Residential Care Homes - Presentations - Regulation and Quality ...

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Residential Care Homes - Presentations - Regulation and Quality ...

11/02/2013

Annual Residential Roadshow

February 2013

Programme

• 9.30 Welcome

• 9.45 Rosemary Wilson

• 10.45 Tea/Coffee

• 11.00 Pharmacy

• 11.30 Inspection year 2012/13

• 12.00 Monitoring Reg 29

• 12.30 Finance (Briege Ferris)

• 13.00 Lunch

• 13.45 Standards for 2013/14

• 14.30 Video

• 14.45 Sense Service User involvement in recruitment

• 15.15 Comfort Break

• 15.30 Safeguarding a Trust Perspective

Management of medicines in

residential homes

Cathy Wilkinson

Pharmacy Inspector

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Inspection year 2012-13

Type of home April 2011-

31 January 2012

Nursing homes 124 110

Residential homes 84 78

Total 208 188

April 2012-

25 January 2013

Prescriptions

• Letter from HSCB re ordering and

dispensing of prescriptions for care homes

• Management of photocopies of

prescriptions

– Used if GP doesn‟t verify personal medication

record

– Copy of up to date medicines/dosage regimes

– Renew 6-12 monthly of if a change

Improvements

noted during

inspection

• The management of

external preparations

• The management of

warfarin

• Overall improvement in

the management of

controlled drugs

including schedule 4

• Annual improvement in

the completion of PMRs

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Room for

improvement

• Fridge temperatures

• Audit systems

– Use of QIP

• MDS

• Running out

MDS

• Medicines available at start of new cycle

• Ensure PMR agrees with MARs sheet

• Handwritten entries signed by two trained

and competent staff

• Recording of non administration

• Wastage at end of cycle

Prescribed medicines - caution

• „Running out‟ unacceptable

• Zero tolerance

• Responsibility of staff

• What if?

• Be proactive

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Enforcement activity

• Additional inspections to give registered

persons time to address failings

• Formal meetings to raise concerns and

seek reassurance that these will be

addressed

• Issue of failure to comply notices

– Patients not receiving prescribed medicines

– Poor governance arrangements

No of medicine incidents reported

Type of home 2010-11 2011-12 2012-13

Nursing 225

(38%)

Residential 128

(22%)

DCA 199

(34%)

Others 38

(6%)

316

(29.5%)

192

(18%)

499

(46.5%)

67

(6%)

525

(34%)

240

(16%)

679

(44%)

89

(6%)

Total 590 1074 1533

Types of incidents – residential

homes

Type 2010-11 (%) 2011-12(%) 2012-13(%)

Wrong dose 27 20 15

Wrong time 4 2 5

Frequency 4 8 6

Wrong medicine 21 10 10

Omissions 16 26 30

Discrepancyloss

10 8 5

Other 18 26 29

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NO INCIDENTS – a dream?

To err is human

To cover up is unforgiveable

And to fail to learn is inexcusable

Liam Donaldson

World Alliance for Patient Safety 2004

Learning from incidents

• Fix the small

• Challenge

• Promote good practice

Inspection year 2013-14

• Controlled drugs Standard Operating

Procedures (SOPs)

– These should now be in place

• Use of thickening agents

– Evidence of SALT assessment

– Evidence in care plan

– Evidence of consistency

– Evidence of use

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Sources of information

RQIA Pharmacist Inspectors – Tel 9051 7500

RQIA web site – www.rqia.org.uk

Any Questions?

Inspection Year Outcomes

2012-13

Kate Maguire

Acting Head of Programme

Adult Residential Services

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Inspection Activity

Type Announced Unannounced Total

Care 185 148 333

Finance

Estates

Pharmacy 78 78

Compliance

Standard

Non

compliant

Moving to

compliance

Substantially

Compliant

Compliant Not

Assessed

8 0% 5% 34% 60% 1%

15 1% 9% 23% 62% 4%

20 1% 12% 30% 56% 2

Finance

• RQIA has two inspectors to cover the

region

• Significant enforcement in this area

• Transport policies

• Residents agreements

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Estates

• RQIA should be informed of any physical

changes to the home (variations)

• Risk assessments should be undertaken

for residents during the time of the works

• Fire safety- some enforcement action

• Ensure fire safety equipment is well

maintained

• All staff should have fire training

biannually

Enforcement

Residential Care Home

2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13

1 1 8 3 0 0 16 42

• Significant increase

• Failure to Comply through to cancellation of registration

Issues

1. Safeguarding

2. Estates / Health and Safety

3. Fitness of Manager / Provider

4. Record Keeping

5. Restating of Requirements

Notifiable Event

Type

Count

Theft/Burglary 9

Absence 49

Death 151

Injury 296

Accident 978

Serious Illness 158

Infectious Disease 55

Allegation of

Misconduct 133

Police Incident 56

Other Event 1208

Total Notifications 3093

Incidents

Uncategorised

18%

Head Injury

39%

87

Fracture (Hip)

27%

Fracture

(Other)

