The Health Information and Quality Authority (HIQA) is the statutory authority with responsibility for setting standards for health and social care services and for ensuring that such standards are met. HIQA is responsible for the registration and inspection of residential services for people with disabilities under the Health Act (2007). The Authority published National Quality Standards: Residential Services for People with Disabilities in 2009. There are regulations being developed at present to give statutory strength to the standards and which organisations will be measured against as part of the registration and inspection process. These regulations will also provide further detail to organisations on what is expected of them.
Preparing staff for registration and inspection
The registration and regulation system will not involve only senior managers; staff at all levels and carrying out all types of roles will be part of the process. It is vital that adequate time and resources are deployed in advance to ensure that all staff are prepared for inspections.
Table 1 provides some direct quotes from inspection reports from older persons’ services, in relation to issues relevant to staff. These are useful as they indicate good practice and poor practice identified by inspectors in various reports of inspections.
As can be seen from the table, inspectors utilise three different approaches to gathering evidence and forming judgments during inspections. This approach to inspection is set out in the HIQA National Quality Standards: Residential Services for People with Disabilities, as illustrated by the following:
‘An inspection typically consists of three elements: analysis of records and documentation; interviews with individuals, families, professionals involved with the service and those who provide and work in the service; and observation of practice.’
Based on the above and based on our experience of working with services who have undergone inspections, inspectors appear to spend considerable time during inspections:
- Observing staff practice and the type and quality of service that they provide. This includes observing the interactions of staff with residents and with other staff; the manner in which staff engage with residents; the quality of staff practice in core areas such as medication management, reporting and recording and care practice; the quality of staff supervision; and the maintenance of dignity and respect.
- Auditing documentation and records including, but not restricted to, resident’s files, personal profiles, individual plans, communication records, food menus, medication administration records, staff meetings, records of staff supervision, records of complaints and the complaints log, and residents’ financial records.
- Interviewing staff with regard to their knowledge of residents, their knowledge of core policies and procedures, their understanding of the standards and the regulations, their knowledge of residents’ assessed needs and individual care and Person-centred plans, and their understanding of key safety issues in the service.
Table 1: Examples from HIQA inspection reports, as relevant to staff
Examples of good practice, as taken from HIQA reports:
— “Inspectors saw staff interacting positively with residents. The manner in which staff addressed residents was respectful, they stopped to talk and give residents their time, maintaining eye contact and chatting to them”
— “All staff interviewed displayed good knowledge of the centre’s policy and procedures..communication links throughout the centre were good”
— “Staff training records viewed showed training in areas identified as being mandatory requirements or meeting residents’specific needs was delivered to staff”
— “The meal was unrushed and was a social occasion for all”
— “Staff demonstrated a clear understanding of their roles and responsibilities”
Examples of poor practice, as taken from HIQA reports:
— “Policies and procedures were inadequate….there was no evidence that they had been implemented. Staff spoken to were unaware of their contents.”
— “Inspectors observed staff address female residents using terminology such as good girl. This form of address did not preserve the dignity of the residents”
— “Food was poorly presented, all ingredients were blended together”
— “The nursing documentation and language used therein did not provide evidence of Person-centred or dignified care for such residents”
— “The activities nurse and occupational therapist develop goals for the residents but these are not available to other staff and are not incorporated into residents’ daily routine”
How best to prepare staff for the inspection and registration process
In our experience, it is insufficient just to provide staff with copies of the standards and expect them to fully understand and implement the standards based on reading them. Organisations need to focus their quality processes heavily on educating staff on the standards and regulations and building a culture of quality improvement within staff teams.
In order to prepare staff for the level of scrutiny that clearly occurs in HIQA inspections, it is vital that managers provide support and guidance to their staff. Staff need to be clear on how the system for regulation and registration works and what their exact roles are. It is important that all staff know how evidence is collected and how they may be involved in the inspection and information gathering process. Inspectors will gather information from a number of different sources and staff need to be aware of their responsibilities in each area. Staff must also be aware of the different types of inspections (announced and unannounced, registration and non-registration.related) and the requirements on them for the different types of inspections. Some questions that managers and providers should ask themselves in relation to inspections are:
Table 2: Key questions for managers and providers in preparing staff
— Are staff aware of the standards they should work to and on the regulations (to be published by HIQA)?
