Non-compliance with residential disability care regulations in Ireland: a retrospective analysis of frequency and causes

Study design

This was a descriptive, qualitative study using document analysis. The document analysis was conducted in accordance with the seven phase process outlined by Moilanen. First, determining the purpose, data and study design; second, determining the selection strategy; third, selecting or developing an extraction matrix; fourth, pilot testing; fifth, collecting and analysing data; sixth, credibility of the study; seventh, research ethics¹⁸. Thematic analysis was conducted as a part of the fifth step.

We identified inspection reports for providers of residential care for people with disabilities [hereafter referred to as ‘centres’] published by the health and social care regulator in Ireland [hereafter referred to as ‘the regulator’] as potentially suitable for addressing the research questions. Inspections of centres in Ireland are typically carried out by one inspector over one to two days. Inspectors do not assess all regulations during an inspection. In advance of an inspection inspectors will choose what to assess from a total of 32 regulations. During the course of an inspection, inspectors will speak with residents and staff as well as carers or relatives of residents should they make themselves available. They will also observe care, assess the physical environment and review documentation¹⁹.

There were 1329 inspections carried out by the regulator in 2022, 70% of which were unannounced²⁰. The frequency of a centre’s inspections can be higher where poor levels of compliance are identified. In 2022, 145 centres were inspected twice and 23 were inspected 3 or more times²⁰. The regulator publishes most inspection reports within four months of the inspection (some are withheld in the interests of protecting people’s identity, see section on ethical approval) after a process of quality assurance and allowing centre a right of reply to the findings¹⁹.

Population

All centres in Ireland that were inspected by the regulator between 1^st January 2019 and 31^st October 2022 inclusive, were included. There were 1401 centres operating in Ireland as of 31^st December 2021 (the most recently-published data by the regulator for the sample period), these included the following service types: adults (n=1270; 90.7%), children (n=94; 6.7%), mixed i.e., all age groups (n=37; 2.6%)²¹.

Data

Access to compliance data was approved by the regulator via a letter from the Chief Inspector of Social Services. In addition, PD was legally authorised to access this data as a current employee of the regulator and their status as an authorised person. PD obtained the data by accessing the regulator’s IT system (PRISM), selecting the necessary variables through an ‘advanced find’ search and exporting the resulting data to an Excel spreadsheet²².

These data included the inspection reference number (alphanumeric), inspector’s name (character), centre name (character), centre identification number (alphanumeric), inspection type (categorical: risk inspections [conducted due to significant concerns about quality and safety of a service]/thematic inspections [focused solely on infection control practices]/new applicant inspections [assessments of centres prior to admitting residents]/regular inspections [wide-ranging assessments that were carried out twice per three year period for each centre]) and service type (categorical: adults/children/mixed).

Compliance judgments for each regulation that was assessed by the inspector on the day(s) of inspection were included. There were three possible judgments: compliant, substantially compliant, and not compliant. The regulatory judgments are described by the regulator as follows: “Compliant means the provider and or the person in charge is in full compliance with the relevant regulation. Substantially compliant means that the provider or person in charge has generally met the requirements of the regulation but some action is required to be fully compliant. A judgment of not compliant means the provider or person in charge has failed to comply with a regulation and that considerable action is required to reach compliance”¹⁹.

We used published and unpublished inspection reports as a data source. Inspection reports were authored by inspectors and contained descriptions of their findings on the day of inspection. Reports follow a template with three main sections: section 1, what residents told inspectors and what inspectors observed; section 2, capacity and capability (the governance arrangements and resources available to a centre to carry on the service); section 3, quality and safety. Section 1 contains descriptions of interactions with residents and inspector observations on how care was provided. There are no regulatory judgments in this section. In section 2, the inspector(s) write a narrative describing the centre’s capacity and capability for providing the service, referencing issues such as governance arrangements, training, complaints and the management of incidents. At the end of section 2 the reports contain a list each of the regulations assessed in the capacity and capability category as well as the regulatory judgment (compliant/substantially compliant/not compliant) for each, along with text as supporting evidence for the judgment. In section 3, the inspector(s) describe in narrative form their findings with respect to quality and safety (e.g. quality of life, activities, fire safety, safeguarding) and the report lists each of the regulations assessed in the quality and safety category, along with the regulatory judgment and the supporting evidence for each. During the period covered by this study there were 32 regulations that could feature in inspection reports²³ (Supplementary file 1 contains a full list of regulations). The 32 regulations contain multiple sub regulations, as demonstrated for regulation 10 (communication) below:

“Communication

10.  (1) The registered provider shall ensure that each resident is assisted and supported at all times to communicate in accordance with the residents’ needs and wishes.

      (2) The person in charge shall ensure that staff are aware of any particular or individual communication supports required by each resident as outlined in his or her personal plan.

      (3) The registered provider shall ensure that—

Some regulations are worded in a manner that seeks to provide support to people relative to their specific needs whereas others are more prescriptive in terms of the facilities that should be provided to people (e.g. a telephone).

All inspection reports described the evidence identified by the inspector to support each compliance judgment. The evidence supporting judgments of ‘not compliant’ and ‘substantially compliant’ were the data of interest for this study. While ‘substantially compliant’ could be read as a positive finding, we opted to include data pertaining to these judgments because, as per the description above, they referred to some element of the regulation not being satisfactorily met.

Sample

The time period for the sample (1^st January 2019 to 31^st October 2022) was chosen because the regulator changed the way regulations were assessed during the course of 2018. Any inspections conducted prior to this used different compliance judgments. The end date for the sample was the last full month available prior to commencing data extraction.

There are four inspection types: monitoring inspections which are conducted routinely regardless of the level of risk in a service; risk inspections which are carried out on foot of concerns around the quality and safety of a service; new applicant inspections that take place prior to a service commencing operations; and thematic inspections which focus on a specific aspect of care. We selected monitoring inspections for our analysis (n=1917). We did this because of the nature of the other inspection types. Risk inspections could have biased the sample as they are conducted due to specific quality concerns. Thematic inspections only covered infection control during the study period. New applicant inspections only assess the likelihood of future compliance.

To ensure a centre was represented only once in the sample we retained the most recent inspection reports for each centre. This sample contained inspection reports for 1263 centres, one report per centre.

A thematic analysis was conducted of causes of non-compliance on a sub-sample of 35 inspection reports. The sub-sample was identified by first excluding all reports with 100% ‘compliant’ judgments (n=777) as they contained no relevant data i.e., information on non-compliances. We then randomly sampled the remaining 1140 inspection reports. Each included inspection was allocated a random number in MS Excel²² through the random number generator function which produced the seed for the sample. Inspections were then sorted in ascending order by the seed. We selected the first 25 inspections on the list and this constituted the first tranche of reports in the sub-sample. To ensure an inspector was only represented once in the sub-sample we retained their numerically first inspection and deleted any subsequent ones. We then replaced a deleted inspection with the next inspection on the list by an inspector that did not appear in the initial 25.

Analysis

Data were imported into R Studio (Version 2023.03.0, RStudio PBC)²⁴. We calculated the frequency each regulation was assessed and the non-compliance percentage for each regulation ((total number of judgments of ‘not compliant’ and ‘substantially compliant’/total number of judgments) * 100) in the sample (n=1263).

We calculated the mean non-compliance percentage for all centres by first calculating the non-compliance percentage for each individual centre. This was done by summing the number of judgments of ‘not compliant’ and ‘substantially compliant’ in each inspection and dividing the result by the total number of regulations assessed in the inspection: ((number of judgments of ‘not compliant’ and ‘substantially compliant’/total number of judgments) * 100). We used this to calculate the mean non-compliance percentage for all centres.

We calculated the number of centres that were fully compliant (i.e. were found to be in compliance with all regulations that were assessed on an inspection) and centres that were fully non-compliant (i.e. no regulations assessed during the inspection were found to be compliant).