16%

Suicide/Self

Harm

3%

Uncategorised

21%

12 11 10

4 4 2 1 1 1

Medication

Issue

17%

Behavioural

Issue

56%

Estates Issue

3%

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Compliants

Source Care

Practice

Environmental

Issue

Food and

Nutrition

Other Service

User

Finance

Staff

Attitude

Total

Informal

Advocate

1 1

Other 5 3 2 5 1 2 18

Relative 63 38 6 43 2 13 165

Service

User

47 90 63 99 8 17 324

Total 115 132 71 147 11 32 508

Whistleblowing

• A notable increase in whistleblowing to

RQIA

• The winterbourne affect

• Information available on RQIA website

• Lead to serious V/A safeguarding

investigations

• Increased inspection monitoring activity

• Improvements to safety and quality of

care

Areas of Good Practice

• Small but meaningful environmental

modifications for dementia residents

• Use of technology for resident satisfaction

survey

• Improvement in monthly monitoring

information since roadshow

• Annual quality review reproduced in

pictorial format

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Areas of Good Practice

• Improved information in regard to

whistleblowing

• Financial Support Assessment- helping

residents to manage their own monies

• Comprehensive assessment for variation

for dementia

• Manager undertaking course for dementia

Thank you

Any Questions ?

Residential Care Homes

Quality Monitoring

Regulation 29 – Manager Role

February 2013

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Context: Regulation 29 Monitoring

• Inspection year 2011-12: lack of quality

monitoring identified

• Lack of clarity: who, what, why and when

• Linked to other service weaknesses

• Key element in governance arrangements

• Support for providers / registered managers.

RQIA – Inspection Outcomes

• Need to ensure evidence of senior manager

activity

• Need to ensure quality assurance systems

are related to regulation

• Need to ensure clarity about who is

responsible for quality monitoring.

Quality belongs to everyone

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Good governance – good outcomes

• “Good governance leads to good

management, good performance … and,

ultimately, good outcomes”

(Sir Alan Langlands, Good Governance Standard for Public

Services, 2004)

Three Roles in Regulation

• The registered provider: the entity that is registered

with RQIA to provide a particular service, whether it is an

organisation, partnership or individual. Sometimes “the

registered person”

• The responsible individual: a director, manager,

secretary or officer of an organisation – responsible for

supervising the management

• The registered manager: appointed where the provider

is not an individual.

Regulations - Responsibilities

10 (1) The registered provider and the

registered manager shall, having regard to the

size of the residential care home, the statement

of purpose, and the number and needs of the

patients, carry on or (as the case may be)

manage the residential care home with

sufficient care, competence and skill.

Expectations: the competence and skill of the

individual manager and the provider body

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The Registered Manager

A key Role

Appointing a Registered Manager

Practice in residential and nursing homes –

managers recruited on the basis that they could

be registered with RQIA.

Advertisements that suggested appointments

subject to achieving RQIA registration.

Recently – a number of applicant managers

who do not meet qualification or experience

criteria.

Minimum Standards - Managers

RQIA is assured through the registration

process that the person:

• Has knowledge and understanding of his/her

legal responsibilities

How will the provider make sure they appoint a

‘manager’ who has this knowledge and understanding?

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Minimum Standards - Managers

RQIA is assured through the registration

process that the person:

• Intends to carry on the establishment in accordance

with legislative requirements, DHSSPS Minimum

Standards, and other standards set by professional

bodies and standards setting organisations

How will the provider ensure that the ‘manager’ will

discharge his/her responsibilities to meet requirements

and/or standards?

Minimum Standards - Managers

RQIA is assured through the registration

process that the person:

• Intends to undertake update training to ensure

he/she has the necessary knowledge and skills

• Will maintain registration with NISSC/NMC and

adhere to the Code of Professional Conduct.

The ‘manager’ needs to demonstrate familiarity with the

regulatory framework.

The Manager and Training

10 (3) The registered manager shall undertake

from time to time such training as is appropriate

to ensure that he has the experience and skills

necessary for managing the home.

Ensure documentary evidence and records maintained.

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Monitoring: Quality & Management

Regulation 29(1) - (6)

• Standard 2O - monthly monitoring at 20.11

• Should be complemented by any

organisational quality framework/systems

• Annual review – regulation 17 & standard

criteria at 20.12 (a separate process)

Monthly Monitoring Visits

Regulation 29 and Minimum Standard criteria 20.11

The registered person or delegated person:

• Carries out an unannounced visit to the home on at

least a monthly basis 29(3)

• Interviews patients and/or their representatives and

staff 29(4)(a)

• Inspects the premises, its record of events and

records of any complaints 29(4)(b)

• Prepares a written report on the conduct of the

nursing home 29(4)(c)

• Ensures a copy of the report is available in the home

and made available to others..29(5) & (6)

Monthly Monitoring Report

20.11 This report summarises:

• Any comments made by residents and/or their

representatives and staff about the quality of the service

provided

• Any actions taken by the registered person or the

registered manager to ensure that the organisation is

being managed in accordance with minimum standards.

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Monthly Monitoring Report

• A copy must be available in the home

• A copy must be made available to or on request of

- The registered manager, directors or partners

- RQIA: may request a report at any time

- Resident or their representative

- Officer of the Trust.

