St Mary of the Angels Beaufort

HIQA Reports

For the purpose of HIQA registration and inspection regime, St John of God operate TWO centres on the campus of St Mary of the Angels. There have been a number of inspections and reports which are detailed below. Click on the dates to see the actual reports.

In July 2018, HIQA confirmed full registration of both centres on the St Mary of the Angels campus. This is a great achievement and in no small measure due to the positive influence and hard work of the Parents and Relatives Association which has been acknowledged in recent reports. Confirmation in newspaper articles as part of 50th Anniversary coverage.

Reports for Centre DC1 (OSV-0003630):

• October 2015
• Four units on the grounds of a large campus in a rural area of Co. Kerry.
• 33 residents
• The report is favourable overall but lists two units as having privacy issues arising from the multi occupancy in bedrooms: St Fidelis and St Brendan's.
• Page 28 shows the following action item on foot of the inspection, amongst others: "Consultation and agreement with the HSE to set up National Joint Task Group to progress the de-congregation of Saint Mary of The Angels as a national pilot site - St Fidelis in DC 1 is prioritised for phase one of this plan in agreement with HSE."
• January 2017
  • a more organised, supportive and effective management system
  • access to allied health/specialist services such as dietetics
  • a review of the contracts of care
  • provision of appropriate staff training and refresher training.
• Unannounced inspection over 3 days in January 2017
• 31 residents (two less than in October 2015)
• Since last inspection, no further admissions were being taken into the unit which had the reduction in resident numbers. This improved the living arrangements for those remaining in the unit. For example, no more than three residents occupied shared accommodation whereas in 2015 one room was shared by five residents.
• Inspectors observed how staff interacted with residents, observed the general comfort of the environment and the atmosphere within the houses. Interactions were characterized by a relaxed, competent and caring approach from staff.
• It was clear staff took pride in their work. They told the inspector they enjoyed their work and worked well with their frontline colleagues. However, staff were not always clear on the reporting structures. Inspectors concluded staff views were not always heard by managers and that systems were such that staff were not adequately supported.
• Inspectors identified a number of areas of good practice. Staff members were seen to interact with residents in a kind and caring manner and residents appeared to be comfortable in their presence.
• Since the previous inspection the provider had taken measures to improve the physical environment. A significant undertaking had taken place to bring the centre into compliance with fire safety requirements. Some further premises improvements were needed.
• Major non-compliances were found in the following areas. All are related to poor management, under-staffing and under-funding:
• Work was ongoing in identifying areas for improvement including the manner in which resident finances were managed. However, at the time of inspection, inspectors found deficits in this area.
• There were weaknesses in the manner in which risk was managed. For example, some risks were not reviewed in a timely manner and the review of other risks did not adequately take into account factors that impacted on this risk.
• Inspectors were not satisfied that there were adequate numbers of staff on duty at all times to meet the needs of residents. For example, access to activities/day services had been curtailed for some residents due to staffing arrangements. There were inadequate numbers of staff on night duty, taking into account the significant physical and psychological needs of the residents living in the centre.
• Other improvements required included:
• None of the proposed remedial actions mention anything about 'de-congregation'. This is in sharp contrast to the previous report of 2015 where St Fidelis in DC 1 was prioritised as a national pilot site for 'de-congregation'. Inspectors were informed that the centre was currently closed to admissions and residents were transferred from the main building to other houses when vacancies arose.
• November 2017
  • Unannounced inspection over 3 days. 
  • In a short amount of time since the previous inspection, the number and severity of non compliances has reduced markedly: From 6 Major and 2 Moderate in January to 7 Moderate in November.
  • The positive impact of the fundraising and family involvement has been recognised by HIQA: "Monies raised by families through fundraising events, were directed to enhancing the quality of life for those residing in the centre."
• May 2019
  • Unannounced inspection on one day with a mix of positive and more critical findings. Positives mostly relate to frontline staff and negatives to management issues and staff shortages impacting the rights and quality of life of the residents. Examples below:
  • The inspectors observed interaction between residents and staff and it was evident that staff had a very good understanding of residents needs. The residents appeared to be happy with the support of staff and this was evident through gestures and sound. The inspectors noted the positive and warm engagement between staff and residents.
  • The inspectors found that since the last inspection there was no increased opportunity for residents to access the community or to take part in daily one to one activities.
  • The staffing complement identified in the statement of purpose did not reflect the staffing numbers rostered in the designated centre.
  • The staffing levels allocated to night times were insufficient to meet the assessed needs of the residents.
  • Overall inspectors observed positive and gentle interactions between staff and residents that was respectful and kind. Staff demonstrated good knowledge of the residents they provided direct care to and there was evidence that the registered provider supported staff development and provided training for professional development.
  • Improvements planned for one premises remained at tender stage to address personal bedroom spaces for residents where shared bedrooms were still in operation.
