northern ireland association for mental health · web viewalongside the above paul has continued to...

January 2014

Northern Ireland Association for Mental Health

(Niamh)

Name: Hope

Beacon Day Support Centre

Address: 25 Glasvey Drive

Twinbrook

Belfast

BT17 0DB

Statement of Purpose

Telephone: 028 – 90 61 11 97

E-mail: [email protected]

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ContentsIntroduction1.0 Registered Provider1.1 Registered Manager2.0 Number and relevant Qualifications & Experience of Staff3.0 Philosophy of Care

Aims of the FacilityAims and Objectives

4.0 Status and constitution 5.0 Organisational Structure of the Facility6.0 Number of Members to be provided with Services7.0 The range of needs (categories of care) that the

Beacon Day Support is intended to meet and the number in each category

8.0 Admission Criteria 9.0 The arrangements for Members to Engage in Social

Activities, Hobbies and leisure Pursuits10.0 The arrangements made for consultation with

Members or their representatives about the operation of the day care setting

11.0 The fire precautions and associated Emergency Procedures

12.0 The arrangements made for contact between Members and their representatives

13.0 Complaints Procedure

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14.0 Review Procedure15.0 Number and size of Rooms in the Beacon Day Support

Setting16.0 Details of any specific therapeutic techniques used in

the day care setting and arrangements made for their supervision

17.0 The arrangements made for respecting the privacy and dignity of Members

IntroductionAbout NiamhNiamh, the Northern Ireland Association for Mental Health, is the longest established mental health organisation in Northern Ireland. Niamh is a group consisting of three elements, Compass, Beacon and Carecall.

Niamh was established by Lady Margaret Wakehurst in 1959. Through her experience with her son’s mental illness, Lady Wakehurst had direct exposure to the lack of support for people outside formal psychiatric institutions. In response to this Niamh set up the first Beacon House Club on University Street in 1959, the chosen symbol was a beacon - ‘shedding its light on the darkness of the mind’.

Niamh Mission: We want to build a flourishing society in which all people have access to services and support appropriate to their mental health and wellbeing needs. To achieve this we will promote, support and explore flourishing mental wellbeing throughout society. We will be an exceptional organisation marked by excellence, efficiency and innovation.

About BeaconBeacon provide a range of person-centred services across Northern Ireland to approximately 1,500 people per week based on the Beacon Social Care Model for flourishing

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mental health. These Services include Day Support, Supported Housing, Home Support, Advocacy and Support Services.

Beacon Social Care is an essential public service that provides day-to-day care and support where needed, to enable people to live full and active lives. We believe that high levels of emotional, psychological and social wellbeing are essential components of flourishing mental health.

Beacons Mission is: To work in partnership with individuals and systems to cultivate their capacity for creativity, care, compassion, realism and resilience. To promote and support the recovery of hope and ambition for flourishing mental health.

The core values by which we work are:

Quality Providing a Mental Health and Social Care service that

is based on personalization and recovery. Providing comprehensive, innovative and evidence-

based social care and quality professional service delivery.

Integrity Acknowledging the uniqueness of the individual. Promoting and sustaining independence, wellbeing and

social inclusion. Supporting people to exercise choice and control over

their lives, including focusing on safety and risk-taking, not merely minimising risk.

Understanding and valuing diversity and difference.

Partnership Promoting honesty in all relationships internal and

external.

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Promoting partnership with service users, carers, volunteers, staff, health professionals and other external agencies in the planning, development, evaluation and monitoring of services.

Hope is one of 15 Day Support Services which operate throughout Northern Ireland.

The NIAMH originally opened Hope (Then known as Twinbrook drop-in or Beacon Centre) on December 10th 1990 in collaboration with the Down and Lisburn Unit, EHSSB, Making Belfast Work and the NI Housing Executive. It was later known as Willowtree House for several years before being again renamed as Hope on 21st May 2015. This current name was chosen by the members who attend the centre. The aim was/is to provide support to people within the community who live with mental ill-health issues.

From its’ base at 25 Glasvey Drive (in the Twinbrook Estate), Hope provides service to Colin Valley, Lisburn and surrounding areas, it is within a short walk of all local shops and amenities and is also ideally situated close to busy public transport routes which are regularly serviced by bus companies and black taxis.

Although Hope is staffed by NIAMH, we have links to (and work closely with) several local health and community organisations including Lisburn and Stewartstown Road CMHT’s, CAB, Colin Neighbourhood Partnership, Oaklee Housing, Habinteg, NIHE, Falls Community Council and others.

Hope opening hours are as follows:

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Monday 10am to 4pm

Wednesday 10am to 4pm

Thursday 10am to 4pm

The Registered Provider is:

Northern Ireland Association for Mental Health (Niamh)

Business Address: Beacon HouseCentral Office80 University Street BelfastBT7 1HE

Company Number: ni 25428Charity Number: xn 47885

Registered RQIA Responsible Person.

The Registered RQIA Responsible Person is:

Name: Rose Reynolds (Quality Manager, Niamh).

