Gap Analysis for St. Augustine’s Care Unit

“We requested HCI to conduct a Gap Analysis at St Augustine’s Ballyboden Care Unit. We required a comprehensive assessment of our Quality and Safety Management System against evidence based best practice. HCI conducted an in-depth audit and provided us with a detailed report of their findings. We are utilising this report as a guide to implement a best practice, Quality and Safety Management System.”

Fr Stephen Shields

Provincial Bursar, Augustinians Ireland

Background

The Augustinians are a Catholic Religious Order made up of Priests and Brothers who live and work in different locations around the country. St. Augustine’s Provincial Office in Ballyboden, includes a Care Unit that offers convalescence, and short or long-term care to 15 residents.

In line with their commitment to safeguarding, and compliance with current evidence-based best practice, St Augustine’s Ballyboden commissioned HCI to conduct a Gap Analysis of the current Quality and Safety Management System (QSMS) at St. Augustine’s Ballyboden Care Unit against S.I. No. 415 of 2013 Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013.

Objectives

To identify the strengths and weaknesses of St Augustine’s Ballyboden Care Unit current Quality and Safety Management System in line with S.I. No. 415 of 2013, Health Act 2007.
Identify areas of good practice and a line listing of areas for improvement in relation to the regulations.
Provide a report outlining the findings from the audit.

Solution

In order to ensure a comprehensive evaluation was completed, HCI provided the following service:

Work Plan Development.

Offsite documentation review.

Two-day Onsite Review, including staff interviews, document review and process observation.

Analysis of Findings.

Development of Draft Gap Analysis Report.

Client Reviews Draft Report

Final Report is circulated to the client.

Challenges

St Augustine’s Ballyboden Care Unit is currently not registered with HIQA.
Assessing the regulations considering the care unit premises is part of a community facility.

Outcome

HCI presented St. Augustine’s with a detailed report on the findings of the Gap Analysis which identified areas of good practice and areas for improvement against the S.I. No. 415.

St. Augustine’s Ballyboden Care Unit will use this report to implement the necessary Quality Improvement Plans (QIPs) to address any gaps identified in the audit and ensure there is a best practice Quality and Safety Management System in place to support resident safety and quality improvement within the care unit.

Benefits

A comprehensive and independent review of systems and processes.
Establishes the current baseline of the QSMS.
A detailed report on the findings of the audit including areas of good practice and opportunities for improvement.
The Report provides a roadmap for improvement and allows the necessary QIPs to be identified and implemented.
Risk areas are identified.
HCI has extensive knowledge of the regulations and standards in relation to residential care settings for older people. This knowledge is transferred to staff during the audit.
Improve resident safety and quality of care.
Reassurance to Management Team that the correct processes are in place.
Demonstrate to stakeholders a commitment to Quality and Safety.