Descriptive statistics (n (%) or median (IQR) as appropriate) for centre type; publication status; bed number; year of inspection; overall non-compliance percentage; number of fully compliant and fully non-compliant centres for all inspection reports in the sample and sub-sample were calculated.

We adopted a thematic analysis approach to identify reasons for non-compliance using the first tranche of 25 inspection reports in the sub-sample. Two researchers (PD and LMK) piloted a data extraction process for three inspection reports. The focus of data extraction was on phrases or sentences that supported compliance judgements made by the inspector. We included the number of the regulation that was associated with the extracted text. Subsequent to the pilot we amended the data extraction form to specify which section in the report the extracted data came from.

Two researchers (PD and LMK) independently coded an initial five reports. Coding was performed inductively where each researcher assigned codes to the text using NVivo²⁵. There were occasions in reports where a non-compliance was referenced in more than one section. Similarly, there were instances where several issues that contributed to a single instance of non-compliance were listed e.g. multiple rooms in a premises that required cleaning. In such cases, to avoid counting multiple instances of the same reasons for non-compliance and increasing the frequency count for that code, we only coded one piece of text relevant to a reason for non-compliance per report. However, the same piece of text was placed in multiple codes where appropriate. For example, the following text “one resident had no plan in place to guide how they should be supported with their mental health diagnosis” could be placed in a code related to ‘documentation’ as well as ‘guidance for staff’.

Upon completion of coding the initial five reports, codebooks were generated through NVivo²⁵ where PD and LMK then met to compare and agree coding and interpretation of the data, and devise any additional codes for inclusion. Disagreements were resolved through consensus or through discussion with the third author (JB). The codebook was subsequently revised and PD coded the remaining data independently.

PD reviewed the codes to group them into sub-themes and parent themes that characterised the reasons for non-compliance. Once completed, PD reviewed all sub-themes and parent themes to identify similarities and determine whether any could be combined or collapsed. We proceeded to add five inspection reports to the sub-sample until saturation was reached i.e. no new themes were identified.

We then determined the frequency effect size (FES) and intensity effect size (IES) for each parent theme and sub-theme by adapting an approach to meta-summary as described by Sandelowski (2007)²⁶. The FES represents how prevalent each theme and sub-theme was in the sample of inspection reports and the IES represents the quantity of data coded to a theme and sub-theme as a proportion of all coded data. The FES was calculated by dividing the number of reports that included a theme by the total number of reports in the sample. The IES was calculated by dividing the total number of texts (‘texts’ refers to words or phrases which were coded during thematic analysis) included in a theme and sub-theme by the total number of texts. We reported our thematic analysis findings under each parent theme in order of highest FES.

We mapped the parent themes back to the regulations by identifying which regulation was being referred to in each individual piece of text, calculating the frequency and percent contribution of themes to each regulation and tabulating these data as a heat map.

Data management

Inspection reports contained no personally identifiable information (PII) relating to residents as this is the policy of the regulator²⁷. As such, there was no PII contained in these data apart from the name of the person in charge of the centre which is publicly available. All data pertaining to this research were stored on a secure online platform. Files used for the analysis were only accessible by the first author and shared with the other authors as necessary.

Researcher characteristics

The lead author, PD, is a full-time employee of the Health Information and Quality Authority (HIQA) which is the regulator for health and social care in Ireland. PD is engaged in a PhD that is funded by HIQA and this study comprises part of the PhD research. PD is a male with over 10 years of experience working in a regulatory capacity. There is a potential for the experience of working in a regulatory capacity to influence the means by which documents were analysed in this study and in the interpretation of data. To guard against this, document analysis involved the input of the other authors and the potential for bias or assumptions to be introduced into the interpretation of data was openly discussed among the authors at all stages of the research.

Ethical approval and consent

The Social Research Ethics Committee of University College Cork, Ireland, granted ethical approval for this research (Log: 2023-011) on 16/3/2023. Ethical approval was sought in order to access the inspection reports that were not published by the regulator. Non-publication of inspection reports is typically done to protect the identity and privacy of people living in a centre. For example, where a centre has only one resident, making that inspection report (which may contain sensitive information such as their healthcare or safeguarding needs) publicly available would compromise that person’s privacy and dignity. Unpublished reports accounted for 150 (11.9%) of the total sample. There were no human participants so there was no need to obtain consent from any individual for participation.