Address: Niamh Head Office

80 University Street

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BT7 1HE

Qualifications:

2009 - Post Qualifying Award – Social Work 2004 - Diploma in Social Work 2000 – Masters Degree in Business Administration, Healthcare Specialisms 1999 - Post graduate Diploma in Health Service Management 1986 – BSc Hons – Psychology Registered with NISCC – Registration number 1102305

Additional:

EFQM Trained AssessorAccredited Trainer - Train the Trainer

Experience:

17 years management experience in the Social Care Sector

2010 – Present – Quality Manager, NiamhDevising, implementing and monitoring audit programmes. Overseeing the implementation of the EFQM Excellence Model and promoting a culture of continuous improvement. Ensuring appropriate governance arrangements within Beacon. Ensuring compliance with regulatory requirements. Establishing appropriate performance indicators and measures, ensuring that the views of Service Users and Key Stakeholders are explicitly and routinely sought.

2005-2010 - Service Manager, Niamh.Maintaining internal quality assurance systems, monitoring inspection visits, maintaining regulatory registration of services, conducting announced and unannounced inspections, developing and co-ordinating quality assurance initiatives. Producing outcome information.

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2004-2005 - Manager, Mental Health Day Hospital, Newtownards (UCHT)

Leading a team of nursing, occupational therapy and social work staff in the delivery of high quality services to adults with mental health problems.

1995 – 2004 - Officer in Charge (UCHT)Leading a team of residential workers in the delivery of a comprehensive assessment and rehabilitation service to adults with mental health problems.

Registered Manager

The Registered Manager of ‘Willowtree House’ Beacon Day Support is:

Name: Paul Crawford

Address: 25 Glasvey Drive

Belfast

BT17 0DB

Relevant Qualifications and Experience:

Paul has been involved in providing support in various settings over the past several years. He joined the Niamh as Assistant Home Manager (South Belfast Supported Housing) during June 2003 after some years at the Wave Trauma Centre Belfast. He was appointed as Peripatetic Support Manager during April 2005 and to Home Manager of Lagan Valley Supported Housing Scheme January 2007. Since July 2007 he has additionally been Manager of Willowtree House Beacon Day Support Centre. Paul served on the Niamh group of companies Health and Safety Committee from 2010 to

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2012. He was Chairperson of the Niamh Anti-Stigma Campaign Committee from May 2012 to May 2013.

Alongside the above Paul has continued to practice as a Counsellor and has delivered accredited Trauma Training to other professional therapists. He has been a member of BACP for 14 years, is a member of IAM (Institute of Administrative Management) and ILM (Institute of Leadership Management) and is enrolled on the NISCC Social Care Register as well as being an RQIA Registered Manager.

Paul has been involved in various business/management roles almost continuously for over 40 years and holds either Core Competence or IFF qualifications for all of the posts he has held in the Niamh. He has also completed a continuously renewing cycle of Niamh essential training qualifications, holds a Diploma in Counselling, Level 4 Management Diploma, legionella responsible person qualification and QCF Level 5 in Health and Social Care. He also holds qualifications in Post Conflict transformation and maintains an active role in the community in this area.

2.0 Number, Relevant Qualifications and Experience of Employees

Niamh has in place robust recruitment procedures, which ensure only those of the highest integrity and caring qualities are employed.

Niamh is dedicated to staff development. All staff complete a comprehensive Induction and staff at Support Worker level and above complete Induction and Foundation Training (IFF) which is accredited through OCN.

In addition there is an ongoing schedule of training provided to ensure that staff maintain and update the knowledge, skills and values required to develop their practice. There are a variety of delivery methods which include formal essential training days, on-line training, and scheme level training. Niamh also promote staff development through access to QCF’S at Level’s 3,4 &5.

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Staffing Complement for ‘Hope’ Beacon Day Support is:

OCN level 2 (IFF – Induction & Foundation Framework).

Cheryl Bell, Project Worker.

(37 hours per week split 15 hours Beacon Day Support and 22 hours Supported Housing) with 7 years working for Niamh to date.

Rian Lloyd, Support Worker.

(28 hours split between Supported Housing, Day Support and Floating/Home Support)

Rian gained experience as a Niamh volunteer before being appointed to his present role during February 2015.

The scheme also has access to Peripatetic Staff and Managers as required.

Volunteers

Traditionally the use of volunteers has been central to the work of Niamh and it is envisaged that this will continue to be seen as a major resource in the provision of services. All volunteers will be recruited and trained in keeping with Niamh Policy.

Hope currently enjoys input from two volunteers:

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Stephen – Who is an elected member of Belfast City Council.

Kate – Retired houswife

Project Liaison Group

The Project Liaison Group will be convened by the Service Manager where it is considered appropriate. In an advisory capacity the PLG will assist with the planning, monitoring and evaluation of Beacon Day Support.

The PLG will also facilitate good communication between The Beacon Day Support Service and local Statutory Mental Health Services. Members input into the PLG can be by attendance at the meeting or by minutes of members meeting or putting forward member’s views via the Beacon Day Support Manager. Examples of agenda items include:

- Discussion on Referral and Review issues- Statutory Mental Health Team input into the

Beacon Day Support Programme (where appropriate)

- Discussion on the programme of activities and how this meets the needs of members

- Identification of new needs and ideas - Analysis of statistical returns - Analysis of complaints and untoward incidents- Evaluating the work of Willowtree House Beacon

Day Support and setting specific targets at the annual

review.

Membership of the PLG may consist of any of the following:

Beacon Day Support MembersNiamh staffNiamh volunteersRepresentatives of local statutory mental health team

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Representatives from local community and voluntary sector

There will be a maximum of two from any group represented.

