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:

    • 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 24 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.

Reports for Centre DC2:

    • 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.