness and the competency of staff in its use. Inspectors recommend that the HSE DML closely monitors all use of physical restraint and review incidents of restraint used in the four weeks prior to this inspection. Safety This was met in part. Inspectors found that the system in place to ensure that the centre was a safe and secure place for young people to live was not always robust. There was a process in place to report accidents and injuries. The centre had a safety statement in place dated 2013 and had completed a written risk assessment in January However, at the time of inspection there was no evidence that risk was being assessed on an ongoing basis to ensure that the centre was a safe and secure place for young people. For example, a significant amount of damage had occurred in the house in recent weeks including damage to the banister at the top of the stairs and the stair rails, damaged walls, fire doors, floors and furniture. There was limited evidence that there had been an appropriate risk assessment of this damage and that the required repairs had been prompt and timely to mitigate the risks. The HSE DML should ensure that risks in the centre are appropriately assessed with remedial actions taken as required. 10

11 Practices that did not meet the required Purpose and function This was not met. The centre had a statement of purpose and function which clearly specified the children catered for and the service it aimed to provide which was accessible to young people and had been authorised by the regional manager. However, it did not reflect the day-to-day operations and practices in the centre at the time of this inspection. The statement of purpose outlined that the centre provided care for year olds for a duration of up to 12 weeks. It also stated that in exceptional circumstances, children under 13 years maybe admitted but for a maximum placement of four weeks. At the time of this inspection there were two young people living in the centre whose placements did not comply with the placement duration requirements of the centre s purpose and function. One child, who was under 13 years of age, had been living in the centre for more than three months pending the completion of a needs assessment. Another young person was living in the centre for more than six months. Inspectors recommend that HSE DML ensures that the centre adheres to its stated purpose and function in all respects. Suitable placements and admissions This was not met. There were defined criteria in place for the admission and referral process. However, the Authority had previously identified concerns with the admission of children under 12 years to the centre. At the time of this inspection there was one child placed in the centre who was under 12 years of age. The centre managers reported that, while this child s admission was an exceptional case and had been pre-approved by the area manager, the staff team were not in a position to assess the needs of this child and that a private company had been procured to provide support and undertake a formal needs assessment. The centre manager and deputy services director reported that regular meetings were held with the private company to review the young person s case and progress in completing the proposed needs assessment. However, inspectors found that a formal service level agreement was not in place. Inspectors recommend that the HSE ensure that the policy in relation to children under 12 years placed in residential centres is implemented in all cases. Inspectors also recommend that when/if an external company is procured to provide a service for children within the centre that the HSE DML ensure that a service level agreement is in place, with inbuilt quality assurance mechanisms to ensure a high quality service is provided. 11

12 Managing behaviour This was not met. All incidents of challenging behaviour were documented and reported to relevant social workers, the monitoring officer and deputy services manager. There was evidence of one-to-one direct work undertaken with young people with their key worker and that young people s behaviours was discussed at team meetings, review meetings and informal and formal supervision by the deputy services director with the centre managers. Care files reviewed had an Individual Crisis Management Plan (ICMP) in place. These identified times when the young person might display challenging behaviour and ways in which staff should respond to these. Inspectors found these to be comprehensive and reflective of the young person s individual needs. Inspectors found that staff, in an effort to manage the behaviour of the young people, endeavoured to engage young people in one to one activities, effectively separating them from each other. However, as previously identified, staff reported that there were occasions over the past four weeks were they had not had an opportunity to read an updated safety plan and had not received an appropriate handover on shift change due to work demands. Inspectors found that staff struggled to maintain control of the young people currently living in the centre and were not assured that the staff had the capacity and capability to ensure that these children and young people were safe and had their needs met. Staff reported that the mix of young people (one of whom had been discharged two days before this inspection) living in the centre over the past four weeks had presented challenges for staff in managing their behaviours. This behaviour included extensive property damage, risk-taking behaviour, assaultive, aggressive and threatening behaviour to staff and other young people. Inspectors reviewed a significant event notification whereby three of the young people barricaded themselves into a room for a two hour period one evening. Although staff remained outside of the room for the duration of this incident the centre manager was not informed of the incident until the following morning and An Garda Síochána were not contacted. The centre managers reported that they were in the process of reviewing this incident and had spoken with the staff members involved. There was some evidence of learning from practice and tailoring approaches to deescalate individual s challenging behaviour. However, there was limited formal evaluation or review by the management team to establish if the operational approach to behaviour management was effective and that the risks to the young people was reduced. Through interview with staff and young people, inspectors found that sanctions were used appropriately. However, staff reported they were not always able to 12