.0 Niamh Philosophy of Care/Support

BeaconBeaconSocial Care ModelSocial Care Modelf o r F l o u r i s h i n g M e n t a l H e a l t h

Beacon Supporting Mental Wellbeing

believe that Social Care is an essential public service that provides day to day care and support where

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needed, to enable people to live full and active lives.

We believe that high levels of emotional, psychological and social well-being are essential components of Flourishing Mental Health.

The Beacon Social Care Model embraces Recovery Principles to acknowledge that Wellbeing is accessible to all, including those who have experienced a Mental Illness. The Beacon Social Care Model includes a wide range of services such as Day Services, Supported Housing, Floating Support and Advocacy, that are designed to work with people to:

1.Find and Maintain Hope2.Re-establish a Positive Identity3.Build a Meaningful Life4. Take Responsibility and Control

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Philosophy of Care

The overall goal of Beacon Day Support is to promote member involvement and personal development through a range of support and opportunities.

Aims of Beacon Day Support

Objectives

To provide a range of constructive options promoting positive mental health within the community and facilitating the individuals recovery

- to work as a community resource that enables and supports the individual to excess other services

- to offer a relevant and balanced programme of Activity that incorporates Community Outreach opportunities for each individual

To help support and maintain the individuals recovery

- all members to have an identified key-worker, that will offer support, advice and guidance

- to develop an individual support plan for each individual that is based on their areas of need

To encourage and enhance each individuals quality of life

- to encourage participation in a variety of activities that will improve confidence, self esteem and mental well being, thereby promoting inherence

- to provide an individual support plan that reflects goals for individuals to achieve

To provide person centered provision where care and support is based on individually assessed needs

- to actively provide opportunities for individuals to engage in user led activities and promote the individuals

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right to choose their input

- to provide age specific activities that meets the individuals needs

To promote a holistic approach to mental health care.

- to provide a range of activities that enhance each individuals physical, emotional & psychological wellbeing

To promote meaningful interaction which enables members to attain their full potential

- members are encouraged to participate at all levels of service provision

- members are offered support and training to participate in members meetings, partnership groups, interview panels, inspection visits etc

- to encourages the development of user led sessions and service support teams

- to consult with members regularly in planning and implementing the service programme

To work in partnership with other helping agencies which support the individual

- to actively establish links with community and Statutory Organizations to meet the requirements of individual areas of need, such as tailored outreach activities

To promote integration thus minimizing social isolation

- to provide access and regular use of community / social facilities for groups and individuals through the centre Programme

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4.0 Status and Constitution

This is a day care setting owned by a Voluntary Organisation (Northern Ireland Association for Mental Health) and registered under the Regulation and Improvement Authority (Registration) (Amendment) Day care Regulations (Northern Ireland) 2007

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5.0 Organizational Structure of the Organisation and Facility.

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NIAMH Board

Chief Executive

Director Of Services

Service Team Manager

Service Manager

Scheme Manager

Project Workers

Support Worker

Peripatetic Staff

Director Of Resources

Director of Compass

Director of Carecall

November 2010

6.0 Number of Service Users to be provided with Services

Hope Beacon Day Support Centre provides 12 Beacon Day Support Places per day for a total of 04 days per week for 48 Weeks per year. This gives a total of 2304 Beacon Day Support places per year.

Niamh may undertake to develop additional sessions outside these for example Member Led Sessions or sessions for which we receive additional funding.

7.0 The range of needs that the facility is intended to meet

Adult Mental Health.

8.0 Admission Criteria/ Referral Procedure

People considered suitable for referral are:

A) Aged 18-65 yearsb) Those with a recognised form of mental illness

Or those who have successfully completed rehabilitation Programme for an addiction problem

c) Those that would benefit from attending Beacon Day Support

People considered unsuitable for referral are those:- With severe dementia- Where learning difficulties is the primary condition- With a physical disability and who need significant

assistance in relation to this - Where addiction is the primary condition- Who need a high level of individual supervision.

The Referral Procedure may be implemented informally and with some flexibility according to the needs and wishes of the Member.

Arrangements are made with the Beacon Day Support Manager/assistant for the prospective new Member to visit

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accompanied by the Referral Agent/Key-worker. The Manager should record the visit in the Referral and Review Diary and in their Progress Notes when they start to attend Hope Beacon Day Support.

During the visit the following will be discussed with the Member and Referral Agent:

- Beacon Day Support Activities

- Opening hours

- Member interests

- Participation

- Contributions – i.e. tea/coffee

- Physical Health Needs e.g. diabetes, epilepsy, mobility, hypertension, sensory impairment.

- Risk/Vulnerability Assessment e.g. self harm; violence/aggression, self neglect.

- Copy of Programme of activity, Member Handbook, Beacon Day Support leaflet and any relevant information should be given.

- Introduced to staff, Key Volunteers and other Members.

- If considered appropriate, a Member should show the new Member around the Scheme. This should be recorded in the Referral and Review Diary.

- If the Member is agreeable to attend Beacon Day Support, agreement will be reached on how the attendance will help him/her. (Members supportplan)

- Discuss with the member the sessions they will attend, the activities they will take part in, needs regarding transport, diet etc, and agree the date for commencement.

