Dementia care self assessment tool - Form



1460538100Health Information and Quality AuthorityResidential Services for Older PeopleProvider Self-Assessment Tool on Dementia CarePublished: June 2015IntroductionThis self-assessment tool aims to help providers prepare for inspection, to measure their performance against regulations and standards, and to identify ways they can improve their service. The questionnaire includes a series of detailed questions assessing how the provider meets residents’ needs for health and social care, environmental suitability and suitable staffing, with particular reference to the needs of residents with dementia.About the self-assessment tool on Dementia CareThe self assessment tool contains six sections. It should be filled in with reference to HIQA’s Judgment Framework for Dementia Care at Designated Centres for Older People available on our website, hiqa.ie. The Judgment Framework is used to support the provider and person in charge in reaching decisions on whether the service is compliant with the regulations and or standards. Each section assesses how compliant the centre is with each ‘outcome’ listed in the Authority’s judgment framework, with particular attention given to the specific needs of residents with dementia. Section 1 requires Information about the CentreSection 2 assesses Health and Social Care NeedsSection 3 assesses Safeguarding and SafetySection 4 assesses Residents’ Rights, Dignity and ConsultationSection 5 assesses Complaints ManagementSection 6 assesses Suitable StaffingSection 7 assesses Safety and Suitability of the Premises Please note that section 2-7 contains two parts; one about the physical environment in the general nursing home and another about the physical environment of the Dementia Specific Unit (DSU).If the centre does not have a Dementia Specific Unit you should only complete the first part.There is an action plan within each section. This should identify how the provider and person in charge intends to rectify any problems where full compliance was not achieved. The action plan should specify the following:Improvement to be achieved.Actions that need to be takenResources (if any) that are needed.How the improvement is to be measuredTimescales by which improvements will be achieved.How to return the self-assessment The provider should return the completed self-assessment tool to dcop@hiqa.ie. The policies and procedures listed below should be returned along with the completed questionnaire:AdmissionsManagement of behaviour that is challengingThe use of restraintCommunicationsInspectors will review the policies and this self-assessment and action plan in advance of the inspection. Section1: About the centre1. Centre name: FORMTEXT ?????2. Centre ID: FORMTEXT ?????3. Registered provider: FORMTEXT ?????4. Number of Residents: FORMTEXT ?????5. Person in charge: FORMTEXT ?????6. Number of residents formally diagnosed with dementia FORMTEXT ?????6A. Number of residents aged 65 years and over formally diagnosed with dementia FORMTEXT ?????6B. Number of residents aged under 65 years formally diagnosed with dementia FORMTEXT ?????7. Number of residents suspected of having dementia by nursing staff FORMTEXT ?????7A. Number of residents aged 65 years and over suspected of having dementia by nursing staff FORMTEXT ?????7B. Number of residents aged under 65 years suspected of having dementia by nursing staff FORMTEXT ?????8. Do you have a dementia specific unit (DSU) for people with dementia? FORMCHECKBOX Yes FORMCHECKBOX No8A. If “Yes”, please state the number of residents the DSU can accommodate? FORMTEXT ?????RESIDENTSSection 2: Overall self-assessment of compliance under Health and Social Care NeedsThe outcome against which you should access your service is as follows: The wellbeing and welfare of each resident with dementia is maintained by a high standard of evidence-based nursing care and appropriate medical and allied health and social care.The arrangements to meet each resident’s assessed needs are set out in an individual care plan, that reflect his/her needs, interests and capacities, are drawn up with the involvement of the resident, their relative as appropriate and reflect his/her changing needs and circumstances.References for Health and Social Care NeedsRegulation 5: Individual Assessment and Care planStandard 3: ConsentRegulation 6: Health CareStandard 8 ProtectionRegulation 