Monthly monitoring – specifics

• Follow-up from previous monthly visit

• Adequacy of staffing arrangements

• Number of residents interviewed and summary of

their views on the quality of care provided in the

home

• Number of relatives/visitors interviewed and

summary of their views on the quality of care

• Number of staff interviewed and summary of their

comments on the standard of care provided in the

home

Monthly monitoring – specifics

• The number of accidents/incidents or other

untoward events, as detailed under Regulation 30

which occurred during the month

• Key findings from looking at the records of

events and complaints

• Condition of the environment and detail any action to be

taken

• Any identified health and safety risk are eliminated

• Comment on the fabric, furnishings and decor

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Monthly Monitoring – specifics

• Review of the quality improvement plan /

commentary on progress made on planned

improvements

• Other improvements planned as a result of this visit

• Action plan agreed as a result of this visit - by whom

and timescale for completion

When monitoring does not occur

• Significant governance/ management weakness

• A safeguard that is missing

• Fitness:

• Manager: RQIA may review, or may ask provider

to review

• Provider: if consistently poor governance and

management occurs – RQIA may review fitness

of provider

RQIA has no role in deregistering the responsible

individual, but assesses fitness of the registered person

– the organisation/ partnership/ individual provider

Monthly Monitoring - Summary

• Should reflect quality improvement initiatives

• Should evidence quality monitoring of the service

• Report includes an action plan and a copy is available

• Should evidence the provider‟s commitment to

continuous improvement and to meeting the Minimum

Standards

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Enforcement Approach

Practice changes and learning

Enforcement – Revised Practice

Failure to Comply/ Improvement Notices

• Notice is placed on website, along with explanatory

note

• Website will highlight recent enforcement actions

• Likely raised media and political interest

• Resumed compliance – this information will also be

placed on website

• Impact – services need to consider the risk of noncompliance

with much greater public, media and

professional awareness

• Similar process for application of conditions.

Context for Enforcement Action

• Services where there are concerns about potential risks

to service users

• Services where there has been poor, or no response to

requirements/recommendations

• Continued non compliance - repeated requirements /

recommendations.

Common theme – managers unfamiliar with regulatory

responsibilities / expectations

Senior managers unaware of concerns

Oversight of manager – a critical issue

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Key messages about Enforcement

Avoid it:

• Monitor responses to requirements and

recommendations within timescales

• Know your service – and make sure the

manager understands the regulations and

standards

• Senior managers should establish quality

monitoring arrangements that use the

regulatory framework.

Key messages about Enforcement

Learning points:

• Responsible persons need to make sure they

have clear accountability arrangements with

managers

• It is concerning that some managers have

appeared unclear about their accountability

within regulation.

Questions?

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Finance Inspections

2013/2014

Briege Ferris

Finance Inspector

Areas to be Covered Today

• Introduction of Self- Assessment for Finance

Inspections

• Guidance on Transport Services

Introduction of Self- Assessment

• Recap of outgoing method

• Benefits of Self-Assessment

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Self-Assessment- Discussion of Key Areas

• Resident Guide & Individual Resident Agreement

• Acting on behalf of a Resident

• Safeguarding of Residents‟ Money and Valuables

• Resident Transport

• Records

Resident Guide & Individual Resident Agreement

RESIDEN T GUIDE AN D IN DIVIDUAL AGREEM EN T

The home maintains full records relating to the terms and conditions of the Resident’s stay at the home

Criterion Assessed:

CO M PLIANCE

LEVEL

•The home provides to each Resident a written guide, including a personalised written agreement detailing

the specific terms and conditions of that Resident’s stay at the home

•Each Resident agreement details the home’s current fees charged and by whom each element of the fee is

payable including the method of payment by each contributory to the fee

•The individual agreement also includes a list of charges for any additional services provided by or

facilitated by the home

•Where the home is responsible for managing a Resident’s finances, the arrangements and records to be

kept are specified in the Resident’s agreement

•The home notifies each Resident in writing of any increase in the fees payable by the Resident at least 28

days in advance of the increase and the arrangements for these notifications are included in each

Resident’s agreement

Provider's Self-Assessment:

Inspection Findings:

Acting on behalf of a Resident

ACTIN G ON BEHALF OF A RESIDEN T

Arrangements for the receipt and expenditure of residents’ monies are transparent, agreed to and appropriate records

maintained

Criterion Assessed:

• The home maintains a record of the amounts paid by/ in respect of each Resident for all agreed itemised

services and facilities as specified in the Resident’s agreement

CO M PLIANCE

LEVEL

• The home maintains a record of all allowances/ income received on behalf of the Resident and of the

distribution of this money to the Resident/ their representative. Each transaction is signed and dated

by the Resident/ their representative and a member of staff. If a Resident/ their representative is unable

to sign or chooses not to sign for receipt of the money, two members of staff witness the handover of

the money and sign and date the record

• The home ensures that records of, and receipts for, all transactions undertaken by the staff on each