Insufficient resources

This parent theme refers to the physical and human resources available to the centre to provide a service. For clarity, the reference to resources in the title does not necessarily relate to financial resources. There were 27 inspection reports containing instances of this parent theme.

Quality of physical premises. Twenty-two inspection reports contained references to the quality of the physical premises where care was provided. The codes included in this sub-theme outlined problems related to inter alia the suitability of the premises for meeting the needs of residents; refurbishment requirements; worn surfaces and fabrics; accessibility difficulties and general maintenance or repairs. The code that most frequently appeared in this sub-theme was ‘fixtures, fittings or surfaces in need of repair’, for example: “damaged seals on a floor and other bathroom fittings and a damaged mirror”; “large furnishings required repair or replacement”; “internal window sills in one house were water damaged”. ‘Painting or decorating required’ was the second most frequent code: “chipped and worn paintwork was noted around both buildings”; “A number of rooms, including residents’ bedrooms required painting”.

Other resources. This sub-theme contained instances of where an inspection report described issues related to an identified lack of physical and human resources within the premises. Resources sometimes referred to relatively minor items such as clinical waste bins but also included inadequate staff levels to meet the assessed needs of residents, for example: “staff had told the inspector that recent staffing levels negatively impacted on their ability to support residents in activities both in the centre and in their local community, especially at the weekends”; “the provider had not consistently allocated sufficient staff to the centre to support residents' assessed needs”.

Governance and management failings

This parent theme refers to instances where the practices and structures relating to governance contributed to non-compliance; this theme was identified in 23 inspection reports.

General governance issues. This sub-theme contained instances of where services had failed with regard to routine governance matters. For example, codes included ‘no training needs analysis’, ‘no observational audits of hand hygiene’ and ‘failure to adhere to statement of purpose’. There were other examples where inspection reports described concerns with governance due to inaction or a failure to implement commitments that were previously made to the regulator: “improvements identified as required in relation to the premises at the time of the last inspection, had not yet been undertaken”; “A protective measure, stated by the registered provider to be in place, related to staff supervision. This protective measure was not in place on the day of inspection and only related to days that the person in charge was present in the house”. The code that appeared most frequently in this sub-theme related to a service’s failure to act on the findings of their own audits, for example: “The person in charge had identified that there remained an ongoing issue with the heating of the centre and temperature of water, as the controls were not contained within the building. There was no time bound plan to address this, and some areas of the centre were uncomfortably warm during the inspection”.

Reporting failures. Centre staff are responsible for reporting various incidents to relevant authorities. Ten inspection reports described failings in this responsibility. Primarily, these related to a failure to notify the regulator of certain prescribed incidents within the required timeframe e.g. “The use of some restrictive practices, including chemical and physical restraints, had not been notified to the Chief Inspector”; “13 notifications in relation to safeguarding were submitted retrospectively following inspection”. There were a smaller number of incidents relating to failures on behalf of staff to report certain incidents to management: “incidents were reported by staff when they encountered the person in charge rather than when the alleged event happened”; “staff had failed to record or report these behaviours as they felt it was unnecessary”.

Quality improvement issues. Eight inspection reports contained findings related to how quality improvement in services was not managed effectively. For example, in some cases audits were conducted that did not result in actions for quality improvement: “While the registered provider had in place a recent annual review of the quality and safety of the service provided to residents, there was no improvement plan identified in relation to notifiable incidents”. Inspectors also occasionally found fault with the quality of audit practice: “the inspector found that audits did not comprehensively reflect the known risks in the centre. Furthermore, there was no comprehensive plan in place to address these risks. It was not established therefore that these audits were being used as a tool to drive service improvement”.

