Preparation for Inspection in International Accommodation Services – Planning the Route via Gap Analysis
Introduction
In 2022, HIQA undertook preparations to establish a regulatory function for the monitoring and inspection of International Protection Accommodation Services. A programme of recruitment was undertaken in HIQA to on-board and integrate an inspection and monitoring team.
To develop the function, a series of pilot inspections were carried out in December 2022. Of the 3 centres inspected by HIQA under the pilot, it is reported that all 3 fell short in meeting the National Standards for accommodation offered to people in the protection process. Some of the issues identified included overcrowded facilities, cramped living spaces with limited and inappropriate storage, undignified conditions, not homely, limited access to laundry, unsafe recruitment practices, including incomplete Garda vetting, limited space for children and adults and children sharing beds.
With regulation of the sector by HIQA swiftly approaching, now is the time to consider what this means for your service, the way you provide care and support to residents and if you have the correct processes in place as required by the National Standards.
In this blog, we discuss why utilising a Gap Analysis approach is beneficial when facing a new regulatory framework to help put you on the right path to regulatory compliance and service improvement.
Why take a Gap Analysis approach?
It is always positively perceived by regulatory bodies to see a proactive approach been taken by services to understand what the regulations mean for your service and the care and support it provides to service users.
When facing new regulations or standards, HCI recommend utilising a Gap Analysis approach. A Gap Analysis is a method of objectively assessing the performance of a service to determine whether the requirements are being met, and if not, what steps should be taken to meet them.
A Gap Analysis acts as a starting point, allowing you to identify where the gaps are so that you can develop an action plan to achieve compliance and service improvement.
It is important to note that this is different from an audit, as an audit is a verification that the processes, which are already in place, conform to the requirements.
6 Stages for Gap Analysis
- Establish the Target
- Understand the Assessment Approach
- Analyse the current processes
- Detail the findings
- Rate the service’s level of compliance
- Develop a comprehensive, step by step action plan
Stage 1: Establishing the Target
The target is achieving full compliance with the National Standards for accommodation offered to people in the protection process. This is a movable target, as further guidelines are likely to come.
It is also important, before you start to prepare a tool, such as an excel spreadsheet, to record your findings and action plans. Some of the key areas to include in the tool are the regulations, the findings, a compliance rating, any action plans, responsibility, timeline and the ongoing status.
Stage 2: Understand the Assessment Approach
When you are undertaking your Gap Analysis, it is important to consider what would the regulatory body expect to see and what is their approach when they go out to analyse services.
Presently, we don’t have any documentation from HIQA for International Protection Accommodation Services, but we do have documentation from other sectors such as residential services for disabilities or aged care. The two documents that are normally released for onsite inspections are the Assessment Judgement Framework and the Guidance for the assessment of centres. The Assessment Judgement Framework details the lines of enquiry and the Guidance for the assessment of centres details examples of evidence to be reviewed. HIQA Inspection reports are another type of documentation worth reviewing to understand the types of non-conformances that are trending in services.
Stage 3: Analyse the Current Processes
Once you have identified your target, developed the Gap Analysis tool and gained an understanding of the assessment approach required, then you can embark on the Gap Analysis process. It is important to utilise a triangulation model which incorporates interviews, observation and documentation reviews.
The first step is to schedule the Gap Analysis. To do this you need to identify who the facilitators are, the regulations covered, the agenda and timeline for the observation and interviews and who are the required attendees.
Objectivity is critical and must be reflective of a regulatory body approach. As such, it is important to review beyond the paperwork. Information may be sourced from observations, one to one discussions (with staff and residents if possible) as well as review of documentation.
When conducting observations and interviews, consider the following:
- Look for evidence of implementation
- Need to observe the processes being implemented.
- Be considerate of privacy, dignity and consent
- Speak to the staff that implement the processes on a day to day basis, not just the Managers
- Discuss with staff whether they know what to do when things go wrong not just when they go right do they know the escalation process?
Examples of documentation for review include:
- Governance records: Strategic and operational plans, Team charts, Teams terms of reference, minutes, agendas, Statement of Purpose, business continuity plan, financial records.
- Service monitoring and measurement documentation: Audit reports, KPI’s, annual review data, incident management records, risk registers, Quality Improvement Projects/Initiatives, external reporting information
- HR records: Staff files, job descriptions, training plans, induction and ongoing training records, staff rotas, agency staff records, performance reviews, supervision records.
- Resident records: Individual support plans, records of service provision, survey reports, complaint management records.
- Supplier contracts and monitoring records
Stage 4: Detail the Findings
Once the onsite audit and the documentation review has been completed, compare the current evidence of compliance with the expected evidence of compliance and identify the gaps.
Stage 5: Rate Compliance
The compliance rating applied during a Gap Analysis should be reflective of the Regulatory Bodies rating model, i.e.
- Not compliant (Red): The service has not complied with a regulation and considerable action is required to come into compliance. Continued non-compliance or where the non-compliance poses a significant risk to the safety, health and welfare of residents will be risk rated red (high risk).
- Not compliant (Orange): The service has not complied with a regulation and considerable action is required to come into compliance. Where the non-compliance does not pose a risk to the safety, health and welfare of residents it is risk rated orange (moderate risk).
- Substantially compliant (Yellow): The service has generally met the requirements of the regulation, but some action is required to be fully compliant. This finding will have a risk rating of yellow which is low risk.
- Compliant (Green): The service is in compliance with the relevant regulation.
Stage 6: Develop the Improvement Plan
At this stage, you must develop a comprehensive, step by step action plan to bring the current status to where we need to be to meet the regulatory requirements. You need to ensure that that individuals are provided with responsibilities not Teams. If it becomes a Teams responsibility, then it decreases the likelihood of the action being undertaken.
It is also important to set a timeline for implementation of the actions and from this review the open actions on a scheduled basis, e.g. as part of the Management Team meeting on a monthly basis. Incorporate this as part of the agenda items for the Management Team to ensure that it is monitored appropriately. Achievement or otherwise of open QIP’s should be documented in the Team Meeting minutes.
How can HCI help?
HCI has been working with health and social care organisations for almost two decades, supporting them make intelligence driven decisions to attain, manage and improve quality, safety and regulatory compliance.
We are currently working with a number of International Protection Accommodation Services to conduct Gap Analysis against the National Standards for accommodation offered to people in the protection process. We use our knowledge and understanding of HIQA’s approach to develop a comprehensive report that will detail areas of good practice and areas of non-compliance against the Draft Regulations. This report can be used to support the development of a compliance plan that will put you in a good position as you move forward within the regulatory framework model.
For more information contact HCI at 01 629 2559 or info@hci.care.