  • The response from the provider (i.e. St John of God Community Services) to the above issues are:
    • The recruitment drive will continue to be implemented to fill existing gaps in the compliment and the Programme Manager will review the recruitment strategy quarterly to pre-empt and respond to leavers as they arise.
    • A business case has been submitted to the HSE to increase by one additional staff across the campus at night to meet the care and support needs of residents in both designated centres on site. This request has been approved and recruitment process commenced.
    • An additional vehicle will be purchased and adapted for the Designated Centre to further increase the implementation of resident’s goals to access the community.
    • The Registered Provider in partnership with the Relative and Friends association will complete the construction of two additional bedrooms in one residential area. This project has completed the procurement process and sufficient fundraising monies are in place to progress the project. [Note: construction has started in September 2019 - see here.]
• November 2019
  • Unannounced inspection on one day with a mix of positive and more critical findings. Positives mostly relate to frontline staff and negatives to fire safety, management issues and staff shortages impacting the rights and quality of life of the residents. Examples below:
  • The inspectors observed meaningful interactions between residents and staff. Staffs focus was person centred.
  • It was evident that staff had a very good understanding of residents' needs and it was apparent from staff that were spoken to, that advocacy on behalf of residents' needs was to the forefront of what they did. Residents appeared to be happy with the support of staff and this was evident through gestures and sound. The inspectors noted that the engagement between staff and residents to be warm and considerate.
  • A number of improvements were noted by the inspectors since the previous inspection. Overall the provider had taken some measures to address staff shortages that included the recruitment of additional staff, as well as a review of all staff within the designated centre for the purposes of best matching staff and skill mix to the assessed needs of the residents. A comprehensive action plan to bring the designated centre into regulatory compliance was actioned and reviewed monthly through all levels of management.
  • The current staff rosters reviewed on the day of inspection reflected less movement of staff between designated centres on the campus. The registered provider had made representation and business cases for additional staffing with the recruitment of one staff member since the last inspection.
  • Residents activation and access to the wider community was subject to and limited by staff availability and numbers.
  • Governance and management improvements were observed and readily identifiable through staff meeting records and information sharing as well as local management's involvement implementing change and improvements in each premises.
  • While inspectors noted many examples of good practice in relation to fire precautions and there was a programme of fire safety works in place, the inspectors were not assured that the fire safety arrangements in place were fully adequate to ensure the safety of residents.
  • The inspectors noted that there was some improvement in the quality and safety of services to residents since the last inspection. Some premises had been decorated and remedial works and renovations were nearing a state of completion.The registered provider demonstrated a commitment to addressing ongoing building works to come into compliance with the regulations, particularly in respect of privacy and residents' rights to suitable premises.
  • A project to deliver two additional single bedrooms for residents was almost at a stage of completion. All other premises were decorated and cleaned to a good standard. [Note: this project was funded by the Parents and Relatives Association and has since been completed and two residents have moved into new single bedrooms.]
  • Inspectors also noted that a visitors room that had been utilised by staff as a locker room had reverted to its primary function as a room for visitors. New and additional furnishings had been secured since the last inspection.
  • There was evidence of residents accessing the community and the registered provider had acquired an additional minibus, however recreation and occupational activities remained limited. The greater proportion of activities for residents remained house or campus based. Activity schedules indicated greater staff involvement in planning and recording activities as well as recording the reasons for non fulfilment when activities were cancelled due to staff shortages.
  • While the registered provider had made improvements to ensure residents access to facilities for occupation and recreation in line with residents interests, capacities and developmental needs, the necessary staff supports to develop and maintain these links required further resources.
  • The response from the provider (i.e. St John of God Community Services) to the above issues are:
    • The recruitment drive will continue to be implemented to fill existing vacancies in the complement and the Programme Manager, in consultation with the PIC, will review the recruitment strategy quarterly to preempt and respond to leavers as they arise.
    • The HSE have approved the business case submitted by the Registered Provider for an increase in staffing to develop a community integration programme to support residents on campus (3 Posts).
    • The Registered Provider in partnership with the Parents and Friends Association will complete the construction of two additional bedrooms in one residential area.
    • The PIC will prioritise the resident in the room of “insufficient size / inner room” for transfer to a single room once a suitable vacancy becomes available.
    • The Registered Provider in consultation with the Architect will review the house where the kitchen area is too small for food preparation and wheelchair accessibility to determine the feasibility of any potential building modifications in this location.