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The referral form and assessment of need will be completed by the Referral Agent in conjunction with the proposed Member and signed by both if appropriate. These forms should be received before the Member starts attending. In the event of the member starting before the referral form has been received, this should be recorded in the Progress Notes and the Manager should pursue the referral form.

It is the referral agent’s responsibility to ensure that the Beacon Day Support Manager is informed of all relevant information relating to the proposed Member.

From information received on the Referral Form or verbally from the Referral Agent, it may be necessary for the Referral Agent to complete a Risk/Vulnerability Assessment sheet. This should be sent to the Referral Agent/Psychiatrist for completion. This form must be received before the member starts attending Beacon Day Support.

Self-Referral – Hope does not accept self-referrals.

GP Referrals – A GP may refer a patient to Beacon Day Support for regular/Sessional attendance, or to attend a short-term group, such as anxiety management. GP referrals will be accepted on Niamh’s Referral Form in either format (long or short) a GP referral form letter or emailed. The Manager should complete the appropriate Niamh Referral form with the potential new member and establish if they are known to the Statutory Mental Health Services.

Schedule One Offender – If a Service User is identified as a Schedule one Offender from the initial referral then this must be brought to the attention of the Director of Services prior to the

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admission panel taking place. Referrals for clients who have been deemed Schedule One offenders must be discussed with the appropriate representatives (Director of Services, Service Manager, Statutory Mental Health Services, Beacon Day Support Manager, Probation Service, Psychiatrist) before a decision is made. If the referral is being accepted a proper monitoring procedure should be set in place. All information, particularly that pertaining to risk, must be received and a management plan agreed before the member starts to attend.

Physical Health Needs - Some members may have particular physical needs. These may be visual or hearing impairment, physical disabilities or particular health needs, such as diabetes or severe allergies. Such physical needs may require special and individual responses from staff. These could include the provision of particular aides or other interventions. If there is a particular way of communicating with a member this information should be clearly displayed within the inside cover of the members file and the index box for health needs.

On referral to the Beacon Day Support Service the Beacon Day Support staff should clearly explain the referral and review process. Members should understand that Progress Notes will be recorded, that they will have an individual Support Plan and a review will be held to look at their progress/activities etc. If the member has any areas of risk around self-harm, self-neglect or violence and aggression the procedure for monitoring risk should be clearly explained to them.

Emergency referrals to Beacon Day Support will be treated under the same policy as stated above.

RISK/VULNERABILITY ASSESSMENT PROCEDURE

It is the policy of Niamh to ensure that all staff know which Members present as being a significant risk of self-harm or being a danger to self or others, and which Members are vulnerable to abuse or exploitation. This is in order to protect the Health, Safety and welfare of Members/Staff/Volunteers and others.

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On referral, Referral Agents are required to complete a Risk/ Vulnerability Assessment sheet (R2). This form will be completed by the referral agent and the Member and will provide information on any Risk/Vulnerability issues.

The Referral Agent and Member completing the form are asked to note situations or circumstances that contribute to, or trigger risk/vulnerability issues, to outline Member strengths and how they cope with risk/vulnerability issues and to note the dangers that exist for the Member and others if the risk/vulnerability issue is not dealt with appropriately. The purpose of this is not to apportion blame but to ensure that risk/Vulnerability issues are acknowledged during the referral process and become an integral part of the planning and review process. Depending on circumstances referral agents and/or Members may be contacted for further clarification.

The Risk/Vulnerability sheet becomes part of the Member’s file and a dynamic document that is then adjusted throughout the year to reflect changes in risk/vulnerability, for example as a result of a review, an incident or to reflect a change in circumstances. A newRisk Vulnerability Assessment is completed each year at review.

Statistical information regarding the number of Members requiring support/care with Risk/ Vulnerability issues will be collated and sent to Service Managers six monthly on form RV1.

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SERVICE USER RISK/VULNERABILITY REPORT

SCHEME: Willowtree House

Code – (initials / age / gender

)

RVA in last 6 mths

RVA in last 12 mths

RVA in last 5 years

Nature of Risk Vulnerability

issues

Dates of Specific Incidents in last 6

months

Issues for Managers/CO

This register is regularly updated to reflect ever changing details and

persons involved.

The current register is available to suitably

authorised professionals for inspection and is held in Willowtree

House.

Where available a copy of SE Trust Risk and Vulnerability ‘Screening Tool’ will be obtained.

Signature: Designation: Date:

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9.0 Arrangements for Members to engage in social activities, hobbies and leisure interests

Each scheme has a programme of activities and members are involved in regularly reviewing the programme to ensure it meets identified need.

There are activity rooms in each scheme. Experienced Tutors are sourced where appropriate Activities take place in the scheme and in the wider community and

at flexible times. Members agree with their key worker their level of involvement. Staff encourage members to participate at a level appropriate to

each individual. Members encourage each other within a peer support system.

10.0 Arrangements made for consultation with Members or their representatives about the operation of the Beacon Day Support setting

Niamh welcomes Member involvement and their suggestions both at scheme and Organizational Level. Members are actively encouraged to be involved in all aspects of the Beacon Day Support's operation. The membership concept is fundamental to the success of Hope in creating a sense of each individual belonging and making a valuable contribution. The following are ways in which Hope Members may be consulted, or are able to put forward their views.

