Practical Preparation for Homecare Regulation

Introduction

Homecare is an essential service which allows people to receive care within their home. As the demand for homecare increases year on year, it is accepted that the preferred place of care for many people is in their own home. Consequently, as the demand for homecare grows, HIQA (2021) acknowledge

“it would be remiss not to reinforce the critical need to expedite the introduction of homecare regulation……. investment in regulatory reform is needed to ensure that the services provided have the capacity and capability to deliver health and social services that meet the needs of the population in a manner that is safe and protects the rights of the citizens of Ireland”.

Given that HIQA are keen to progress the regulation and monitoring of homecare services in Ireland, we prepared this blog as an opportunity to reflect on HIQA’s monitoring of other health and social care settings, in particular the residential care settings for older people. HIQA have been monitoring nursing homes since 2007 and as such there is a vast amount of learnings that can be taken from HIQA’s monitoring of residential care settings for older people which can be used to guide us in our approach to preparing for homecare regulation.

Objectives of Homecare Regulation

1. to improve performance and quality of homecare
2. to provide assurance to people in receipt of homecare and to the public that minimally acceptable standards are achieved
3. to provide accountability both for levels of performance and value for money.

What can we expect regulation to look like?

The Department of Health intends to outline the minimum requirements that providers must meet to hold a licence to operate. HIQA is currently developing draft national standards for home support services to complement the regulations being developed by the government. Once these standards come into effect, HIQA will monitor and manage compliance with the regulatory requirements and standards.

Learnings from Residential Care Sector

HCI review the inspection findings of residential care centres for older people on a quarterly basis and publish these findings as a report. From our reviews we can identify the seven common areas of non-compliance in the residential care sector.

1. Governance and Management
2. Assessment and Care Planning
3. Policies and Procedures
4. Incident Management
5. Risk Management
6. Training and Staff Development
7. Records

Summary of HIQA Findings in Residential Care Settings for Older People

Governance and Management HIQA Findings

• The system of governance and management in place for the service at the time of the inspection did not provide adequate oversight to ensure the effective delivery of a safe, appropriate, and consistent service. The Inspectors found that:
  • Governance meetings were not being completed on a scheduled basis or following a formal structure
  • There was no clearly defined management structure with adequate supports in place to support the day-to-day management of the service.
• There were no formal designates in place for key senior roles within the service to support contingency arrangements.
• There was no monitoring mechanisms in place to provide continual review of the quality and safety of the service provided.
• The service had insufficient resources to provide a safe service for service users and staff, including staffing shortages resulted in inadequate supervision of staff to ensure a safe and effective service.

Assessment and Care Planning

• Some service users did not have comprehensive assessments
• Some service users did not have a care plan initiated within the required timeframes from admission.
• Individual re-assessments were not always completed within the timeframes as required by the regulations.
• Some care plans were generic and did not contain person centred
• Assessments and care plans were not updated in line with the changing needs of the service users and did not guide staff actions and interventions in a way that ensured a good quality of life.
• Improvements were required to ensure that care plans were in place for all identified issues.
• Care plans were in place for service users; however, aspects of care practice did not reflect evidenced based practice.
• There was not always evidence that the service users/representatives were involved in the care planning.

Policies and Procedures

• Policies and Procedures were not approved by a Senior Manager or signed off as read by staff.
• Policies and Procedures were not reviewed and updated in the last three years in line with Regulations.
• The service relied on National Policies and these were required to be adapted locally to provide clear guidance to all staff of the requirements in the service
• The service was not following their own Policies and Procedures on safeguarding, incident reporting and care planning.
• Some newly employed staff did not receive training or refresher training on the Policies and Procedures of the service.
• Policies and Procedures were not consistently implemented in practice.

Incident Management

• The service was not following their own policy on incident reporting.
• The Registered Provider had no system in place for the review of incidents involving service users, meaning that causes and effects were not analysed and acted upon to improve the safety of service users.
• Incidents were not regularly reviewed at the monthly management team meetings.
• Incident records were not audited to identify learning and measures to prevent recurrence. Team meetings to disseminate learning from analysis of incidents had not been held in the last 12 months.
• Staff were not adequately trained to record incidents
• Incidents were recorded but they did not inform assessments or care plans to enable learning and minimise the risk of recurrence.
• Incidents were not followed up to ensure the safety of the service user affected, or other service users or staff.
• The inspector found that all incidents of concern that were required to be notified to the Chief Inspector were not completed as required by the regulations.

Risk Management

• The service had not identified key risks within the service and the senior management team lacked expertise in key areas where high levels of risk were found on inspection.
• The service’s risk management policy requires review and updating:
  • to include all risks in the service and to outline control measures to be put in place.
  • to detail how to assess the level of risks (severity X impact) and the required responses depending on the risk level identified.
• The service’s risk register:
  • did not adequately identify control measures that were in place for the risks identified and the impact of control measures on the risk rating.
  • was not reviewed and updated regularly in line with incidents/ near misses that occurred within the service.

Training & Staff Development

• The Person in Charge had insufficient oversight of mandatory training and the supervision of staff.
• Staff appraisals had not been completed on an annual basis to ensure that staff were appropriately supervised and developed in their roles.
• Training records reviewed by the Inspector did not provide evidence that all staff had received or were up to date with mandatory training.

Record Findings

• Inspectors identified the following issues with staff records:
  • Some staff records did not contain documentary evidence of qualifications
  • Some staff records did not contain a full employment history
  • Some staff records did not contain two written references
  • Some staff records did not contain An Garda Siochana vetting disclosures
• Service user records were not maintained in accordance to Data Protection requirements
• The roster was not correct on the day of inspection as evidenced by the following:
  • There was no current Person in Charge entered in the roster.
  • Staff were included in the roster who no longer worked in the service.
• There were inconsistencies / missing details in a number of the service user records reviewed by the Inspector.

How can HCI help?

With the new regulation of homecare comes challenges and opportunities for your organisation. HCI recognise that resources and knowledge of such a regulatory environment may be limited and so we are here to help reduce the burden of compliance. HCI has been working with health and social care organisations over 17 years, supporting them in building Quality and Safety Management Systems that fulfil regulatory requirements and drive improvement in their services.

HCI offer a number of services that will support you in preparing for regulation:

• Gap Analysis against the National Standards for Safer Better Healthcare
• Education and Training
• Risk Management
• Governance System Reviews
• Quality Improvement Planning
• Quality and Safety of Care Audits
• Incident Management
• Complaint Management

Gap Analysis against the National Standards for Safer Better Healthcare

If you are interested in getting a baseline assessment of where you stand in terms of implementing the National Standards for Safer Better Healthcare, then HCI can conduct a Gap Analysis of your service against the standards. We will provide you with a comprehensive report detailing the areas of good practice and areas for improvement, develop Quality Improvement Plans (QIPs) to address areas of concern and support you to implement the QIPs.

References

HIQA, 2021. The Need for Regulatory Reform https://www.hiqa.ie/reports-and-publications/key-reports-investigations/need-regulatory-reform