    • On receipt of the Independent Fire Risk Assessments within the DC the Registered Provider has prepared a tender document to complete all identified works. The Registered Provider will review the current scope of works based on the HSE Inspection Report in consultation with the Architect, the HSE, the Registered Provider’s independent Fire Consultant in order to agree a schedule of works. The Registered Provider following completion of consultation with the HSE will implement the agreed schedule of works to reach compliance.

    • Two new accessible vehicles have been purchased for two locations to support increased access to community based activities.

• October and November 2020
  • Short Notice Announced inspection with two visits and overall positive results and feedback.
  • The designated centre is registered to accommodate 26 residents but presently has 23 residents and is closed to further admissions. Residents have a range of moderate, severe and profound intellectual disability with complex medical care needs. Some residents have a dual diagnosis and high physical support needs.
  • An inspector met with 12 residents who were present at the designated centre. All of these residents communicated without words. A number of residents had just returned from attending mass. Various other activities as planned and recorded on the activities board, had commenced. These included horticulture and sensory activation. Staffing support on a one-to-one basis was observed. All residents appeared happy and comfortable. Staff were observed to be respectful, gentle and all activities were unhurried. A number of residents were out walking or in wheelchairs in the grounds, supported by staff.
  • A significant change since the previous inspection was that all residents now had their own single occupancy bedroom. This afforded many residents additional space and these spaces were personalised to the occupant. Some new bedrooms that were recently constructed were now occupied.
  • The registered provider contacted families by email with eight families in total making contact on the day. The majority of families spoke of the high standard of care that staff provided to residents. Families were happy with the supports in place.
  • Many families expressed concerns in relation to the current pandemic, the outbreak of COVID-19 within the campus and how it would or did impact on their family member. Concerns were also made in relation to the registered provider's communications regarding the possibility of handing the services to the Health Services Executive.
  • Since the previous inspection in 2019, significant improvements were noted by the inspectors. A substantial amount of actions committed to in the registered provider's previous compliance plan had been achieved. Resources to recruit additional staff and to address outstanding fire and safety works had been received and applied.
  • Three new staff were appointed in September 2020 to plan and support activities for residents. These staff were not included in the general provision of care to residents so that their function of supporting activities was protected.
  • The activity records of all residents reviewed had reflected a significant improvement in the level of community based activities, prior to the start of the COVID-19 pandemic. The majority of community activities had opened up prior to the inspection, only to be restricted again in line with current national public health guidelines. The registered provider had recruited three additional social and recreational staff whose role was to support community activities for the residents and to work with other staff in the centre to promote community engagement.
  • The inspectors reviewed a number of complaints that the registered provider had addressed since the previous inspection. The records reflected a prompt response by all staff to adequately deal with complaints to the satisfaction of the complainant. These records also evidenced a person centred approach where the rights of the resident were prioritised.
  • The inspectors noted that there had been an overall improvement in the quality and safety of services since the last inspection. The focus of service delivery was more aligned with the needs of and the support of residents. Staff allocations were based on the assessed needs of residents and prior to the COVID-19 pandemic had focused on increasing residents' access to the wider community. The movement of residents within the service to avail of individual bedrooms was a significant development.
  • The registered provider had responded appropriately to an outbreak of COVID-19 in this designated centre with staff retrained, crossover of staff between units kept to a minimum and public health guidance adhered to.
  • Main issue of concern was the resident's spending on external therapies and the lack of clarity in this area.
    • The inspectors reviewed the cost of external therapies to residents in the centre and noted that these costs were very high based on the disposal income that residents had.
    • Inspectors were not assured that there were effective management systems in place to ensure that the service was appropriate to residents' needs with the significant amounts of residents' personal funds that were required for external therapies that accounted for resident activities. Supports were not in place in relation to residents' payment for external therapies and were not subject to annual review or accounted for in the registered provider's policy on residents' finances.
  • Proposed actions in relation to above are:
    • Therapies will be sourced in the community in the first instance as part of resident’s activities once national COVID 19 restrictions allow. A review of each resident’s participation in therapies will take place and identify if this activity can be pursued in the community.
    • Financial Will and preference document will be completed in consultation with the resident and their circle of support outlining the proposed annual cost of therapies identified as part of the residents personal planning meeting. This will be implemented in line with the schedule of the residents Annual Planning meeting.

    • Current campus based activities will be identified as part of the resident’s individual planning process to determine if they are in line with resident’s needs. Alternative community based options will be identified to provide residents with increased opportunities for community activity.