Discussion with Key Worker Formal and informal discussions with the Scheme Manager Partnership Meetings/ Members Network (Beacon Voice) Satisfaction surveys/questionnaires Project Liaison Group Inspection Visits (Announced & Unannounced) Member Focused Monitoring Visits Individual Review Meetings Scheme Evaluation Member Led Conferences Member Led Sessions In the context of the Service Agreement the South East Health and

Social Care Trust may carry out their independent evaluation of the Beacon Day Support Setting, and gain Members views on Services.

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11.0 Fire Precautions and Associated Emergency Procedures

Niamh, so far as is reasonably practicable, will manage in compliance with The Fire Precautions Act 1971, The Fire Precautions(work place) Regulations 1997, The management of Health and Safety at Work Regulations 1999 and other appropriate regulations in order to maintain the Health & Safety of Members, Staff, Volunteers and Visitors. The Scheme follows all Fire and Health & Safety Procedures as outlined in Niamh’s Policy and these may be audited by relevant external bodies and through Niamh’s Internal Inspection System.

A file which contains all records pertaining to fire safety within the scheme and is kept in an easily accessible place. The file contains separate sections for:

- Fire Risk Assessment- Sample fire Notice- Annual Test Certificates- Fire Drill- Record of Training- Records of Maintenance Checks carried out

A Health & Safety File may also be maintained at the scheme containing separate sections for:

- Environmental Risk Assessment - First Aid Box Checks

- Body Fluids Spill Box Checks- Portable Appliance Testing

- Security Alarm Checks- Servicing of Equipment i.e. gas, oil burner, chair lift etc - Disability Audit.

The Policy and Procedure Manual gives details on emergencyProcedures (general), a medical emergency, fire, accident and potential Self-harm, as well as guidelines for dealing with untoward incidents.

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12.0 Arrangements made for contact between Members and their Representatives

Members are asked at referral stage if/when they wish carers to be kept informed of their progress

Review meetings are an opportunity for Carers or referral agents to be kept up to date on progress

Each Day Support has a quiet room where Members can meet privately with representatives

When a member requests that contact be made with a representative they will be assisted to do so.

13.0 The arrangements for dealing with Complaints

The arrangements for dealing with complaints are detailed in our policy and procedure manual – Complaints Procedure (QG/3). This procedure is intended to cover all persons involved in the work of NIAMH( Service Users, Staff, Volunteers and General Public) The complaints procedure is in accordance with our charter of standards. Our complaints system is a three stage process.

COMPLAINTS PROCEDURE

INTRODUCTION: Beacon Services are committed to the promotion of a culture that fosters openness and transparency for the benefit of all. Beacon complaints procedures are designed to provide ease of access, simplicity and a supportive and open process which results in a speedy, fair and, where possible, local resolution. The overall aim is to have the opportunity to put things right for service users, as well as improving services.Dealing with those who have made complaints provides an opportunity to re-establish a positive relationship with the complainant and to develop an understanding of their concerns and needs.

Beacon Complaints Procedures are compliant with:- The Health and Social Care Complaints Procedure Directions (Northern Ireland) 2009- Complaints in Health and Social Care – Standards and Guidelines for Resolution and Learning,

DHSSPS, April 2009- Guidance on Complaints Handling in Regulated Establishments and Agencies, DHSSPS, April 2009- The Day Care Setting Regulations (NI) 2007- The Domiciliary Care Agencies Regulations (NI) 2007

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November 2010The Complaints Procedures relate to ‘any expression of dissatisfaction requiring a response’. This includes comments or suggestions that suggest a level of dissatisfaction. Beacon Complaints Procedure does not deal with complaints about services that are not provided by Beacon or Niamh. These should be referred on the appropriate organisation and the complainant should be supported with this. Complaints may also be raised within Beacon that do not fall within the scope of these procedures, and there may be other policies and procedures that need to be followed, for example:

- Grievance Procedures, in the event of a complaint made by a staff member- Safeguarding Vulnerable Adults Policy, in the event of a complaint that relates to abuse,

exploitation or neglect of a vulnerable adult- Child Protection Policy, in the event that the complaint relates to abuse, exploitation or neglect of a

child- Disciplinary Procedures

It should be noted that any complaint that relates to non-compliance with regulatory requirements should be forwarded immediately to the Quality Manager, who will report the matter to the RQIA.

1. Accountability

1.1 The Director of Services will hold overall managerial accountability for complaints within Beacon Services. The Quality Manager will assume responsibility for complaints handling and responsiveness.

1.2 All staff must be aware of, and comply with, the requirements of the complaints procedure within their level of responsibility.

1.3 Scheme Managers / Registered Managers are responsible for ensuring compliance with complaints procedures at scheme level.

1.4 Complaints handling will be included in Beacon’s performance measurement framework and within Niamh’s corporate objectives.

1.5 The Quality Manager will quality assure complaints handling arrangements.

2. Accessibility

2.1 All Members will have open and easy access to the complaints procedure and the information required to enable them to complain about any aspect of services. This will be included in each scheme’s ‘Member Guide’ or ‘Member Handbook’.

2.2 Where possible, arrangements will be made to accommodate the specific needs of Members, such as information in a variety of formats, languages, etc

2.3 A simple flow chart outlining the complaints procedure (Making Your Views Known Appendix 1) will be displayed in a communal area in all group housing schemes and Beacon Day Support Centres.