— Are staff comfortable with being observed?
— Are staff aware of the documentation they must complete in general and the standards required with regard to documentation?
— Are staff aware of the contents of the key documents?
— Are staff aware of the areas they may be questioned about?
— Are staff used to being interviewed about their work and the standard they provide?
In addition to the above, we believe that managers and providers need to focus on five key areas at the start:
Key Area 1: Protection
- Can staff demonstrate an understanding of the systems in place to maintain safety?
- Is there evidence that staff have read and understood the relevant documentation?
- Can staff identify the signs and symptoms of abuse?
- Can staff describe the nature of abuse in settings for people with disability?
- Are staff aware of the particular vulnerability of people with disabilities to being abused?
- Do staff know who to report concerns to?
- Is there clear evidence of staff training in relation to protection work and is there a plan in place to address any essential unmet training needs?
- Are staff clear on how to complete the relevant documentation and are they aware of inappropriate and appropriate terminology?
- Are staff trained in understanding and responding positively to problematic behaviour?
- Can staff demonstrate that they understand behaviour which may indicate that a service user has a concern or complaint which cannot be communicated in other ways?
Key Area 2: Fire
- Can staff demonstrate an understanding of the core elements of the policies and procedures relating to fire safety, including the location of fire exits, fire alarm, fire equipment and assembly points and the procedure to follow in the event of a fire?
- Is there clear evidence of staff training in relation to fire safety and is there a plan in place to address any unmet training needs?
- Can staff answer questions relating to their role with regard to fire safety?
- Is there evidence that all staff have been involved in fire drills?
Key Area 3: Medication
- Can staff demonstrate an understanding of their role in relation to medication management?
- Is there evidence that staff have been given the relevant medication management training?
- Is there evidence that staff have read and understood any relevant policy documents?
- Are staff aware of any individualised requirements such as the administration of PRN medication?
- Can staff demonstrate competence in medication management?
- Have audits been conducted with regard to medication management and have corrective actions been implemented?
- Is there evidence in the records of staff competence in recording medication management issues?
Key Area 4: Health and Safety
- Are staff aware of and clear on any procedures that are in place for the management of major risks such as missing persons?
- Are staff aware of their responsibilities in relation to: personal safety, fire safety, lifting, moving and food hygiene?
- Can staff demonstrate an understanding of any risk assessments that are relevant to their work?
- Is there clear evidence of staff training in relation to key health and safety issues relevant to their work and is there a plan in place to address any essential unmet training needs?
- Can staff demonstrate competence in safe working practices?
- Do staff know how to and where to report and record any safety concerns?
Key area 5: Care Practice
- Are staff competent and confident to carry out care practices?
- Is there evidence of staff receiving training in key areas of care needs of the residents they are supporting?
- Can staff demonstrate an understanding of their role in relation to the delivery of intimate and personal care?
- Is privacy provided when assistance is being given in relation to individual care (such as bathing, washing or going to the toilet)?
- Are service users treated with respect by staff when individual care is being provided?
- Are mealtimes a time to relax and socialise?
- Are staff clear where they can access additional support and advice?
- Can staff demonstrate an understanding of the individualised care needs of those service users they are supporting and does this understanding match what is recorded in the person’s file/plan?
Clearly, the preparation of staff for inspection and registration of services is fundamental. There are valuable lessons to be learned from the inspections of services for older persons and, in particular, on how inspectors appear to have conducted inspections. We hope that the views we have expressed from our experience in working with older persons’ services and from our analysis of the reports of inspections in this area are useful in supporting services for people with disabilities. While our focus here has been on key areas of safety and wellbeing, the principles and processes set out can equally be applied to the other standards and regulation that will be inspected. Every opportunity should be taken to build staff competence and confidence; staff supervision and appraisal, team meetings and self-assessment and audit processes are ideal for doing this.