• February 2022
  • This inspection probably focussed on one specific area. The information from HIQA is: "The report was not published due to low resident numbers. Reports on services with low service user numbers are not published on our website to protect the privacy of the service users."
• May 2023
  • From what the inspector observed and from speaking to staff and management, residents who received supports in this centre were offered a good quality service tailored to their individual needs and preferences. This was an unannounced inspection to monitor the provider’s compliance with the regulations. Overall, the service provided was seen to be safe and effective. However, the provider had identified a placement issue in the centre and this was impacting on some residents.
  • The designated centre was located in a campus setting in a rural area. The campus was observed to very peaceful, with large open green areas populated with wildlife, and accessible walks and pathways. The inspector saw that some of the units had nicely appointed patio areas and family supporters had recently installed pergolas in some parts of the centre and there was outdoor furniture available for the use of residents (Note: Much of the outdoor furniture was also provided by the Parents and Relatives Association.)
  • At the time of this inspection, this designated centre was home to 31 full time residents and one respite resident who had been admitted on an emergency basis.
  • Many of the individual units had originally been purpose built and were specifically designed or had been adapted to cater for residents with additional mobility or sensory requirements. Equipment such as hoists and shower chairs were available to residents if required and since the previous inspection overhead hoists and accessible baths had been installed in one unit of the centre.
  • A group made up of family and friends of residents had been involved in fundraising and had purchased furniture and outside awnings for units in the centre and an inspector observed some residents enjoying time in the courtyard of their unit.
  • Some of the units were seen to be modern, with recent refurbishment noted, while others were seen to have some features that could be considered institutional in nature. (...) The person in charge told an inspector about the plans in place to remove some of these features in the future.
  • Staff were observed to treat residents with respect and to interact positively and in a person centred manner with residents. Staff spoken to were very knowledgeable about residents and their support needs.
  • Residents met with during the inspection provided positive feedback about living in the centre and the staff that supported them. One resident told the inspector about the choices that were available to them while in the centre, such as a choice of food and activities.
  • A number of residents were not present when the inspector completed the walk around of the centre and the inspector was told that they were attending activities such as swimming and external activities with the social and recreation team. A number of residents had recently been away for overnight trips and staff told the inspector that they had enjoyed this.
  • A family member spoken to also provided very positive feedback in relation to the service provided to their relative. They stated that their relative loved living in the centre and that they felt the resident was very happy living in the centre. They were very satisfied with the communication with the centre and were confident that any concerns they raised would be acted upon in a timely manner. They spoke about the positive impact that the reduction in the number of residents in the centre had on their relative. For example, this resident had at one time shared a bedroom with four individuals but now had a bedroom and living space of their own. This had a positive impact for the resident in that the resident now had a personalised area of their own and residents were not impacting on each other if they awoke at night.
  • Staff of all units presented with a very positive attitude towards residents and the care provided to them in the centre and were very aware of their interests and capacities.
  • Overall, this inspection found that there was evidence of good compliance with the regulations in this centre and this meant that most residents were being afforded safe and person centred services that met their assessed needs.
  • However, some residents were being adversely affected by an inappropriate emergency placement in the centre.
  • Management systems in place in this centre were ensuring that the service being provided to residents was overall safe and appropriate to their needs.
  • The provider had completed an annual review in respect of this centre and this included consultation from residents and their representatives and some of this was presented in an easy-to read format. Overall, the feedback provided for the purposes of this review indicated that residents and family members were satisfied with the service provided in the centre.
  • There were ongoing plans to transfer some residents out of the centre to community based homes, in line with residents’ own preferences, and inspectors were told that there was a plan for three residents to transition to homes in the community in 2024.
  • Inspectors were also told that the provider had identified that another residents’ living environment was not suitable for their assessed needs and that they hoped to transition this resident to a community based property also. It was hoped that this would better meet their needs and discussed how the funding for this had recently been secured.
  • Another resident had been admitted to the centre full time as an emergency admission in 2021 and the provider was taking steps to identify actions that were required in relation to this placement.
  • The wellbeing and welfare of residents was maintained by a good standard of evidence-based care and support. Overall, on the day of this inspection, the inspector saw that safe and good quality supports were provided to the 31 residents that availed of services in this centre. However, the provider had identified that they were not meeting the assessed needs of one resident. Despite efforts to mitigate against the impact of this, this was seen to be impacting on other residents in the centre also.
  • This centre is located in a large campus based congregated setting. This did have the potential to impact on some residents’ lived experiences, such as residents’ opportunities to live ordinary lives in ordinary places. However, this inspection found that there were ongoing and sustained efforts to reduce and remove institutional practices and that, overall, residents were supported to live meaningful lives and the care and support of residents was good. Residents were observed to be content in this centre and residents that spoke to the inspectors indicated that they were happy and well cared for in the centre.
  • Overall, the premises was seen to be suitable to the residents using the centre. The premises of the designated centre was seen to be of sound construction and kept in a good state of repair externally and internally.
  • One unit in the centre was observed to be stark in appearance and there were numerous locked doors in this unit also. This was due to the responsive behaviour of a resident living in this part of the centre. Ongoing efforts were being made to Page 12 of 24 reduce the impact of this on the other residents that lived in this unit. For example, some residents had touch points or keypad access at their bedroom doors to allow them to access their bedrooms independently or with staff support.
  • One resident had been availing of part time respite supports in this centre for a period of time but had begun receiving full time supports since late 2021 on an emergency respite basis. The provider had identified that this placement was not suitable in the long term. The provider was making good efforts to provide an appropriate service to this individual in the interim including significant input from allied health professionals. Since the previous inspection, measures had been put in place to reduce the impact of this placement on the resident and their peers, such as 1:1 staffing for the resident.
  • However, documentation viewed and notifications submitted to the chief inspector provided evidence that this resident was continuing to impact on their peers on some occasions, and one resident in particular was seen to be affected. For example, documentation viewed showed that this peer did not feel safe in their home and this had impacted on their sleep and general wellbeing at times.
  • A sample of personal plans were viewed. (...) Inspectors saw that residents were supported to set and achieve goals that were meaningful to them. For example, one resident told an inspector about their experience of visiting a local radio station and taking part in a radio broadcast. Residents had goals that included reconnecting with family members, visiting places of interest, gaining work experience in specific areas, and going on holidays.
  • Residents took part in a variety of activities including swimming, social farming, work experience, sensory baking, day trips, beach walks and table-top activities.
  • Specific supports were available to residents with dementia. Comprehensive healthcare support plans were in place for residents with specific healthcare concerns. (...) Consideration was given to residents’ future needs including end-of-life care, where appropriate.
  • Inspectors had sight of recently reported incidents in the centre. It was seen that these were generally minor in nature and were recorded as appropriate. Given the size of this centre, the records viewed indicated that overall peer-to-peer safeguarding was well managed, with only one peer-to-peer incident recorded in a two month period in one unit reviewed.
  • An inspector visited a single occupancy apartment for one resident attached to one of the units. The resident was not present at the time but the inspector saw that this apartment was personalised to them and provided a pleasant and peaceful space for the resident to live in. The manager of this unit told the inspector about the positive changes and increase in independence that had come about for this resident when they had moved into their own apartment. They also spoke about the efforts that were being made to build on this residents skills for daily living in areas that they might not previously have had an opportunity to take part in. For example, a washing machine had recently been installed in the apartment and there was ongoing skills education for the resident to support them to manage their own laundry.
  • Overall, the registered provider was ensuring that each resident was provided with appropriate care and support, having regard to their assessed needs and wishes. Residents were supported to maintain personal relationships. Residents were provided with opportunities to participate in activities in accordance with their interests and capacities and some residents had taken part in work experience in the local community. Since the previous inspection, the addition of staff on the social and recreational team meant that residents had increased opportunities for community access and overnight breaks.
  • Resident choice was respected in this centre in many areas and residents and staff told the inspector about how choices were facilitated. (...) However, all residents were not provided with meaningful choices in relation to the individuals that they lived with. Residents did not participate in, or consent to, some decisions in relation to the individuals that they shared their homes with and some residents continued to be impacted by other residents that they lived with. The provider had put in place some controls to limit the impact but the lived experiences of residents living in this unit continued to be adversely affected by these living arrangements.
  • The response of the provider to the identified issues is:
    • The Director of Nursing has been in regular contact with the HSE Disability Manager regarding a suitable placement for the individual who is having an impact on the peers they share a home with. This will continue until a permanent placement is sourced. Alternative interim accommodation is being planned for the resident who is having an impact on the peers they share a home with. Complete 30/09/2023
    • Painting schedule is in place for the year ahead. Complete 08/04/2024
    • A request for an upgrade of fitted kitchens to be submitted to the Director of Nursing for approval from the Operations Manager. Completed 10/08/2023
    • The unit considered to be institutional in nature will be reviewed with a view of upgrading same . Complete 30/11/2023