2.4 In single occupancy supported housing or Home Support, complaints information will be provided to Members at the point of introduction to services.

2.5 Members, or their representatives will be made aware that they have the right to make their complaint through the local HSC Trust.

2.6 Members or their representatives will be advised of the role of The Patient and Client Council (Appendix 2). This will be included in the scheme ‘Member Handbook’ or ‘Member Guide’

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3. Receiving Complaints

3.1 All complaints will be welcomed as an opportunity for improvement.3.2 All complaints will be treated confidentially.3.3 Flexible arrangements will be in place to ensure that complaints can be raised in a number of

ways: verbally, in writing, at a group forum.3.4 Complaints may be made by Members or by persons acting on their behalf. Complaints from

a third party must, where possible, have the written consent of the individual concerned.3.5 Every attempt will be made to achieve local resolution of complaints, where possible.3.6 The first point of contact for the complainant has responsibility for ensuring that the

appropriate action / procedures have been followed, relative to their level of responsibility.3.7 All complainants will be formally notified that their complaint has been received and will be

provided with information on timescales for response.

4. Supporting Complainants and Staff

4.1 The individual will be supported in the making of a complaint and Beacon Staff will promote the use of independent advice and advocacy services, including peer advocacy.

4.2 All staff will receive training and guidance on complaints procedures and effective complaints handling.

4.3 The Quality Manager will offer assistance in the formulation of a complaint and guidance on the investigatory process.

5. Investigating and Responding to Complaints

5.1 Not all complaints will need to be investigated to the same degree, however the same principles will apply in terms of timescales and responses.

5.2 Anyone has the right to make a complaint within six months of the event.5.3 All complaints will be acknowledged within two working days of receipt.5.4 Investigations of complaints will normally be undertaken within 10 working days5.5 A response will normally be made within 20 working days of receipt.5.6 The nature of the complaint will determine the degree of investigation required

and the appropriate person to undertake the investigation.5.7 All investigations will be robust and proportionate and the findings will be supported by

evidence.5.8 Where appropriate, joint investigations will be undertaken (HSC Trust, NIHE (SP), Housing

Association).5.9 The complainant will be fully informed regarding the investigatory process.5.10 In exceptional circumstances when timescales cannot be adhered to, the complainant and the

Quality Manager will be informed. Records relating to this will be maintained.5.11 Responses will be clear, accurate, balanced, fair and easy to understand.5.12 All issues raised in the complaint will be responded to and, where appropriate, the response

will contain an apology.

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November 20105.13 Where a complainant remains dissatisfied, he/she will be clearly advised of the options that

remain open to them, including the NI Commissioner for Complaints (Appendix 3).

6. Recording Complaints

6.1 All complaints will be recorded appropriately. The scheme manager is responsible for ensuring this at scheme level.

6.2 All complaints received at scheme level will be recorded on the scheme complaints / dissatisfaction register, detailing the nature of the complaint, action taken and outcome (Appendix 4).

6.3 Dependent on the nature of the complaint and the wishes of the complainant, a Beacon Complaints Record may also be completed (Appendix 5). The person with operational responsibility will use their discretion to assess the appropriate recording method.

6.4 The scheme manager has responsibility for ensuring that complaints information is shared and disseminated as appropriate to the individual scheme. This may include partnership agencies, housing associations, Supporting People or the local HSC Trust.

6.5 All completed ‘Beacon Complaints Records’ must be copied to the Quality Manager.

7. Monitoring

7.1 The number and type of complaints will be monitored by each scheme manager and recorded on the scheme monthly report.

7.2 Monitoring compliance with complaints procedures will be undertaken by the nominated service manager.

7.3 The Quality Manager will conduct an annual review of arrangements for complaints handling and responsiveness.

7.4 The Quality Manager will report annually on complaints received. This report will be made available to all staff and service users.

7.5 The Regulation and Quality Improvement Authority have a duty to monitor complaints in regulated services. They have a right to request a 12 month summary of all complaints and any action taken. It is the responsibility of the scheme manager/registered manager to ensure that accurate records are available if / when requested by RQIA.

8. Learning

8.1 Learning will take place at different levels within Beacon: individual, team and organisational level.

8.2 The scheme and service manager will monitor the nature and volume of complaints at scheme level to ensure that action taken in response to complaints has been adequate and appropriate.

8.3 The Quality Manager will monitor the nature and volume of complaints at organisational level, to ensure that trends are identified and acted upon.

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November 20108.4 Learning from complaints will be shared across services through managers’ forums, in

support of ‘best practice’.

Appendix 1

MAKING YOUR VIEWS KNOWN

If things go wrong or you aren’t satisfied with our services, we want you to tell us so that we

can try to put things right.

If you want to make a complaint, there are a number of ways to do this. All complaints information is

treated confidentially.

STAGE 1 – You can speak directly to staff, who will try to resolve things for you straight away.