7: Managing Behaviour that is ChallengingStandard 10: AssessmentRegulation 13: End of Life CareStandard 11: The Resident’s Care PlanRegulation 29: Medicines and Pharmaceutical ServicesStandard 12: Health Promotion Standard 13: Healthcare Standard 14: Medication Management Standard 15: Medication Monitoring and ReviewStandard 17: Autonomy and IndependenceStandard 16: End of Life Care Standard 21: Responding to Behaviour that is ChallengingPlease tick the box that best represents the level of compliance of your service. (See judgment framework for Dementia Care)Compliance demonstrated FORMCHECKBOX Substantial compliance FORMCHECKBOX Moderate non-compliance FORMCHECKBOX Major non-compliance FORMCHECKBOX Please tick the box that represents the level of compliance of the Dementia Specific Unit (DSU) if applicable DSU Compliance demonstrated FORMCHECKBOX DSU Substantial compliance FORMCHECKBOX DSU Moderate non-compliance FORMCHECKBOX DSU Major non-compliance FORMCHECKBOX Please outline specific measurable realistic, time-bound actions to ensure compliance with the Regulations and Standards listed above, in relation to Health and Social Care NeedsAction Plan: FORMTEXT ?????Section 3: Overall self-assessment of compliance under Safeguarding and SafetyThe outcome against which you should access your service is as follows:Measures to protect residents being harmed or suffering abuse are in place and appropriate action is taken in response to allegations, disclosures or suspected abuse. Residents are provided with support that promotes a positive approach to behaviour that challenges. A restraint-free environment is promoted.References for Safeguarding and SafetyRegulation 7: Managing Behaviour that is ChallengingStandard 8: ProtectionStandard 9: The Resident’s FinancesRegulation 8: ProtectionStandard 21: Responding to Behaviour that is ChallengingPlease tick the box that best represents the level of compliance of your service. (See judgment framework for Dementia Care)Compliance demonstrated FORMCHECKBOX Substantial compliance FORMCHECKBOX Moderate non-compliance FORMCHECKBOX Major non-compliance FORMCHECKBOX Please also tick the box that represents the level of compliance of the Dementia Specific Unit (DSU) if applicable DSU Compliance demonstrated FORMCHECKBOX DSU Substantial compliance FORMCHECKBOX DSU Moderate non-compliance FORMCHECKBOX DSU Major non-compliance FORMCHECKBOX Please outline specific measurable realistic, time-bound actions to ensure compliance with the Regulations and Standards listed above, in relation to Safeguarding and Safety as outlined above. Action Plan: FORMTEXT ?????Section 4: Overall self-assessment of compliance under Residents’ Rights, Dignity and ConsultationThe outcome against which you should access your service is as follows:Residents are consulted with and participate in the organisation of the centre. Each resident’s privacy and dignity is respected, including receiving visitors in private. He/she is facilitated to communicate and enabled to exercise choice and control over his/her life and to maximise his/her independence. Each resident with dementia has opportunities to participate in meaningful activities, appropriate to his or her interests and preferences.Regulation 9: Residents’ RightsStandard 2: Consultation and ParticipationRegulation 10: Communication DifficultiesStandard 4: Privacy and DignityRegulation 11: VisitsStandard 5: Civil, Political and Religious RightsRegulation 20: Information for ResidentsStandard 6: ComplaintsRegulation 34: ComplaintsStandard 17: Autonomy and IndependenceRegulations 17: PremisesStandard 18: Routines and ExpectationsStandard 20: Social Contacts Standard 25: Physical EnvironmentPlease tick the box that best represents the level of compliance of your service. Compliance demonstrated FORMCHECKBOX Substantial compliance FORMCHECKBOX Moderate non-compliance FORMCHECKBOX Major non-compliance FORMCHECKBOX Please also tick the box that represents the level of compliance of the Dementia Specific Unit (DSU) if applicable DSU Compliance demonstrated FORMCHECKBOX DSU Substantial compliance FORMCHECKBOX DSU Moderate non-compliance FORMCHECKBOX DSU Major non-compliance FORMCHECKBOX Please outline what specific, measurable, realistic time-bound actions you intend to take to ensure compliance with regulations and standards relating to Residents’ Rights, Dignity and Consultation as outlined