Reports for Centre DC2 (OSV-0002905):

• March 2014
• Six units. All units were bungalows with the exception of one, which was located on the ground floor to the rear of the main administration building.
• 38 residents, 2 vacancies
• The report is generally favourable with some areas identified for improvement (i.e. under 'Safe and suitable premises': decor not up to scratch, unsuitable shared bathrooms and one unsuitable single bedroom).
• Note that there is no mention of any overcrowding or other issues nor are there any plans for 'de-congregation'.
• December 2015
  • Eight units on the grounds of a large campus in a rural area of Co. Kerry.
  • 42 residents, 3 vacancies
  • Again the report is generally favourable but the assessment of 'Safe and suitable premises' has changed dramatically - even though the reality on the ground would not have changed much since the first inspection. Now we read:
  • Inspectors were not satisfied that the premises were designed and laid out to meet the aims and objectives of the service and the number and needs of residents, due to:
    • the number of residents with complex behavioural needs in each of the units
    • the inadequate communal space for the number of residents living in the units
    • the extended period of time that residents spent in each unit due to inadequate access to activities external to the centre
    • some residents did not have access to their bedrooms with the assistance of staff.
• In response, page 28 lists the following action item: "St John of God Kerry Services is part of a Joint Task Group with the HSE to progress the de-congregation of Residents within St Mary of The Angels. The service is currently progressing phase 1 of the de-congregation plan for the campus which primary focus is on the older building on campus."
• August 2016
  • This was an un-announced inspection with the purpose to monitor ongoing regulatory compliance.
  • The report is favourable overall and has identified several improvements since the last report:
  • Overall, the inspector formed the view that the majority of residents were happy and comfortable in their homes.
  • A number of residents were provided with improved living arrangements (partly achieved by moving one resident to a community house and another resident to a self contained apartment on campus).
  • The inspector observed how staff interacted with residents, observed the general comfort of the environment and the atmosphere within the houses. Interactions were characterized by a relaxed approach from staff. The atmosphere in all houses was good humoured, caring and flexible.
  • The inspector was satisfied that staff and management were person centred in their approach to resident care. The inspector saw residents going on outings, being able to spend leisure time together and develop friendships. Residents were offered independence while safeguarding security.
  • Staff recognised the importance of having consistent staff working with residents. This helped to ensure both staff and residents understood each other.
  • The centre was managed in a way that maximised residents’ capacity to exercise personal autonomy and choice in their daily lives. For example, residents choose what time they got up and went to bed, where they went shopping and who they met. Residents were enabled to take risks within their day to day lives. For example, go for walks, go on holidays and enjoy a social drink.
  • Residents had opportunities to participate in activities that were meaningful and purposeful to them, and which suited their needs, interests and capacities. For example, watching particular television shows, attending a day service or chatting with staff. The inspector noted the level and variety of activities had increased significantly since the previous inspection. Activities appeared to be an integral part of the daily routine, tailored to individual needs and flexible.
  • Residents were provided with a social model of care. They engaged in community activities such as going to the cinemas, to concerts and other events. The activities programme was flexible. On the days of inspection the inspector saw residents going out to a fair in a local town, swimming, enjoying a foot massage, engaged in board games, going for walks, shopping, visiting the onsite church and visiting the onsite canteen.
  • There was a suitable outside areas for residents. Residents were seen to have easy access to these spacious grounds. Care was given to maintaining the grounds and gardens in an attractive state.
  • The care delivered encouraged and enabled residents to make healthy living choices. Residents were actively encouraged to take responsibility for their own health and medical needs.
  • Food was nutritious, appetising and varied and available in sufficient quantities. It was available at times suitable to residents. Residents were supported to prepare their own meals as appropriate to their ability and preference. The inspector saw that meal times were positive social events.
  • There were sufficient staff with the required skills, qualifications and experience to meet the assessed needs of residents at all times. The number of staff employed increased since the previous inspection. Staff reported this increase had positive benefits in that it allowed more time for staff to engage in meaningful activities with residents. The inspector saw that residents received assistance, interventions and care in a respectful, timely and safe manner.
  • Some residents were not best served by virtue of their living arrangements. Not all residents were able to articulate the difficulties they faced in their home such as risk of peer to peer hostilities, inadequate personal space and provision of a more community orientated environment. Financial resources appeared to be the primary reason for the matter not being adequately addressed thus far.
  • Some residents continued to live in houses which did not meet their needs. For example, in one of the mixed gender houses, a resident frequently engaged in undressing when they were not occupied. In another house access to bedrooms was restricted due to the behaviour of one resident.
  • It was identified that some residents were not suitable for communal living and would benefit from living alone or with one other person. While the solution to alleviating the risk, which had been rated high for a protracted period of time, had been identified, implementing the change was resource led and this posed challenges for the management team.
  • Any non-compliances identified where caused by lack of resources:
  • The centre was inadequately resourced. Some residents lived in a house where they had been assessed as being at high risk of intimidation from fellow residents. The management team informed the inspector that constraints on resources were identified as to the reason that alternative living arrangements had not been put in place.