Resident’s behalf, and of the expenditure of allowances kept by the home on the Resident’s behalf are

maintained and kept up-to-date. Where the Resident/ their representative is unable to sign or choose

not to sign, two members of staff sign the record

• If a person associated with the home is nominated to act as an appointee, the arrangements for this

are discussed and agreed with the Resident/ their representative, and, if involved, the representative

from the referring Trust. Documentary evidence of this agreement must be retained. These

arrangements are noted in the Resident’s agreement and a record is kept of the name of the appointee,

the Residents on whose behalf they act and the date they were approved by the Benefits Agency

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Acting on behalf of a Resident

ACTIN G ON BEHALF OF A RESIDEN T

Arrangements for the receipt and expenditure of Residents’ monies are transparent, agreed to and appropriate records

maintained

Criterion Assessed:

•If a member of staff acts as an agent, a record is kept of the name of the member of staff, the date they

acted in this capacity and the Resident on whose behalf they act as agent

CO M PLIANCE

LEVEL

•A reconciliation of the money/ possessions held by the home on behalf of Residents is carried out,

evidenced and recorded, at least quarterly

•When there is evidence of a Resident becoming incapable of managing their own affairs, the registered

person reports the matter in writing to the local or referring Trust

•If a Resident has been assessed as incapable of managing their own affairs, the amount of money or

valuables held by the home on behalf of the Resident is reported in writing by the registered manager to

the referring Trust at least annually, or as specified in the Resident’s agreement

Provider's Self-Assessment:

Inspection Findings:

Safeguarding Residents’ Money and Valuables

SAFEGUARDIN G RESIDEN TS’ M ON EY AN D VALUABLES

A safe place is provided for the storage of money and valuables deposited for safekeeping

Criterion Assessed:

•The home provides an appropriate place for the storage of money and valuables deposited for

safekeeping. Robust controls exist around the persons who have access to the safe place

CO M PLIANCE

LEVEL

•Where the money and valuables of Residents are not stored within the safe place, an alternative place

exists for the Resident to store those items securely

•The home ensures that a record is retained of the items of furniture and personal possessions brought by

the Resident to their room on admission and throughout their stay at the home

•Records are kept of items deposited for safekeeping and return, and receipts are provided to the person

depositing the items and having those items returned. The record is signed and dated by the

Resident/ their representative, and the member of staff receiving or returning the possessions. Where the

Resident, or their representative, is unable to sign or chooses not to sign, two members of staff witness

the hand-over of the possessions and sign and date the record

•Residents are aware of the arrangements for the safe storage of these items and have access to their

individual financial records

•A reconciliation of the money and valuables held for safekeeping by the home is carried out at regular

intervals, but least quarterly.

Provider's Self-Assessment:

Inspection Findings:

Transport

TRAN SPORT

Arrangements for transport, including charges, are transparent and agreed with the Resident/ their representative

Criterion Assessed:

CO M PLIANCE

LEVEL

•Where transport is provided by the home, a written policy and procedure exists

•Where a Resident is in receipt of the mobility component of Disability Living Allowance and this money

is received by the home on behalf of the resident, records are kept detailing the amount received and the

transfer of this money to the Resident/ their representative/ the Resident’s bank account

•Where a Resident avails of transport provided by the home, a written agreement exists between the

Resident/ their representative and the home, which details the arrangements for providing transport to the

Resident and the current charges to the Resident, including the method of payment

•The home maintains up to date records of all charges made to Residents for the provision of transport.

•Where a vehicle is owned by a group of Residents, records are kept of each journey, the names of the

Residents transported, the running costs, and the charges made to each Resident

•The home ensures that where private vehicles are used by the home to provide transport to Residents the

relevant legal requirements are met regarding insurance and road worthiness

Provider's Self-Assessment:

Inspection Findings:

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Records

RECORDS

Transparent, contemporaneous records are maintained by the home for the requisite period

Criterion Assessed:

CO M PLIANCE

LEVEL

•The home ensures that all records pertaining to the financial arrangements of Residents including but not

limited to: agreements between the Residents and the home; income received and expenditure undertaken

on behalf of Residents ; correspondence with the HSS Trust( s) and all other relevant parties and all other

related records are retained by the home for a period of not less than 6 years from the date of the last

transaction

•The home has clear written guidance within the home in respect of the arrangements for the retention of

the ( financial) records of Residents

Provider's Self-Assessment:

Inspection Findings:

Guidance on Transport Services

Transport Services

• Key Principles

– Needs of each Resident

– Charges

– Records

• Capacity Issues

• Obtaining Agreement

• Policies & Procedures

• Banking Arrangements

• Records

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Guidance on Transport Services

Key Principles- Needs of each Resident

Needs of each Resident

• The choices, needs, wishes and resources of each individual Resident are

considered in assessing the appropriateness of the model of transport

provision. In assessing the appropriateness of the model, the opportunity for

Residents to lease Motability vehicles is evaluated

• The service provider carries out a regular value for money exercise to

establish whether the transport service is optimal to meet the needs of each

individual Resident

• Any Resident contributing to the transport service is capable of utilising it

Charges

Guidance on Transport Services

Key Principles- Charges

• The charges for transport provision are based on usage by the Resident

and are not based on a flat-rate charge

• No profit should be realised from the running of the service (the treatment of

any surplus/arrears arising should be detailed within the written agreement)