STAGE 2 – If you are still not satisfied, or you didn’t want to speak directly to staff, you can make a formal complaint to Beacon. This can be done by letter, by using a complaints form or by telephone to any of the Managers at Central Office or to any staff member. If you need help in making a complaint or comment, our staff are trained in dealing with this and will be available and happy to help you. You are also entitled to access independent advocacy services to support you in making a complaint. Additionally, The Patient and Client Council can also assist a person who feels unable to deal with a complaint alone. Details of both are available in your Service User Guide / Handbook and Beacon Complaints leaflet

Beacon: 80 University Street, Belfast, BT7 1HETel: 028 90328474 Fax: 028 90234940 Email: [email protected]

We want our response to be quick, fair, courteous and helpful. Your complaint will be acknowledged in 2 working days Any investigation will take place within 10 working days We will let you know the outcome within 20 working days.

STAGE 3 – If things are still not resolved to your satisfaction, you may wish to take the matter further. You can do this by contacting your local Health and Social Care Trust or the NI Commissioner for Complaints (the Ombudsman) who can be contacted at :Progressive House, 33 Wellington Place, Belfast BT1 6HN or by phone on 028 9023 3821

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mailto:[email protected]

November 2010

Beacon complaints procedures are subject to monitoring and inspection by the Regulation and Quality Improvement Authority (RQIA). If you have any concerns about Beacon Complaints Procedure or how your complaint has been handled, you can contact the RQIA as follows:

RQIA, 9th Floor, Riverside Tower, 5 Lanyon Place, Belfast BT1 3BT or Tel: 028 9051 7500

You have the right to complain.We learn from your complaints and we use them to help us to improve services.

THE PATIENT AND CLIENT COUNCIL

1. The Patient and Client Council (PCC) is an independent non-departmental public body established on 1 April 2009 to replace the Health and Social Services Councils. Its functions include: • representing the interests of the public; • promoting involvement of the public; • providing assistance to individuals making or intending to make a complaint; and • promoting the provision of advice and information to the public about the design, commissioning and delivery of health and social care services.

2. If a person feels unable to deal with a complaint alone, the staff of the PCC can offer a wide range of assistance and support. This assistance may take the form of:

• information on the complaints procedure and advice on how to take a complaint forward;

• discussing a complaint with the complainant and drafting letters;

• making telephone calls on the complainants behalf;

• helping the complainant prepare for meetings and going with them to meetings;

• preparing a complaint to the Ombudsman.

• referral to other agencies, for example, specialist advocacy services;

• help in accessing medical/social services records;

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November 20103. All advice, information and assistance with complaints is provided free of charge and is

confidential. Further information can be obtained from:

[email protected]; or Freephone 0800 917 0222

The Regulation and Quality Improvement Authority

This service is registered with the RQIA, who will regularly carry out inspections to ensure that high standards of care and support are maintained, to ensure that the service is appropriately managed and to ensure that staff are adequately trained and supported to provide high quality services.

The Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for monitoring and inspecting the availability and quality of health and social care services in Northern Ireland, and encouraging improvements in the quality of those services. Their role is to ensure that health and social care services in Northern Ireland are accessible, well managed and meet the required standards.

RQIA was established in 2005 under The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003. The Order also places a statutory duty of quality upon health and social care organisations, and requires the DHSSPS to develop standards against which the quality of services can be measured.

Since April 2009, under the Health and Social Care (Reform) Act (Northern Ireland) 2009, RQIA undertakes the functions previously carried out by of the Mental Health Commission.

What do they do?

RQIA registers and inspects a wide range of health and social care services. Inspections are based on minimum care standards which will ensure that both the public and the service providers know what quality of services is expected.

Inspectors will visit this service to examine all aspects of the care provided, to assure the comfort and dignity of those using the service, and ensure public confidence in the service.

RQIA also has a role in assuring the quality of services provided by Health and Social Care (HSC) Board, HSC trusts and other agencies, to ensure that every aspect of care reaches the standards laid down by the Department of Health, Social Services and Public Safety and expected by the public.

Under the Health and Social Care (Reform) Act (NI) 2009, RQIA undertakes a range of responsibilities for people with a mental illness and those with a learning disability (previously carried out by the Mental Health Commission). These include: preventing ill treatment; remedying any deficiency in care or treatment; terminating improper detention in a hospital or guardianship; and preventing or redressing loss or damage to a patient's property.

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November 2010

Appendix 3

THE NI COMMISSIONER FOR COMPLAINTS

The NI Commissioner for Complaints (the Ombudsman) can carry out independent investigations into complaints about poor treatment or service or the administrative actions of HSC organisations. If someone has suffered because they have received poor service or treatment or were not treated properly or fairly – and the organisation or practitioner has not put things right where they could have – the Ombudsman may be able to help.

The Ombudsman’s contact details are:

Mr Tom Frawley Northern Ireland Ombudsman Progressive House 33 Wellington Place Belfast BT1 6HN Tel: (028) 9023 3821

Further information can be accessed at: www.ni-ombudsman.org.uk

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November 2010

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November 2010

Appendix 4REGISTER OF COMPLAINTS

SAMPLEDate

Complaint Received

Name of person making complaint

Name of person receiving complaint

Beacon Complaints Record form completedYes / No

Description of complaintPlease state whether Verbal/Written

Other relevant documentation ie statements, reports

Action taken,date resolvedand by whom

(Example)1 Jan 2010 Ms Smith Joe Wright No Tumble Dryer is

frequently broken down (verbal)

Daily Notes (31/12/09)Maintenance Request (2/1/10)

Repair arranged and completed.