Inadequate management supervision. There were examples in seven inspection reports of failures related to management supervision of the service and of staff. On occasion it was found that staff were not in receipt of supervision, support or development: “Records reflected that each staff member had been met once in the last twelve months and not every two months as per the providers [sic] policy”; “effective arrangements were not in place to support, develop and performance manage all members of the staff team”. There were some also instances of senior management not having sufficient time to carry out their duties: “The clinical nurse manager worked full-time hours in the centre, however approximately two-thirds of their shifts were spent as one of the two nurses directly supporting the residents throughout the day, with a limited portion of hours protected for attending to management duties”.

Incompatibility of residents. Three reports contained references to interpersonal difficulties between residents which were impacting on the wellbeing of all who lived in the centre. We determined this to be a governance and management issue as the service providers were aware of the difficulties but had not acted promptly: “The provider had failed to address the compatibility of residents in the centre. The inspector met five residents and two spoke of their worry, concern, avoiding contact with the resident experiencing unstable mental health and the limitations this had on their living environment”.

Poor documentation quality

Instances of documents being insufficiently detailed, poor record-keeping or not properly reviewed were reflected in this parent theme. This parent theme was identified in 23 inspection reports.

Failure to review/update a plan or document. Sixteen reports contained examples of where plans or documents were available but had not been reviewed or updated in an appropriate manner. This included occasions where it was mandatory to review a document: “not all of the policies and procedures required to be maintained, as identified in Schedule 5 of the regulations, had been reviewed within the last three years as is required”; or where it would be deemed necessary to support residents’ care and support needs: “associated risk assessments and safety plans required reviewing to ensure that they included measures that were in line with the behaviour support plan”.

Planning documents or information not available, not comprehensive or poor quality. This sub-theme captured instances where inspectors found fault with various documents and information that were important for guiding care and support within a service. Some examples of the types of documentation that were found to be of poor quality or not comprehensive included assessments of need, personal plans, behaviour support plans and medication plans. Inspectors also found documentation and information to have been unavailable: “there was no procedure or guidance available to lone working staff around the supervision and care of residents”; or due to not being of the required quality: “While dietary care plans were on file, these had not been completed in consultation with multidisciplinary professionals such as dietitians or by staff with specific training or knowledge in the relevant areas”.

Record-keeping failures. There were 14 instances where inspection reports outlined failures in the maintenance of records. Among the codes included in this sub-theme were poor record upkeep; poor recording of fire safety precautions taken; poor record-keeping relating to restrictive practice use. In some cases, it was found that important information was not being recorded: “while the residents reported peer-on-peer related issues, they were not being recorded”; “the inspector found that a number of specific behavioural incidents were not being satisfactory logged or recorded”.

Contract of care issues. Four inspection reports detailed issues related to residents’ contracts of care. Some contracts were not signed by the resident or their representative, were generic in nature, or did not detail all charges for services. For example: “the agreements did not include details of the fees to be charged”.

Non-person-centred care

This parent theme included instances where the care provided to people living in centres did not adequately take account of their individual needs and preferences; non-person-centred care was identified in 21 inspection reports.

General non-person-centred care. This sub-theme encompassed a wide range of practices that were considered to reflect care that did not meet the needs of individuals using services. Some of the codes related to failures by services to support residents in living a fulfilling life (e.g. poor access to activities; unresponsive to resident needs/preferences; lack of progress on personal goals) whilst others were related to the nature of the premises (e.g. premises required age-appropriate facilities for children; garden not accessible to wheelchair users; lack of suitable storage for residents). Some inspection reports relayed concerns as expressed by residents. For example, one report contained a reference to a resident telling an inspector that they had no remote control for their television, another described a resident expressing a wish to move to accommodation with fewer service users.

Unmet resident need. Twelve inspection reports noted that residents had needs that were either partially or fully unmet by the service, in part linked to insufficient staffing levels: “On other occasions it was noted that residents were asked to leave the vicinity during an incident where a resident was engaging in behaviours of concern. As there was only one staff member present, there was limited support for all residents during this time”; “Staff spoken with told inspector [sic] that the current staffing levels had affected residents' ability to access the community and attend activities”. There were some codes which appeared in this sub-theme as well as in non-person-centred care above because it clearly reflected an unmet need in addition to a failure to provide care in a person-centred manner. For example, the following text was placed in the ‘unmet responsive to resident preferences’ code in both sub-themes: “a review of daily notes indicated that some residents have limited opportunities to engage in activities that were in line with their interests, capacities and needs”.