13 enforce the sanctions and that sanctions were not always consistently applied by all staff. There was limited evidence that this was monitored by the management team in the preceding four week period. Inspectors recommend that the HSE DML reviews the management of behaviour at the centre and learns from any identified trends. Education This was not met. There was a legal requirement for the three children living in the centre to attend school. There was evidence that the staff team made efforts to encourage and transport children to school on a daily basis and had agreed a schedule of work to be undertaken at the centre during periods of suspension from school. However, inspectors found that only one of the three children living in the centre had regular attendance at school and was progressing well. A second young person had been expelled three weeks previously and some efforts had been made to source home tuition and to secure a new school placement. The third young person had a high level of non attendance with a number of suspensions. There was evidence that the staff and this young person s social worker were in regular contact with the relevant school. Inspectors recommend that all children in the centre are encouraged and attend school. Accommodation This was not met. Each of the young people had their own rooms, which were personalised with pictures, posters and their personal belongings. However, the centre manager reported that over the preceding four week period, considerable damage had been done to the property by a number of the young people living in the centre. Certain items of furniture had been removed from various rooms for the safety of the young people. As a consequence, the centre was sparsely furnished and the ambience of the centre was not homely at the time of this inspection. The centre had some play and recreational facilities available to young people, but these were limited. Inspectors observed that the exterior of the premises was in need of painting with maintenance work required in the court yard. Inspectors recommend that a review is undertaken of the facility to identify refurbishment requirements which should be undertaken as soon as possible. Maintenance and repairs This was not met. Inspectors found that the process to monitor the premises to ensure the maintenance of s and safety required improvement. A record was held of all maintenance requests. However, the date of completion was not always recorded. The HSE monitoring officer had undertaken some visits to the centre and reviewed some safety and maintenance arrangements. The centre managers reported that they routinely checked the premises to ensure that s and safety were maintained. 13

14 However, there was no formal documentation of this process. There was evidence that some repairs to the centre were dealt with promptly others had been delayed. Inspectors recommend that the HSE line manager routinely monitors the premises to ensure the maintenance of s and safety. Inspectors also recommend that a rolling programme of maintenance is undertaken to ensure the maintenance of s and safety and that this process is appropriately documented. Fire safety This was not met. Inspectors observed significant damage to the infrastructure of the building, including four fire doors, in the two weeks prior to this inspection. This presented a significant risk to containing a fire. While there was evidence that fire safety checks were undertaken by staff on each shift and that waking staff were on duty 24/7 no formal risk assessment had been undertaken and inspectors were not assured that there were sufficient mitigating controls in place to reduce the risk. The centre managers reported that while it had been agreed to replace the fire doors there was no agreed date. The provider was required to take immediate action to address these significant non-compliances in relation to fire safety and the Authority issued an immediate action plan. Subsequently, inspectors were provided with written confirmation that a written risk assessment regarding the damaged fire doors had been undertaken and that a written fire safety plan had been put in place, on the day following the inspection. Within five days of the inspection, the Authority received confirmation that each of the damaged fire doors had been replaced. Inspectors observed written confirmation that all statutory requirements relating to fire safety and building control was in compliance with Regulation 12 of the Child Care (placement of Children in Residential Care) Regulations Fire extinguishers were accessible to all staff. At the time of inspection there was clear guidance for staff regarding the location of these extinguishers. While the positions of the fire extinguishers had been risk assessed by centre staff in consultation with the HSE fire officer other fire safety precautions had not been risk assessed. Inspectors found evidence of evacuation plans and fire drills having been undertaken. However, staff were awaiting fire safety training from the HSE fire officer. Inspectors recommend that the HSE fire officer undertakes a formal assessment of fire safety precautions as soon as possible. Inspectors also recommend that fire safety training is provided for all staff as soon as possible. 14