  • There were insufficient resources to support residents achieving their individual personal plans. For example, one resident was assessed as requiring a quiet environment but was accommodated in a house with five others whose behaviours did not lead to a quiet environment.
  • Proposed actions to address the major non-compliances center mainly on Community Living Transition Plans, completed for residents in line with National policies, “Time to move on from Congregated Settings- a strategy for Community Inclusion.”
    • Property identified for purchase - suitable to meet the needs of the residents highlighted
    • Emergency application for additional revenue submitted to the Local H.S.E. who are supportive of proposal
    • Through consultation and partnership with the HSE the registered provider has identified and submitted proposals for requirement of additional revenue to the H.S.E.
• November 2017
  • This was an inspection carried out to monitor compliance with the regulations and standards and to follow up on matters from the previous inspection.
  • Families were active advocates for the residents. Relatives engaged in the life of the centre with the aim of ensuring their family member's voice was heard. Monies raised by families through fundraising events were directed to enhancing the quality of life for those residing in the centre.
  • The inspectors noted that since the August 2016 inspection, a number of improvements had been made in relation to:
    • the decoration and upkeep of the premises
    • the focus on providing a meaningful day for residents and
    • the increased emphasis of maintaining a regular workforce, thus ensuring disruption to attachments were kept to a minimum.
  • There was evidence that, year on year, residents' quality of life had improved. This was primarily due to the increased focus on establishing what a meaningful day meant for each resident. What was particularly noticeable was the increased awareness by staff around facilitating a social model of care. Inspectors also noted the improved lines of communication between frontline staff and the management team and between the management team and family members.
• August 2019
  • This unannounced inspection was carried out to assess compliance with relevant acts and regulations.
  • Compared to the previous report from November 2017, this report is much more critical with most negative findings related to staff and funding shortages.
  • (more details to follow soon)
• November 2019
  • Unannounced inspection on one day with a mix of positive and more critical findings. Positives mostly relate to frontline staff and negatives to fire safety, management issues and staff shortages impacting the rights and quality of life of the residents. Examples below:
  • The inspectors observed meaningful interactions between residents and staff. Staffs focus was more person centred and all premises had current activity boards which reflected the planned activities that residents were engaged in.
  • It was evident that staff had a very good understanding of residents needs and it was apparent from staff that were spoken to that advocacy on behalf of residents needs was to the forefront of what they did. Residents appeared to be happy with the support of staff and this was evident through gestures and sound. The inspectors noted the engagement between staff and residents to be warm and considerate.
  • A number of improvements were noted by the inspectors since the previous inspection. Overall the provider had taken some measures to address staff shortages that included the recruitment of additional staff, as well as a review of all staff within the designated centre for the purposes of best matching staff and skill mix to the assessed needs of the residents.
  • Residents activation and access to the wider community remained subject to and limited by staff availability and numbers. There was evidence in some units of activity cancellations as a result of staff shortages in the campus based day service.
  • Governance and management improvements were observed and readily identifiable through staff meeting records and information sharing as well as local managements involvement, implementing change and improvements in each premises.
  • The systems of governance and management in relation to fire safety required improvement to ensure that the service provided was safe.
  • The inspectors noted that there was some improvement in the quality and safety of services to residents since the last inspection. Some premises had been decorated and remedial works and renovations were nearing a state of completion.
  • The registered provider demonstrated a commitment to addressing deficits and improvement was noted in relation to residents' rights and the application and review of restrictive practices.
  • The premises were observed to be better maintained and one premises that had required decoration and upgrading was near completion.
  • Inspectors also noted that a visitors room that linked two premises had reverted to it primary function as a room for visitors. New and additional furnishings had been secured since the last inspection and the area had been redecorated.
  • There was good evidence of positive behavioural support for residents requiring this support, records were clear and it was evident there was ongoing review and tracking of information.
  • The registered provider had undertaken an extensive review of residents' rights since the last inspection. Each resident had in place a rights awareness checklist and all documentation and referrals to the providers human rights committee had also been reviewed.
  • There was evidence of residents accessing the community and the registered provider had acquired an additional minibus, however recreation and occupational activities remained limited.
  • Activity schedules indicated greater staff involvement in planning and recording activities as well as the reasons for non fulfilment when activities were cancelled due to staff shortages.
  • The response from the provider (i.e. St John of God Community Services) to the above issues are:
    • The Registered Provider is engaged with the Statutory Funding Agency to address the legacy issues relating to staffing levels within the congregated setting and has submitted comprehensive proposals on Funding required to the statutory authority. The Registered Provider has submitted an updated proposal to the Statutory Funding Agency for additional staffing to ensure the numbers of staff are appropriate to the assessed needs of residents and is in ongoing communication to progress same. 
    • A business case has been submitted to the HSE with a request to fund an increase in staffing to aid with the residents preferred community activities. The HSE have advised that they will fund an increase in staffing to develop a community integration programme to support residents on campus (3 posts).