• Only direct costs associated with providing transport are included e.g.: fuel,

servicing, insurance, MOT costs, road tax, depreciation, leasing/rental

charges (see below re ownership details)

• Where a cost per mile system is used, the cost per mile is shared between

the Residents travelling on each journey

Guidance on Transport Services

Key Principles- Charges

Charges (continued)

• Where staff accompany Residents on journeys, the rationale is clear and

appropriate grades of staff are utilised. Additional staff (including the

calculation of costs, staff brought in exclusively for the journey, to be

discussed with the Commissioning Trust e.g.: 24/7 supervision for certain

Residents)

• The cost of journeys undertaken for general business purposes are not

charged to Residents

• Vehicles collectively owned by Residents are not used for general business

purposes

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Records

Guidance on Transport Services

Key Principles- Records

• Clear, up-to-date records are retained including:

o

o

o

o

the calculation of the cost of providing transport

the rationale for including each cost

the records of journeys undertaken

the subsequent charges to the Resident

Transport Services- Capacity Issues

• It is the role of the Commissioning Trust to determine and evaluate whether

the choices, needs and wishes of each Resident are being fulfilled,

regardless of the Resident‟s ability to manage their affairs. In determining

appropriateness of transport provision for the Resident, the following should

be considered:

– The Commissioning Trust regularly evaluate any transport provision in operation to assess

the reasonableness and appropriateness for each Resident placed within a service in

accordance with ECCU 1/2010 (Care Management, Provision of Services and Charging

Guidance)

– Where a Resident lacks capacity to manage their financial affairs, the Resident‟s

representative reviews and signs the agreement in respect of transport arrangements

(except where a representative of the establishment is nominated as appointee or authorised

to control a bank account for a Resident)

– Regardless of a Resident‟s ability to manage their affairs, the Commissioning Trust continues

to play a role in evaluating the appropriateness of transport provided

Transport Services-Obtaining Agreement

• Written agreements are in place between the service provider and the

Resident/their representative in respect of transport arrangements

• The agreements are signed by the Resident/their representative and should

not be signed by a representative of the establishment on the Resident‟s

behalf, including any representative of the establishment nominated as

appointee or authorised to operate a bank account on behalf of the

Resident

• The written agreement details the terms and conditions of the scheme

including: the charges; method of payment; frequency of payment;

treatment of any surplus/arrears arising; arrangements for purchase and

disposal of the vehicle; arrangements for amending the terms and

conditions of the agreements; arrangements for terminating the agreement;

the opportunity to opt out of the scheme including an outline of alternative

arrangements for transport (if any) and the frequency of review of the

transport service

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Transport Services-

Policies & Procedures

• The ownership of the vehicle(s); arrangements for purchase and disposal of

the vehicle(s); the terms and conditions of the transport service including

the frequency of calculation of charges payable; and the responsibilities of

those accompanying residents on journeys

• The records to be retained in respect of the administration of the transport

service

• The arrangements for transport services where the Resident chooses to opt

out of the transport service

• The procedure to follow in reviewing the appropriateness of transport

arrangements where the Resident has no next of kin

• The strategy and timescales for reviewing the service on a regular basis

Transport Services-

Banking Arrangements

• Monies to pay for transport services are held in a separate bank account

• Bank accounts(s) containing Residents‟ monies are properly designated

and clearly identify the monies as belonging to Residents and not the

service provider

• Appropriate controls exist around access to bank accounts containing

Residents‟ monies

• Reconciliations of accounts containing Residents‟ monies are carried out

and evidenced at least quarterly

Transport Services - Records

• Written transport agreements for the current service

• Journeys undertaken by Residents

• Calculation of charges to Residents

• Invoices raised for transport charges to Residents (if specified within the

written agreement)

• Relevant bank account information

• Ownership of the vehicle(s)

• Appropriate insurance cover

• Value for money reviews undertaken

____________________

______________________________________

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Any Questions?

Video

RESIDENTIAL CARE HOME

INSPECTION STANDARDS

2013 – 2014

Ruth Greer

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CARE TEAM STANDARDS 2013 – 2014

Standard: 11 Care Review

Standard Statement: The home contributes to or organises reviews of residents’ placement in

the home

REGULATION/STANDARD REGULATION REFERENCE /

STANDARD CRITERIA

EVIDENCE

Standard 11.1

Regulation 15(2) (a) (b)

The home participates in review

meetings organised by referring Trust

responsible for the resident‟s

placement in the home

Home‟s has a policy on care review.

Care review as per principles of

care management.(Six to eight

week review /annual)

Review as required/as

determined by the registered

manager or Trust care manager.

Care records retained show evidence

of

commissioning trust care

management reviews and staff

participation

The manager and staff can

demonstrate knowledge of the home‟s

policy and procedure on the

commissioning trust care

management reviews

REGULATION/STANDARD REGULATION REFERENCE /

STANDARD CRITERIA

EVIDENCE

Standard 11.2

When the resident is self- referred, the The home has a policy/procedure on care

registered manager arranges a meeting at reviews for self -referred /funded

least annually to review the suitability of residents. Staff can demonstrate

placement.

knowledge of same.