15 3. Findings Purpose and function Standard The centre has a written statement of purpose and function that accurately describes what the centre sets out to do for children and the manner in which care is provided. The statement is available, accessible and understood. Practice met the required Practice partly met the required Practice did not meet the required Purpose and function Recommendations: 1. The HSE (DML) should ensure that the centre adheres to its stated purpose and function in all respects. Management and staffing Standard The centre is effectively managed, and staff are organised to deliver the best possible care and protection for children. There are appropriate external management and monitoring arrangements in place. Practice met the required Practice partly met the required Practice did not meet the required Management Register Notification of significant events Staffing (including vetting) Supervision and support Training and development Administrative files 15

16 Recommendations: 2. The HSE DML should ensure that each of the centre managers have clear lines of responsibility and accountability. 3. The HSE DML should review how they assess the quality and effectiveness of services provided, particularly outcomes for the young people. 4. The HSE DML management team should support the work of the centre and satisfy themselves that appropriate and suitable care practices are in place to meet the needs of children living in the centre. 5. The HSE DML should review the arrangements in place for the handover of information to staff at shift change and of the quality of that shared information. 6. The HSE DML should ensure that there are sufficient staff, who have the required skills and competencies, on duty at all times to meet the needs of young people residing in the centre 7. The HSE DML should ensure that all staff receive formal supervision in line with the frequency and requirements outlined in their policy. 8. The HSE DML should undertake a formal needs assessment to assess the training and development needs of the service. 9. The centre managers should monitor the quality of all the centre records and take appropriate actions to remedy any deficiencies. 16

17 Monitoring Standard The HSE, for the purposes of satisfying itself that the Child Care Regulations 5-16 are being complied with, shall ensure that adequate arrangements are in place to enable an authorised person, on behalf of the HSE to monitor statutory and non-statutory children s residential centres. Practice met the required Practice partly met the required Practice did not meet the required Monitoring Recommendations: 10. In-line with the National Standards for Children s Residential Centres (2001), written reports of the monitoring process should be made available on an annual basis to senior managers, centre staff and inspectors by the HSE monitoring officer. In so doing and in accordance with the national s, the monitoring officer should satisfy himself/herself that the centre is in compliance with all the regulations and s. Planning for young people and young people Standard There is a statutory written care plan developed in consultation with parents and children that is subject to regular review. The plan states the aims and objectives of the placement, promotes the welfare, education, interests and health needs of children and addresses their emotional and psychological needs. It stresses and outlines practical contact with families and, where appropriate, preparation for leaving care. Practice met the required Practice partly met the required Practice did not meet the required Suitable placements and admissions Emotional and specialist support 17

18 Recommendations: 11. The HSE DML should ensure that the policy in relation to the children under 12 years placed in residential centres is implemented in all cases. 12. The HSE DML ensure that when / if an external company is procured to provide a service for children within the centre that a service level agreement is in place, with inbuilt quality assurance mechanisms to ensure a high quality service is provided. 13. The HSE DML should ensure that appropriate emotional and specialist support is made available for young people in the centre in a timely fashion. Care of young people Standard Staff relate to children in an open, positive and respectful manner. Care practices take account of the children s individual needs and respect their social, cultural, religious and ethnic identity. Children have similar opportunities to develop talents and pursue interests. Staff interventions show an awareness of the impact on children of separation and loss and, where applicable, of neglect and abuse. Practice met the required Practice partly met the required Practice did not meet the required Managing behaviour Restraint Absence without authority Recommendations: 14. The HSE DML should review the management of behaviour at the centre and learn from any trends identified. 15. The HSE DML should monitor closely all use of physical restraint and review incidents of restraint used in the four weeks prior to this inspection. 18

19 Safeguarding and Child Protection Standard Attention is paid to keeping children in the centre safe, through conscious steps designed to ensure a regime and ethos that promotes a culture of openness and accountability. Practice met the required Practice partly met the required Practice did not meet the required Safeguarding and Child protection Education Standard All children have a right to education. Supervising Social Workers and centre management ensure each young person in the centre has access to appropriate educational facilities. Practice met the required Practice partly met the required Practice did not meet the required Education Recommendation: 16. The HSE DML should ensure that all children in the centre are encouraged to attend school. 19

