Gap Analysis for Sunbeam House Services against S.I. No. 367 of 2013 (Health Act 2007)

“Working with HCI on a Gap Analysis of our Quality and Safety Management System was an extremely valuable and informative experience for Sunbeam House Services. Their expert approach helped us clearly understand our existing strengths and where further development was required. HCI’s specialists were highly professional, demonstrating an in-depth understanding of regulatory requirements. The report has equipped us with a clear, practical roadmap for continuous quality improvement and further strengthens our commitment to delivering safe, high-quality supports for people with intellectual disabilities.”

Fran Murphy

CEO, Sunbeam House Services

Background

Sunbeam House Services is a dedicated provider offering a range of supports to adults with intellectual disabilities. The organisation aims to empower people with the necessary skills to live full and satisfying lives as equal citizens of their local communities.

In keeping with their focus to provide the highest level of services, Sunbeam House Services proactively decided to evaluate its current Quality and Safety Management System (QSMS) against the Health Act 2007 (Care and Support of Residents in Designated Centres for Persons (Children and Adults) With Disabilities) Regulations 2013 (S.I. 367 of 2013). Consequently, they commissioned HCI to conduct an independent Gap Analysis of their service in line with these regulations, and in conjunction with the relevant National Standards, to identify areas of strength and opportunities for improvement.

Objectives

Identify the strengths and weaknesses of Sunbeam House Services’ current Quality and Safety Management System against the S.I. No. 367 of 2013 (Health Act 2007) and applicable National Standards.
Provide a comprehensive report identifying areas of good practice and opportunities for improvement.
Utilise an audit model reflective of HIQA’s approach to monitoring and inspection, ensuring the findings are reflective of regulatory expectations and sector best practice.

Solution

In order to ensure Sunbeam House Services received a thorough assessment of their QSMS, HCI provided the following solution:

Development of project plan and project governance.

Offsite document review.

Two-day onsite review including a document review, staff interviews and process observation.

Analysis of findings.

Development of Draft Report.

Client review of Draft Report and feedback provided to HCI.

Gap Analysis Report is finalised and presented to client.

Regulations and National Standards Considered

S.I. No. 367 of 2013 (Health Act 2007).
National Standards for Residential Services for Children and Adults (HIQA, 2013).
National Standards for Infection Prevention and Control in Community Services (HIQA, 2018).
National Standards for Adult Safeguarding (HIQA & MHC, 2019).

Outcome

The Gap Analysis conducted by HCI provided Sunbeam House Services with a clear baseline assessment of their current Quality and Safety Management System against the S.I. No. 367 of 2013 (Health Act 2007) and relevant National Standards.

The analysis provided clear insights into existing areas of good practice, while also identifying focused opportunities for improvement. The final report serves as a roadmap to guide continuous improvement, reinforcing Sunbeam House Service’s commitment to delivering safe, high-quality supports to adults with intellectual disabilities.

Benefits

A comprehensive and independent review of processes.
Clear identification of strengths and improvement areas within the QSMS.
Alignment with S.I. No. 367 of 2013 (Health Act 2007) and relevant National Standards.
Actionable findings that serve as a strategic roadmap for continuous quality improvement.
Reinforced oversight and accountability structures across care teams.
Increased staff awareness and understanding of key regulatory requirements.
Strengthened internal culture of quality, safety, and compliance.
Demonstrate to stakeholders, staff and service users your commitment to quality and safety.
HCI’s extensive quality, safety and regulatory compliance knowledge is transferred to staff during the project.
Strengthened preparedness for future HIQA inspections and regulatory audits.