above.Action Plan: FORMTEXT ?????Section 5: Complaints Procedure and ManagementThe outcome against which you should access your service is as follows:The complaints of each resident with dementia, those of his or her family, advocate or representative, or those of visitors, are listened to and acted upon, and there is an effective appeals procedure.Regulation 34: Complaints ProcedureStandard 6: ComplaintsPlease tick the box that best represents the level of compliance of your service. (See judgment framework for Dementia Care)Compliance demonstrated FORMCHECKBOX Substantial compliance FORMCHECKBOX Moderate non-compliance FORMCHECKBOX Major non-compliance FORMCHECKBOX Please also tick the box that represents the level of compliance of the Dementia Specific Unit (DSU) if applicableDSU Compliance demonstrated FORMCHECKBOX DSU Substantial compliance FORMCHECKBOX DSU Moderate non-compliance FORMCHECKBOX DSU Major non-compliance FORMCHECKBOX Please outline specific measurable realistic, time-bound actions to ensure compliance with the Regulations and Standards listed below in relation to Complaints Procedure and Management Action Plan: FORMTEXT ?????Section 6: Overall self-assessment of compliance under Suitable StaffingThe outcome against which you should access your service is as follows:There are appropriate staff numbers and skill mix to meet the assessed needs of residents, in a person-centred way. Staff have up-to-date training and access to supervision, education and training to meet the needs of residents with dementia.Regulation 15: StaffingStandard 22: RecruitmentRegulation 16: Training and Staff DevelopmentStandard 23: Staffing levels and QualificationsRegulation 30: VolunteersStandard 24: Training and SupervisionPlease tick the box that best represents the level of compliance of your service. (See judgment framework for Dementia Care)Compliance demonstrated FORMCHECKBOX Substantial compliance FORMCHECKBOX Moderate non-compliance FORMCHECKBOX Major non-compliance FORMCHECKBOX Please also tick the box that represents the level of compliance of the Dementia Specific Unit (DSU) if applicableDSU Compliance demonstrated FORMCHECKBOX DSU Substantial compliance FORMCHECKBOX DSU Moderate non-compliance FORMCHECKBOX DSU Major non-compliance FORMCHECKBOX Please outline specific measurable realistic, time-bound actions to ensure compliance with the Regulations and Standards listed below in relation to Suitable Staffing.Action Plan: FORMTEXT ?????Section 7: Overall self-assessment of compliance under Safe and Suitable PremisesThe outcome against which you should access your service is as follows:The location, design and layout of the centre are suitable for its stated purpose and meets residents’ individual and collective needs in a comfortable and homely way. The premises, having regard to the needs of residents with dementia, conform to the matters set out in Schedule 6 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013.References:Regulation 17: Premises Standard 25: Physical EnvironmentPlease tick the box that best represents the level of compliance of your service. (See judgment framework for Dementia Care)Compliance demonstrated FORMCHECKBOX Substantial compliance FORMCHECKBOX Moderate non-compliance FORMCHECKBOX Major non-compliance FORMCHECKBOX Please also tick the box that represents the level of compliance of the Dementia Specific Unit (DSU) if applicableDSU- Compliance demonstrated FORMCHECKBOX DSU -Substantial compliance FORMCHECKBOX DSU - Moderate non-compliance FORMCHECKBOX DSU - Major non-compliance FORMCHECKBOX Please outline specific measurable realistic, time-bound actions to ensure compliance with the Regulations and Standards listed below in relation to a Safe and Suitable Premises Action Plan: FORMTEXT ?????Please email the completed self-assessment to rst@hiqa.ie.Please ensure that the policies and procedures listed below are returned along with the completed questionnaire:Admissions Management of behaviour that is challengingThe use of restraintCommunicationsInspectors will review the information returned through this questionnaire and the accompanying policies and procedures in advance of the inspection visit.If you have any queries, please contact us by email: dcop@hiqa.ie or by phone on:01 8147400 or 021 2409300Thank you for completing the self-assessment. ................
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