20 Premises and Safety Standard The premises are suitable for the residential care of the children and their use is in keeping with their stated purpose. The centre has adequate arrangements to guard against the risk of fire and other hazards in accordance with Articles 12 & 13 of the Child Care Regulations, Accommodation Practice met the required Practice partly met the required Practice did not meet the required Maintenance and repairs Safety Fire safety Recommendations: 17. The HSE DML should ensure that a review is undertaken of the facility to identify refurbishment requirements which should be undertaken as soon as possible. 18. The HSE line manager should routinely monitor the premises to ensure the maintenance of s and safety. 19. A rolling programme of maintenance should be undertaken to ensure the maintenance of s and safety with the process appropriately documented. 20. The HSE DML should ensure that risks in the centre are appropriately assessed with remedial actions taken as required. 21. The HSE DML should as an immediate action review measures in place for the containment of fire and outline further mitigating actions taken to address risks associated with the damaged fire doors in the centre. 22. The HSE fire officer should undertake a formal assessment of fire safety precautions as soon as possible. 23. The HSE DML should ensure that fire safety training is provided for all staff. 20

21 4. Summary of Recommendations: 1. The HSE DML should ensure that the centre adheres to its stated purpose and function in all respects. 2. The HSE DML should ensure that each of the centre managers have clear lines of responsibility and accountability. 3. The HSE DML should review how they assess the quality and effectiveness of services provided, particularly outcomes for the young people. 4. The HSE DML management team should support the work of the centre and satisfy themselves that appropriate and suitable care practices are in place to meet the needs of the children living in the centre. 5. The HSE DML should review the arrangements in place for the handover of information to staff at shift change and of the quality of that shared information. 6. The HSE DML should ensure that there is sufficient staff on-duty at all times who have the required skills and competencies to meet the needs of the young people residing in the centre. 7. The HSE DML should ensure that all staff receive formal supervision in line with the frequency and requirements outlined in their policy. 8. The HSE should undertake a formal needs assessment to assess the training and development needs of the service. 9. The centre managers should monitor the quality of all the centre records and take appropriate actions to remedy any deficiencies. 10. In-line with the National Standards for Children s Residential Centres (2001), written reports of the monitoring process should be made available on an annual basis to senior managers, centre staff and inspectors by the HSE monitoring officer. In so doing and in accordance with the national s, the monitoring officer should satisfy himself/herself that the centre is in compliance with all the regulations and s. 11. The HSE DML should ensure that the policy in relation to children under 12 years placed in residential centres is implemented in all cases. 12. The HSE DML should ensure that when/ if an external company is procured to provide a service for children that a service level agreement is 21

22 in place, with inbuilt quality assurance mechanisms to ensure a high service is provided. 13. The HSE DML should ensure that appropriate emotional and specialist support is made available for young people in the centre in a timely manner. 14. The HSE DML should review the operational management of behaviour at the centre to ensure it meets the needs of the young people admitted to the centre. 15. The HSE DML should closely monitor all use of physical restraint and review incidents of restraint used in the four weeks prior to this inspection. 16. The HSE DML should ensure that all children in the centre are encouraged to attend school. 17. The HSE DML should ensure that a review is undertaken of the facility to identify refurbishment requirements which should be undertaken as soon as possible. 18. The HSE line manager should routinely monitor the premises to ensure the maintenance of s and safety. 19. A rolling programme of maintenance should be undertaken to ensure the maintenance of s and safety with the process appropriately documented. 20. The HSE DML should ensure that risks in the centre are appropriately assessed with remedial actions taken as required. 21. The HSE DML should as an immediate action review measures in place for the containment of fire and outline further mitigating actions taken to address risks associated with the damaged fire doors in the centre. 22. The HSE fire officer should undertake a formal assessment of fire safety precautions as soon as possible. 23. The HSE DML should ensure that fire safety training is provided for all staff. 22

23 ACTION PLAN

24 Regulation Directorate Action Plan for Inspection No. 625 Centre ID: 424 HSE Area: HSE DML No. Recommendation Action to be taken Person Responsible Implementation Date 1 The HSE (DML) should ensure that the centre adheres to its stated purpose and function in all respects. The centre purpose and function will be reviewed, amended as necessary and thereafter adhered to in all respects. Deputy Service Manager Service Manager The HSE (DML) should ensure that each of the centre managers have clear lines of responsibility and accountability. 3 The HSE DML should review how they assess the quality and effectiveness of services provided, particularly outcomes for the young people. The centre management structure will be reviewed and clear lines of responsibility will be defined. Line management will be maintained by the Deputy Service Manager. As above, clear lines of responsibility will be defined and these will include, to ensure that all records prepared by staff are read and Deputy Service Manager Service Manager Centre Manager Deputy Service Manager Service Manager