The resident has a right to choose to

attend, to be involved in the organisation

of the meeting and to be consulted about

who attends. When the resident is unable

or chooses not to attend, he/she can

make his/her views known and these are

recorded and presented at the meeting

Records are retained of review meetings

of self- referred residents.

Self -referred/funded resident can confirm:

involvement/representative/advocate

where applicable

choice of attendance

opportunity to express view

REGULATION/STANDARD REGULATION REFERENCE /

STANDARD CRITERIA

EVIDENCE

Standard11.3

A written review report is prepared by staff The home‟s staff has prepared a Care

in consultation with the resident and Management review report for the

provided for the review meeting

meeting which includes the following;

(Human rights based approach.)

Physical needs

emotional

Social needs

Psychological needs

Financial

Spiritual

Complaints

Accidents / incidents

Risk assessments / management

Resident / representative views on

the quality of care/life in the home.

Multi-professional

collaboration/involvement

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REGULATION/STANDARD REGULATION REFERENCE /

STANDARD CRITERIA

EVIDENCE

Standard 11.4

Regulation 16 ( 2) (b)

Regulation 30

Review reports held refer to:

‣ Progress in attaining any personal

outcomes sought by the resident

Residents can confirm their involvement

in the preparation of the review report.

Record of action taken since last care

review

‣ The residents views about care

‣ Any changes in the residents

situation

The resident /representative views on the

quality of care provided are documented.

Care review record shows evidence of

any changes in the residents care.

Care review meeting record shows

evidence of personal response

outcomes/follow up action.

REGULATION/STANDARD REGULATION REFERENCE /

STANDARD CRITERIA

EVIDENCE

Standard 11.4

Regulation 16 ( 2) (b)

Regulation 30

‣ Details of important events including

incidents or accidents occurring

since previous review.

Accident / incidents /complaints records/

notifications – identification of recurring

issues/high risk

Consideration (examples) re:

*Trust Behavioural support team.

*Referral to Falls Clinic

*Memory Team

*Occupational Therapist

*District Nurse/comm psychiatric nurse/LD

Nurse

*Sensory Impairment Resource team

*NI Dementia services/resources

*Appropriateness of placement

*SALT

*Any referral to Designated Officer for

POVA.

REGULATION/STANDARD REGULATION REFERENCE /

STANDARD CRITERIA

EVIDENCE

Standard 11.4

Regulation 16 ( 2) (b)

Regulation 30

‣ Any matters regarding the current

care plan and management of risks.

‣ The need for any rehabilitation or

specialists‟ intervention.

‣ Any other matters regarding

services and facilities provided by

the home or others.

Recorded evidence of any changes in the

resident‟s situation as shown in the

residents evaluation notes/care plans and

from discussion with residents.

Issues identified in regard to specialists

intervention is reflected in the care

management review

Additional matters arising in regard to

care and life in the home is reflected

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11/02/2013

REGULATION/STANDARD REGULATION REFERENCE /

STANDARD CRITERIA

EVIDENCE

Standard 11.5

.

The home keeps records of review Records of review meetings are retained.

meetings that identify outcomes of review,

actions required and those responsible for Records/minutes of reviews held show

actions. When the meeting is organised evidence of outcomes, actions required

by the home, a copy of the record of the and who is responsible for actions.

meeting is issued to the resident and

where appropriate their representative, The resident / representative, and where

and any other who contribute to the appropriate others who contributed,

review, unless there are clear and receive a copy of the review meeting

recorded reasons not to do so.

organised by the home.

Records / minutes are signed by all

present at the meeting. (unless there is a

clear indication not to do so.)

Review minutes are available in the

residents file within twenty eight days.

REGULATION/STANDARD REGULATION REFERENCE /

STANDARD CRITERIA

EVIDENCE

Standard 11.6

Regulation 16 (2) (b)

Following the review meeting the

resident‟s care plan is revised if

necessary, and when this happens the

resident is provided with a copy of the

revised care plan in a format and

language appropriate to their needs.

Care plans show evidence of revised

changes, if appropriate.

Care plans are in a format and language

appropriate to the resident‟s needs.

Care plans / dated are signed by the

resident / representative, registered

manager and the staff member who

developed the care plan.

Standard: 16 Protection of vulnerable adults

Standard Statement: Residents are protected from actual or potential abuse and their human rights are

respected and upheld at all times

STANDARD / REGULATION CRITERIA EVIDENCE

Standard 16.1

Regulation 14 (1) (b)

Procedures for protecting vulnerable adults

are in accordance with, DHSSPS guidance,

regional protocols and local procedures

issued by Health and Social Care Board and

Trusts.

For example;

Safeguarding Vulnerable Adults.

Regional Adult Protection Policy &

Procedural Guidance.( DHSSPS) 2006

Safeguarding Vulnerable Adults – A

shared responsibility. Volunteer Now

(Oct 2010)

Commissioning HSC Trust / Board

procedural guidance.

The home‟s policy / procedure on

Protection of Vulnerable Adults reflect

current DHSSPS guidance, regional

protocols and local procedures issued

by HSC Boards and Trusts.