Joe Wright (4/1/06)

(Example)3rd Jan 2010

Mr Jones Joe Wright Yes – see Beacon Complaint records

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November 2010REGISTER OF COMPLAINTS

Date Complaint Received

ComplainantName of person making complaint

Name of person receiving complaint

Beacon Complaints Record form completed:Yes / No

Description of complaintPlease state whether Verbal/Written

Other relevant documentation ie statements, reports

Action Taken, date resolvedand by whom

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Pg 37 of 10 Beacon Complaints Procedure SP 21 May 2010

Appendix 5

Beacon Complaints Record

Scheme: __________________________ Date: _______________

Verbal Written Phone

Name of person making complaint?

What is the complaint? Please provide as much information as possible; written or emailed, complaints to be attached, additional paper to be used as required.

What does the person want to see happen / what action do they want?

Signature of Complainant (if appropriate): ________________________________

Name and designation of person completing form: _______________________

Has complaint been resolved at scheme level? Yes No

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Pg 38 of 10 Beacon Complaints Procedure SP 21 May 2010

What action was taken?

What further action is required and by whom?

Signature of Scheme Manager: _____________________________________

Service Manager Comments (to include summary of investigation and outcomes as appropriate, additional reports to be attached)

Service Manager name and signature: _____________________________

Service manager to complete this section and copy complaints form to Quality Manager

Complaint acknowledged within 2 working days Yes / No Actual Date: ________________

Investigation completed within 10 working days Yes / No Actual Date: ________________

Outcomes shared with complainant within 20 days Yes / No Actual Date: ________________

Complaint Record copied to Quality Manager Date _________________

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14.0 The arrangements for dealing with Reviews of the Member’s Plan referred to in Regulation 16(1)

Progress Notes

Progress notes should commence on the day the member starts attending Beacon Day Support. There should be an introduction providing information on how the member settled in, what they were involved in, how they communicated with staff and others, their days of attendance, sessions/activities to be involved in, information they received e.g. Handbook, transport arrangements etc.

For new referrals the minimum standard is weekly until the Support Plan is drawn up or first 6 weeks of attendance, then monthly, unless circumstances dictate otherwise or depending on the level of attendance.

Members should be actively encouraged and supported to write their own Progress Notes.

Support Plan The short-term objectives stated on the referral form and the referral agent’s assessment of need form the basis of the first Support Plan, which should be drawn up within the first 4-6 weeks depending on attendance and circumstances of the member. For whatever reason this is not completed it should be recorded in the members’ progress notes. Support Plans will be reviewed as the member progresses within Beacon Day Support. They are attached to the Progress Notes for this purpose and are considered a working document.

Members should be fully involved in the updating of their support plans and encouraged to write their own Support Plan, when they wish to do so.

Reviews

The first review should be held as soon as possible after the member has of 42

completed 12 attendances or three months then annually unless an issue or concern arises then a review should be arranged. If a review is delayed or cancelled the reasons should be clearly recorded in the progress notes. Dates should be recorded in the review diary and the members file.

Non Attendance

If a member has not been attending for a period of three months their attendance should be reviewed. If there are valid reasons for non-attendance then they should be held on the register for a further three months. This information should be recorded in their progress notes.

Leaving Procedure

When a member no longer attends, the Beacon Day Support Manager may write to them and copy to file, phone the member or speak to the members Key Worker (Referral Agent). This should be recorded in the Progress Notes and the file closed. The date the file is closed should be clearly recorded on the front of the file and the Progress Notes. A date eight years hence should also be recorded on the front of the file for shredding.

15.0 The number and size of Rooms in the day care setting

One open plan ground-floor activity room encompassing kitchen area.

One ground-floor toilet and access hallway.

One 1st floor toilet.

One 1st floor relaxation room.

One 1st floor staff office.

One 1st floor Manager and meeting office.

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16.0 Details of any specific therapeutic techniques used in the day care setting and arrangements made for their supervision

There are no specific therapeutic techniques available at Hope requiring additional supervision.

17.0 The arrangements made for respecting the privacy and dignity of Members

The core values of Niamh include Quality, Integrity and Partnership. These are maintained and upheld by ensuring each member is fully involved in all aspects of his/her care and support.

All staff work towards providing an atmosphere of mutual respect between Members and Staff, and to uphold the dignity of the individual.

Members are addressed in the manner they prefer. I.e. Mr/Mrs or by first name etc.

All staff work within Niamh’s Confidentiality Policy. All staff exercise non-discriminatory practices. Appropriate areas are available for Members to have

private discussions. Members are consulted and kept informed of changes

within the Service.

Date Approved and Implemented: Feb 2008

Date of Review and Record of changes Made: Statements of Purpose are usually reviewed on a regular basis. The date of review will be noted here and copies circulated to all relevant parties.

Reviewed: Sept / Oct 2010 – Copies to RQIA, Scheme & Niamh

Reviewed: Sept 2011 – Copies to RQIA, Scheme & Niamh

Variance: August 2012 - Copies to RQIA, Scheme & Niamh

Reviewed December 2012 – Copies to RQIA, Scheme & Niamh. of 42

Reviewed September 2013 – Copies to RQIA, Scheme & Niamh.

Reviewed January 2014At request of RQIA - Copies to RQIA, Scheme & Niamh Reviewed May 2014 - Copies to RQIA, Scheme & NiamhReviewed February 2015 -Reviewed July 2015 -

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