Information unavailable for residents. Seven inspection reports contained findings where information on fees and services were not provided in contracts of care as required. In addition to contracts, there were failings found in terms of how information was presented (“some of the information displayed was too high on the wall for the children to see”) and with information not being made available (“the resident did not have access to information about their payments or financial affairs”). There was text in this sub-theme that also appeared in the contracts of care sub-theme above. For example, the failure to include details on additional charges was regarded as a shortcoming in the content of the contract and also a lack of information available to the resident.

Lack of privacy. This sub-theme reflected two distinct aspects of resident privacy. The first related to being facilitated to have a private space such as one’s own bedroom: “One area for improvement noted on the walkabout of the centre was the practice and use of viewing panels on residents bedroom doors…The inspector was not assured that these checks were required in response to the assessed needs of residents”; “the inspector saw that one resident had recently expressed a wish to have their own bedroom. There was no comprehensive, time-bound plan in place to support this resident to have their own room and to uphold their right to privacy”. Secondly, there were failures in terms of keeping personal information private: “Inspectors observed personal information regarding residents were being stored in communal areas”; “residents [sic] files were left in the kitchen area on an open shelved unit and one residents feeding support plan was taped to the kitchen table”.

Weak processes

This parent theme refers to instances where processes in a centre (e.g. cleaning routines or ongoing risk management) contributed to non-compliances. There were 20 inspection reports that contained instances of weak processes.

Risk management problems. Fourteen inspection reports detailed examples of where services had failed to identify risks (e.g. “a number of risks had not been identified within the designated centre's risk register, including the risk of injury to residents due to sloping roofs in residents’ bedrooms”); failed to carry out risk assessments for identified risks (e.g. “not all identified risks to residents had corresponding risk assessments”); and had not reviewed risk assessments appropriately (e.g. “risk assessments and safety plans required reviewing to ensure that they included measures that were in line with the behaviour support plan”). Some inspection reports also described occasions where the risk assessment processes required improvement, for example, in the context of risk rating: “some risk assessments required review as the ratings were not reflective of the risks posed by hazards in this centre”.

Cleaning required improvement. Nine reports noted that cleaning processes were inadequate. One of these reports described mould in areas. Others identified stains on carpets and toilets. Areas of general uncleanliness were also found: “shared shower spaces which were not clean and thick dust or cobwebs in some corners and ceilings around the house”.

Infection control practices. The processes supporting infection control were found to be insufficient in eight reports. The most frequent issue related to worn or damaged surfaces that could not be adequately cleaned and thereby presented an infection control risk. In addition, there were examples of where services had operated outside of national guidance for managing COVID-19 (e.g. “the inspector saw that the provider's written guidance and procedures for managing cases of COVID-19 had not been updated in line with the most recent public health guidance”; “staff practices regarding wearing of PPE [Personal Protective Equipment] at the start of the inspection did not reflect the most up-to-date guidance”.

Inadequate safety

This parent theme contained examples of where safety precautions were insufficient to ensure the wellbeing of people living in centres. Inadequate safety was noted in 17 reports.

Fire safety concerns. Fifteen reports contained instances where fire safety contributed to non-compliances. There were seven reports in which issues with fire doors (doors with a technical specification to withstand fire for a certain number of minutes) were identified. Fire doors were sometimes not in places they should have been (e.g. “considerable areas of the centre did not have fire doors fitted”), or they were being held open inappropriately (e.g. “it was observed that a resident's bin was placed in front of their bedroom door, which may prevent the door from closing in the event of a fire”). Other findings related to fire safety included: personal emergency evacuation plans (personalised plans for managing the evacuation of individuals) were not sufficiently comprehensive or not available in accordance with the service’s fire plan; fire equipment in need of repair/review; inadequate fire containment measures; and fire drills not being comprehensive.