The home‟s Policy / procedure are in

keeping with the commissioning Trust

procedure including modes of referral

both during and out of hours contact.

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11/02/2013

STANDARD / REGULATION CRITERIA EVIDENCE

Standard 16.1

Regulation 14 (1) (b)

The contact details of the out of hours

social worker is recorded (including

weekends and bank holidays) and is

known by all staff

The named trust designated officer for

the POVA and contact details is

recorded, displayed and reporting

procedure known by all staff.

The home has a written policy /

procedure on “Whistle Blowing” that

identifies who staff can report concerns

about poor practice.

STANDARD / REGULTION CRITERIA EVIDENCE

Standard 16.2

The procedures for protecting vulnerable

adults are included in the induction

programme for staff

The home‟s staff induction programme

includes the home‟s vulnerable adults‟

procedure.

STANDARD / REGULTION CRITERIA EVIDENCE

Standard 16.3

Regulation14 (2) (c)

Staff have completed training on and can

demonstrate knowledge of;

‣ Protection from abuse

‣ Indicators of abuse

‣ Responding to suspected, alleged or

actual abuse

‣ Reporting suspected alleged or actual

abuse.

Staff training records show evidence of

training provided to all staff.

Care staff can demonstrate knowledge

on the POVA including reporting to the

designated officer both during and out

of hours.

Competency and capability

assessments of staff that are in charge

of the home reflect evidence of training

and knowledge of the policy /

procedure including reporting both

during and out of hours in keeping with

the commissioning trust

protocol/procedure.

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STANDARD /REGULATION STANDARD CRITERIA EVIDENCE

Standard 16.4

Regulation 14 (2) (c)

All suspected, alleged or actual incidents of

abuse are reported to the relevant persons

and agencies in accordance with procedures

and legislation.

Accidents / incidents/complaints

records show evidence, where

applicable, of alleged or actual abuse

and action taken in regard to timely

reporting.

Examination of records of alleged

abuse held in the home shows

evidence of prompt reporting to;

Trust designated officer or „out of

hours‟ social worker (as

appropriate) including dates/time

resident representative ( if

appropriate)

Care manager /social worker.

RQIA

Professional body.

STANDARD /REGULATION STANDARD CRITERIA EVIDENCE

Standard 16.5

Regulation14 (2) (c)

All suspected, alleged or actual incidents of

abuse are fully and promptly investigated in

accordance with procedures.

Care records show evidence of

immediate referral and prompt

investigation by the trust designated

officer

STANDARD /REGULATION STANDARD CRITERIA EVIDENCE

Standard 16.6

All relevant persons and agencies are notified There is recorded evidence of persons

of the outcome of any investigations

/ agencies notified including;

undertaken by the home.

Resident

Relative / representative (where

appropriate)

Commissioning Trust

RQIA

Access NI

NISCC / NMC

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STANDARD /REGULATION STANDARD CRITERIA EVIDENCE

Standard 16.7

Written records are kept of suspected,

alleged or actual incidents of abuse. Where

the home has been involved in the

investigation, these records include details of

the investigation, the outcome and action

taken.

There are detailed records retained in

the home of suspected, alleged or

actual incidents of abuse.

Where appropriate, records show

details of investigation / outcome /

action taken and lessons learned.

STANDARD / REGULATION CRITERION EVIDENCE

Standard 16.8

Regulation 14 (2) (c)

Where shortcomings in systems are

highlighted as a result of investigation,

identified safeguards are in place

Records of the investigation show

evidence of any shortcomings which

require to be addressed.

Action plans are in place to address any

shortcomings.

The manager has taken the necessary

action to address shortcomings and

retains a record of same.

Reference of follow up action is illustrated

within the registered provider‟s

unannounced monthly monitoring report.

STANDARD / REGULATION CRITERION EVIDENCE

Standard 16.9

Regulation 14 (2) (d)

Refresher training on the protection of

vulnerable adults is provided for staff at

least every three years.

The home‟s staff training records show

names of all staff who has received

training on the protection of vulnerable

adults in keeping with RQIA Guidelines on

Mandatory training. (refresher training

annually)

Staff can confirm attendance (ref

questionnaires and discuss with staff

during inspection)

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STANDARD 19:

STATEMENT:

RECRUITMENT OF STAFF

Staff are recruited and employed in accordance with relevant statutory employment legislation.

STANDARD /REGULATION CRITERIA EVIDENCE

Standard 19.1

Regulation 21 Sch2

The policy and procedures for staff

recruitment detail the recruitment process

which complies with Residential Care

Homes Regulations (Northern Ireland)

2005 and Residential Minimum Care

Standards (DHSSPS) 2008

The home‟s policy / procedure reflect the

recruitment process as described within

legislation and DHSSPS guidance.