    • The registered provider is implementing an ongoing recruitment strategy to fill existing vacancies within the Designated Centre, which will be in keeping with the revised skill mix allocation.

    • The registered provider is currently working jointly with the HSE in the purchase of an additional house in the community to support residents from this Designated Centre who have identified their wish to move to a community setting. CAS application is currently being progressed with a view to securing the property.

    • The registered provider has consulted with a suitably qualified architect who has commenced the construction of an additional conservatory to two residential areas on site. These works will create an extension to two locations which will increase the living space of the residents. These conservatories will subsequently be decorated with input and consultation from the residents. [Note: The extension works are being funded by the Parents and Relatives Association]

    • Re. Fire Safety works, The registered provider will review the current scope of works based on the HSE inspection report in consultation with the architect, the HSE, the registered providers independent fire consultant in order to agree a schedule of works. 

• November 2020
  • Unannounced inspection on one day to coincide with inspection in DC1. This was a follow up inspection to determine the level of compliance in relation to the registered provider's compliance plan response to the inspection of November 2019. Significant improvements were noted by the inspectors.
  • The registered provider contacted families by email. Four families in total made contact. The majority of families spoke of the high standard of care that staff provided to residents. Families were happy with the supports in place.
  • Some families acknowledged that they consented to the spending of residents monies on the provision of external therapies to their family member. No family was aware of the amount of money spent on external therapies.
  • Families were complimentary of the efforts that staff made to provide a meaningful day and to also maintain family contact through direct visiting, transporting residents home and the use of information technology and mobile phones to aid communication.
  • A substantial amount of actions committed to in the registered provider's previous compliance plan had been achieved. Resources to recruit additional staff and to address outstanding fire and safety works had been received and applied.
  • A staff recruitment process had been undertaken and there were additional staff recruited. Additionally, three new staff were appointed in September 2020 to plan and support activities for residents. These staff were not included in the general provision of care to residents so that their function of supporting activities was protected.
  • The inspectors noted that there had been an overall improvement in the quality and safety of services since the last inspection. The focus of service delivery was more aligned with the needs of and the support of residents. Staff allocations were based on the assessed needs of residents and prior to the COVID-19 pandemic had focused on increasing residents' access to the wider community.
  • Some premises had undergone extensive redecoration and two units had an additional sunroom completed. Residents appeared to enjoy these new spaces which gave them an additional vantage point of the campus. [Note: The extension works were funded by the Parents and Relatives Association]
  • On the previous inspection, significant fire and safety issues had been highlighted to the registered provider. In response, the registered provider had secured funding to address such areas. On the day of inspection, the registered provider had a schedule of completed and proposed fire works.
  • Since the previous inspection the registered provider had undertaken a significant review of its risk register and risk assessment process. The risk register for the designated centre was very comprehensive and allowed drill down to the individual risk assessments for each individual resident which were current and reflected the COVID-19 pandemic.
  • A significant outbreak of COVID-19 had recently occurred on the campus. The registered provider had notified to HIQA a break in infection control procedures on campus. It was evident that the registered provider had taken this breach extremely seriously and this outbreak had little impact on the residents of this designated centre.
  • The activity records of all residents reviewed had reflected a significant improvement in the level of community based activities, prior to the start of the COVID-19 pandemic. The majority of community activities had opened up prior to the inspection, only to be restricted again in line with current national public health guidelines. The registered provider had recruited three additional social and recreational staff whose role was to support community activities for the residents and to work with other staff in the centre to promote community engagement.
  • Main issue of concern was the resident's spending on external therapies and the lack of clarity in this area.
    • Local management had been requested to provide a detailed audit of all residents' monies spent over a defined 12 month period. It was evident from financial records requested from the registered provider, that a significant amount of residents' personal funds were spent on a range of external therapies. These therapies were reflexology, massage, gong and music.
    • It was evident that some residents were spending a significant amount of their disposable income on external therapies. Inspectors were not assured that there were effective management systems in place to ensure that the service was appropriate to residents' needs with the significant amounts of residents' personal funds that were required for external therapies.
    • It was noted that the weekly activity schedule incorporated external therapies as part of the programme of activities. In some cases the number of paid external therapies on the weekly activity sheet exceeded what was provided for in the residents' financial passport. The provider's policy on resident finances did not include reference to external therapies and the cost to residents.
  • Proposed actions in relation to above are:
    • Therapies will be sourced in the community in the first instance as part of residents’ activities once national COVID 19 restrictions allow. A review of each resident’s participation in therapies will take place and identify if this activity can be pursued in the community.
    • Prior to the recommencement of any campus based therapies a Financial Will and Preference document will be completed in consultation with the resident and their circle of support outlining the proposed annual cost of therapies.
    • Financial Will and Preference document will be completed in consultation with the resident and their circle of support outlining the proposed annual cost of therapies identified as part of the residents personal planning meeting.
• November 2021
  • This was the best inspection report received so far.