25 signed. Any issues arising from same will be addressed by the centre manager with staff and the discussion will be recorded. Learning from these discussions will be brought for to each team meeting and incorporated into the daily practise of caring for the young people in the centre. 25

26 Regulation Directorate Action Plan for Inspection No. 625 Centre ID: 424 HSE Area: HSE DML No. Recommendation Action to be taken Person Responsible Implementation Date 4 The HSE DML management should support the work of the centre and satisfy themselves that appropriate and suitable care practices are in place to meet the needs of the children living in the centre. The centre manager will support the work of the centre by ensuring that all individual plans for young people are upto-date and reviewed/amended as necessary. Young People s Daily Journals will be read by the centre manager to ensure that the Young People s Individual Plans are being implemented. All Significant Event Notifications will be reviewed and signed by the Centre Manager. Centre Manager Deputy Service Manager Service Manager

27 The team meeting will dedicate a period of time to discussing care practise. Staff will be supervised in accordance to the current Supervision Policy and Care Practise will always form part of each supervision session. 5 The HSE DML should review the arrangements in place for the handover of information to staff at shift change and of the quality of that shared information. All of the above will be overseen and reviewed through centre managers supervision with the deputy service manager and through centre systems checks/audits. The current arrangements in place for the handover of information between staff will be reviewed. On completion of this review a written procedure will be made available to the centre manager and staff. Deputy Service Manager Service Manager

28 Regulation Directorate Action Plan for Inspection No. 625 Centre ID: 424 HSE Area: HSE DML No. Recommendation 6 The HSE DML should ensure that there are sufficient staff, who have the required skills and competencies, on-duty at all times to meet the needs of the young people residing in the centre, 7 The HSE DML should ensure that all staff receive formal supervision in line with the frequency and requirements outlined in their policy. Action to be taken The centre manager will ensure that the roster is managed to ensure that the centre is adequately staff with suitably qualified staff and will only use agency staff when absolutely necessary. The Supervision Policy will be implemented and adhered to. A Supervision Schedule will be developed. Person Responsible Centre Manager Centre Manager Deputy Service Manager Implementation Date The HSE should undertake a formal needs assessment to assess the training and development needs of the service. A formal Training Needs Assessment will be completed and all training requirements will be addressed without delay. Centre Manager Deputy Service Manager

29 Regulation Directorate Action Plan for Inspection No. 625 Centre ID: 424 HSE Area: HSE DML No. Recommendation Action to be taken Person Responsible Implementation Date 9 The centre managers should monitor the quality of all the centre records and take appropriate actions to remedy any deficiencies. The centre manager will read and sign all Young People s Daily Journals and any other care records produced on a daily basis. Any deficits will be addressed immediately and the learning will be brought to the team meeting. Any ongoing recording issues which may arise for individual staff members will be discussed within supervision. Centre Manager Deputy Service Manager

30 10 In-line with the National Standards for Children s Residential Centres (2001), written reports of the monitoring process should be made available on an annual basis to senior managers, centre staff and inspectors by the HSE monitoring officer. The DML Monitoring service has recently been expanded to ensure that this recommendation will be met. Monitoring Officer

31 Regulation Directorate Centre ID: 424 HSE Area: HSE DML Action Plan for Inspection No. 625 No. Recommendation Action to be taken Person Responsible Implementation Date 11 The HSE DML should ensure that the policy in relation to children under 12 years placed in residential centres is implemented in all cases. The Policy in relation to Children under 12 placed in residential centres will be implemented and adhered to with all new admissions. The placement of children under 12 years will be reviewed alongside the purpose and function. Centre Manager Deputy service Manager