Safeguarding concerns. Safeguarding is the practice of protecting a person from harm or neglect whilst also promoting their individual wellbeing²⁸. Six inspection reports contained examples of where safeguarding investigations were not carried out: “an allegation of abuse raised in May 2020 had not been resolved. While the provider had put steps in place to begin the investigation it had not commenced at the time of this inspection”; safeguarding plans not put in place: “safeguarding plans had not been updated or put in place following incidents”; residents leaving a centre unsupervised: “three incidents had occurred in recent months which resulted in the resident leaving the centre without staff support”; and residents not being protected against the behaviours of concern of other residents: “residents were not safeguarded against the effects of behaviours of concern in the centre”.

Staffing-related concerns

This parent theme referred to instances where staff did not have the capacity to carry out their duties, due to being uninformed on people’s needs or not having access to training; there were 16 such instances in inspection reports.

Staff training unavailable or not provided. Fourteen inspection reports noted issues with mandatory training (e.g. fire safety) and with service-specific training (e.g. management of dysphagia). For example, “there were some gaps in staff being in receipt of training in mandatory areas and also in relation to training to support residents in relation to specific assessed needs”. In some instances, the inspector noted reasons for the lack of training of staff such as the unavailability of in-person training programmes due to COVID-19 restrictions and the inaccessibility of online training due to a cyber-attack on the computer systems of the Irish national health service.

Uninformed staff. Inspectors drew attention to staff not having the required knowledge or guidance to carry out their duties or meet the needs of residents in four reports. For example, “staff were unaware of specific sensory and tactile responses to be employed in the event that a resident was upset and required a behavioural support intervention. These therapeutic interventions were clearly documented in the resident’s behaviour support plan but the inspector did not see evidence that staff could identify and alleviate the cause of a resident’s behaviour”. One report noted excessive use of relief/agency staff which impacted on continuity of care and created extra work for regular staff.

Poor care management

This parent theme contained examples of where the care of persons living in a service was not managed in accordance with their identified needs and preferences. There were nine reports that contained such instances.

Care not provided as per plan. The types of plans referred to in this sub-theme included ‘personal plans’ which provide an overall assessment of a person’s needs and how these are to be met, as well as plans to address specific care needs such as behaviour support plans or a percutaneous endoscopic gastronomy (PEG) feed plan. Six inspection reports described occasions where the care provided was not in accordance with such plans. For example, “one resident had a protocol in place for the use of a psychotropic medication as needed (PRN). The protocol in place advised staff to monitor the resident for the presentation of three of six identified behaviours before administering this PRN. Progress notes suggested that at times, the resident only presented with one or two of these behaviours when staff had adminstered [sic] the PRN”.

Behaviour management issues. The management of residents’ behavioural support needs was found to be an issue in three inspection reports. In some instances these issues were impacting on the wellbeing of other residents: “the behaviours of a small number of residents were sometimes difficult for staff to manage in a group living environment and this had the potential to have a negative impact on other residents”.

Mapping of themes to regulations

Of the 32 regulations, 25 were featured in the sub-sample i.e. were found to be ‘not compliant’ or ‘substantially compliant’ in at least one inspection report (Figure 2). The theme of ‘poor documentation quality’ was linked to 18 of the 25 regulations, followed by ‘governance and management failings’ (n=15 regulations) and ‘non-person-centred care’ (n=12 regulations). The theme that was linked to the least number of regulations was ‘weak processes’ (n=4 regulations).

Figure 2. Heat map representing the frequency of texts coded to themes.

One regulation (positive behavioural support) was linked to all eight themes indicating that it was the area with the greatest variety of potential causes of non-compliance. Seven themes were identified as causes of non-compliance for the ‘risk management procedures’ regulation and six themes were linked to the ‘governance and management’ and ‘protection’ regulations. There were six regulations that appeared only once in the data and, by default, where only one theme appeared (communication; persons in charge; directory of residents; information for residents; medicines and pharmaceutical services; Notification of periods when the person in charge is absent).