  • For the first time there are NO non-compliances: All areas are either compliant or substantially compliant.
  • Inspectors noted marked improvements in many areas since the last inspection only a year ago.
  • Improvements in the living conditions, especially kitchen upgrades, were co-funded by the Parents and Relatives Association.
  • Imminent further substantial expenditure by the Parents and Relatives Association is envisaged for new furniture in all houses on the campus – as of 8th February 2022, about 75% of the ordered furniture has been delivered. See Achievement page for photos.
  • Some quotes from the report:
    • "All residents that were met appeared happy and content. Private and communal spaces within houses had been upgraded and were clean, bright and homely."
    • "Staff that inspectors met with were proud to outline recent developments that demonstrated a person centred focus on the support and care given to residents. Some residents had been directly involved in the redecorating and upgrading of their bedrooms and personal living space."
    • "Mealtimes were observed to be relaxed and social. Staff provided direct support to residents who all used plates and crockery specific to their needs. Residents expressed satisfaction with the food eaten."
    • "Food available to residents was presented and offered to residents in line with preferences and dietary requirements. A resident who had requested dinner and subsequently refused it, was supported by staff to make a sandwich that they ate."
    • "The inspectors found that the focus of support to residents was person centred in a homely environment. Residents had purposeful engagement with their families and access to meaningful activities as well as day services. The designated centre was well managed to meet the assessed needs of residents."
    • "Residents appeared and stated that they were happy and families spoke of residents been well supported. Residents appeared relaxed and staff were very open in their engagement with inspectors as well as strongly advocating on residents behalf."
    • "Staff were familiar with the triggers that could cause residents to exhibit behaviours of concern. It was evident that staff interactions were both gentle and respectful. One resident who demonstrated self injurious behaviour was seen to be supported calmly by staff who encouraged them to self soothe, was suitably distracted and provided with familiar items of comfort."
    • "Residents had positive behaviour support plans in place that staff adhered to and were knowledgeable of. Functional assessments and triggers to behaviours were clearly described. Staff adhered to positive approaches to reduce behaviours that challenge and demonstrated the skills necessary to the early identification of issues through familiarity of residents."
• May 2023
  • Unannounced inspection to monitor compliance with the regulations and to follow up on the provider’s progress with actions identified from the previous inspection completed in November 2021
  • Overall a very positive report again
  • "All residents had their own bedroom in this designated centre since February 2022. ... Staff spoke of one resident expressing their preference to live on their own in the apartment which was achieved during 2022."
  • "The inspectors were informed there was a number of residents being supported to attend activities during the day as part of their “meaningful day”. ... Two residents were gone to a local park with plans to visit a café before inspectors called to their home."
  • "Staff were observed to interact with residents in a kind and respectful way. There was a positive atmosphere in the centre, with residents and staff observed going for walks, listening to music, supporting activities such as, painting, table top craft work and going out in the community to do some shopping."
  • "Another resident proudly showed an inspector their tricycle as they went for a cycle around the grounds with a staff member in the afternoon."
  • "Inspectors observed residents in a number of the houses being supported to have their mid-day meals in an un-rushed manner. Staff were observed to sit close to the residents they were supporting and engage with each resident."
  • "The inspectors found that there was a governance and management structure with systems in place which aimed to promote a safe and person-centred service in this designated centre."
  • "The inspectors were informed that there were a number of staff vacancies on the day of the inspection. The provider was actively recruiting to fill these positions. The designated centre was supported with relief staff and agency staff. These staff were seen to be consistently utilised by the centre and were familiar with the needs of the resident they were supporting."
  • "Overall, a dedicated staff team were providing a good standard of care and support to provide a person centred service where the individuality of the resident was respected. The provider had made progress in addressing actions identified in the previous HIQA inspection completed in November 2021. For example, all residents were being supported in single bedrooms, new furnishings were evident in some areas and the successful transition of some residents had taken place."
  • "Overall, the inspectors found most of the residents were being supported to live in a homely environment, with minimal restrictions and adequate resources to ensure a good quality of life."
  • "The provider had ensured residents were supported in –line with their expressed wishes and known preferences to participate in a variety of activities. These included attending day services, swimming pool and gym facilities on the campus. In addition to community activities such as attending art classes, social groups such as the men's shed and social farming. Residents were also supported to attend concerts and social events."
  • Some concerns related to premises, personal storage space and fire safety:
    • "Two residents were living in noisy and busy environments as per the auditors findings in the recent annual review. While the staffing resources were available to support residents to engage in meaningful activities and reduce the noise in the residents home, the environment was not deemed to be suitable for them." - Plans are in place to transition these residents to a new community house in Killarney.
    • A number of staff have completed fire safety training since the inspection and all remaining staff members will be scheduled to attend fire safety training by 30th Sept 2023 (training provided by APEX Fire).
    • Insufficient storage space for some residents: In consultation with the individual and their keyworker additional storage will be provided to a number of residents bedrooms in the form of seated storage units. In another resident’s bedroom there will be storage fitted under the sink. These works have also been included in the maintenance schedule.
    • Relating to premises: Two locations in the DC have been approved for kitchens to be upgraded. The Registered Provider is presently awaiting on the availability of procured contractors to carry out this work. AND: Communal areas and bedroom flooring to be upgraded. These works have also been included in the maintenance schedule.