32 12 The HSE DML should review that when/if an external company is procured to provide a service for children within the centre that a service level agreement is in place, with inbuilt quality assurance mechanisms to ensure a high quality service is provided. The HSE DML does not intend to use a private contractor to provide this type of intervention within the service again, however if used the HSE Service level agreement for Private Providers will be in place, as will an approved Placement proposal which clearly details the aims and objectives and required outcomes of such a service. Regional Manager

33 Regulation Directorate Action Plan for Inspection No. 625 Centre ID: 424 HSE Area: HSE DML No. Recommendation Action to be taken Person Responsible Implementation Date 13 The HSE DML should ensure that appropriate emotional and specialist support is made available for young people in the centre in a timely manner. The centre manager will request in writing that applications are made without delay to services which provide emotional and specialist supports for any young person who s Care Plan states that this is required. Centre Manager Deputy service Manager The HSE DML should review the operational management of behaviour at the centre to ensure it meets the needs of the young people admitted to the centre. Each young person s Behaviour Management Plan will be reviewed by the deputy service manager. Any amendments required will be made in consultation with the young person s social worker and implemented by the team. Centre Manager Deputy Service Manager

34 The team meeting will dedicate a period of time to review and amend the young people s individual plans, including the Behaviour Management Plan. 34

35 Regulation Directorate Action Plan for Inspection No. 625 Centre ID: 424 HSE Area: HSE DML No. Recommendation Action to be taken Person Responsible Implementation Date 15 The HSE DML should monitor closely all use of physical restraint and review incidents of restraint used in the four weeks prior to this inspection. All incidents used in the four weeks prior to the Inspection will be reviewed and finding will be forwarded to HIQA. All Physical restraints will be notified through the Significant Event Notification System, and will continue to be reviewed by the centre manager and deputy service manager. Deputy Service Manager Service Manager All Significant Events will continue to be reviewed on a monthly basis by the Significant Event Review Group, and on a weekly basis by the Monitoring officer. 35

36 16 The HSE DML should ensure all children in the centre are encouraged to attend school. The staff will encourage young people to attend school. These discussions will be recorded on one-to-one session notes and in the Young Person s Daily Journal, which will be reviewed by the centre manager. Centre Manager

37 Regulation Directorate Action Plan for Inspection No. 625 Centre ID: 424 HSE Area: HSE DML No. Recommendation Action to be taken Person Responsible Implementation Date 17 The HSE DML should ensure that a review is undertaken of the facility to identify refurbishment requirements which should be undertaken as soon as possible. A review of all refurbishment requirements will be undertaken as a matter or urgency. All required works will be identified. Quotes for same will be secured and funding allocated for their completion. Deputy Service Manager Regional Manager The HSE line manager should routinely monitor the premises to ensure the maintenance of s and safety. The Deputy Service Manager will visit the centre every 6 weeks and as part of the visit will complete a review of the premises to ensure s and safety are being maintained. This review will be recorded as part of the centre Managers supervision. Centre Manager Deputy Service Manager

38 Regulation Directorate Action Plan for Inspection No. 625 Centre ID: 424 HSE Area: HSE DML No. Recommendation Action to be taken Person Responsible Implementation Date 19 A rolling programme of maintenance should be undertaken to ensure the maintenance of s and safety with the process appropriately documented. 20 The HSE DML should ensure that risks in the centre are appropriately assessed with remedial actions taken as required. A quarterly review of all refurbishment requirements will be undertaken. All required works will be identified. Quotes for same will be secured and funding allocated to their completion. Any further damage /repairs will be addressed on an ongoing basis. A Health and Safety Officer will be appointed in the centre. The Health and Safety Risk Assessment document will be Centre Manager Deputy Service Manager Centre Manager Deputy Service Manager

39 reviewed on a weekly basis and updated / completed accordingly and as risks arise. Regulation Directorate Action Plan for Inspection No. 625 Centre ID: 424 HSE Area: HSE DML No. Recommendation Action to be taken/taken Person Responsible Implementation Date 21 The HSE DML should as an immediate action review measures in place for the containment of fire and outline further mitigating actions taken to address risks associated with the damaged fire doors in the centre. Within one day of the inspection, the Authority were provided with written confirmation that a written risk assessment had been undertaken and that a fire safety plan had been put in place. Within five days of the inspection, the Authority received confirmation that each of the damaged fire doors had been replaced. Deputy Services Manager