STANDARD /REGULATION CRITERIA EVIDENCE

Standard 19.2

Regulation 21 Sch2

Before making an offer of appointment;

The applicant‟s identity is confirmed

Two written references, linked to the

requirements of the job are obtained, one

of which is from the applicant‟s present or

most recent employer

Staff employment files contain:

Current photographic evidence

Birth certificate

Two written references are retained, one

from present employer or most recent

employer

Any gaps in an employment record are

explored and explanations recorded

Explanations recorded if gaps identified

STANDARD /REGULATION CRITERIA EVIDENCE

Standard 19.2

Regulation 21 Sch2

Criminal history information, at the

enhanced level, is sought from Access NI

for preferred candidate; (note: Agencies

that intend to employ applicants from

overseas will need to have suitable

complementary arrangements in place.

Professional and vocational qualifications

are confirmed

Registration status with relevant

regulatory bodies is confirmed

A pre-employment health assessment is

obtained

Current status of work permit/employment

visa is confirmed.

Evidence of Access NI checks/record

Record of Pre-employment checks (if an

overseas applicant)

Certificates of professional /vocational

qualifications

Recorded evidence of registration status.

(NISC Council and NMC if appropriate)

Pre-employment health check (e.g. GP)

Employment Visa / permit where required

for overseas applicants

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STANDARD /REGULATION CRITERIA EVIDENCE

Standard 19.3 (DNSSPS revised)

Regulation 21 Sch2

Records are kept of all the documentation

relating to the recruitment process

are kept in compliance with principles of

the Data Protection Act 1998 and with

Access NI Code of Practice.

Records as illustrated above in 19.3

(criteria) is contained with staff files

Access NI record is retained in keeping

with Data Protection Act and Access NI

Code of Conduct

(available

http:/www.accessni.gov.uk/code-of –

practice.pdf.)

Discussion with staff to confirm receipt

prior to appointment or within thirteen

weeks after appointment.

Examination of copy of terms and

conditions held in staff file/s

STANDARD /REGULATION CRITERIA EVIDENCE

Standard 19.4

Staff is issued with a written

statement of main terms and

conditions prior to employment and

no later than thirteen weeks after

appointment.

Staff can confirm receipt of term and

conditions within timescale stated

Standard 19.5

Job descriptions are issued to staff

on appointment

Staff can confirm receipt of job

description

Standard 19.6

Residents, or where appropriate Manager can confirm

their representatives, are involved in

the recruitment process where Evidence of resident involvement

possible.

Any

Questions?

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11/02/2013

Involving Service Users in the

Recruitment & Selection Process

Why do it?

Sense is committed to a set of values that should underpin everything

we do within the organisation

• I will listen to others

• I will understand and respond

• I will respect others

• I will be honest and open

• I will participate and contribute

• I will take informed risk

• I will find things to celebrate

• No decision about me, without me

It makes Sense

• Clear Economic Benefits –

• Reduction in direct recruitment costs due to lower staff turnover

• Indirect cost savings due to less management time spent on

– The recruitment process

– Supporting new staff

– Managing employee relations

– Dealing with performance issues

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How did we go about it

• First attempts at involvement

• Identified service users who wanted to be involved

• Provided training and support around advocacy and communication

skills

• Ensured the environment was accessible and comfortable and

appropriate support was available

• Feedback

• Too long a day

• Too boring – could be doing better things with their time.

Adapting the process

• Respond to service user feedback and ensure the process is

• more meaningful,

• Interesting

• Shorter

• Measuring key criteria via tasks which involved the service user

• Introduced a two stage approach, the first part of which must include

deafblind people

Issues

• Differences of opinion

• adapted the two stage process to ensure that all candidates who

reached the second stage had been assessed and approved by

service users

• Challenges

• Candidates who service users strongly favoured were not scoring

well against our specification

• Review the person specification

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11/02/2013

Reviewing the Person Specification

• Core Competencies

• What was important to service users?

• Consultation Process with Service Users

– Individual meetings

– Questionnaires

– Focus Groups

Outcomes

• Staff need to spend time with me to get to know me and need to be friendly

and interested in what I have to say.

• Staff should show concern for me, I want to feel that they care about me

• Staff need to get into our heads so that they understand us, know how we are

going to react. They should know that I‟m different from other users in same

way they are different from other staff

• Staff should talk to me about themselves and ask me about me

• Staff should realise I would like to do the same things as they do

• Staff should treat me like an adult; don‟t lie to me, share things with me and let

me make my own decisions even if you don‟t agree with it

• Staff should help me to make choices not make them for me, so sometimes

they need to help me understand things so that I can make that choice

Outcomes

• Staff need to support and encourage me - people have always done things for

me so I‟m not used to doing things myself, I need to learn how to do these

things – I‟m not like you, I just can‟t do them and I need to be taught

• Staff need to be patient – to let you have time to do things and let you ask

questions

• Staff need to be positive - When I get something right tell me/praise me.

• Staff need to respect me and realise they can learn from me

• Staff need to focus on me - don‟t talk to other staff when you are supposed to

be supporting me

• Staff need to be straight talking

• With good staff you feel that they really want to do something with you and

aren‟t just doing it because that„s their job.

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What next?

• Agree a revised person specification that reflects the qualities

that service users value.

• Provide service users with further opportunities to develop their

skills in this area to ensure they can be fully involved in all

aspects of the process if they wish.

• Incorporate feedback from service users as a key part of the

probationary, supervision and appraisal process.

39

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