WESTERN CARE ASSOCIATION

2018 Annual Report Table of Contents

Photo of Board of Directors 2017/2018……………………………………………………………………………………… 01

Chairperson’s Report…………………………………………………………………………………………………………….. 02-03

Chief Executive Officer’s Report…………………………………………………………………………………………….. 04-08

Services Report……………………………………………………………………………………………………………………… 09-17

Report on the Rights Review Committee……………………………………………………………………………..…… 18

Report on Mayo Self-Advocacy Group…………………………………………………………………………………..…… 19

Records Management , Complaints………………………………………………………………………………………. 20-21

Board Attendance, General Information and Membership…………………………………….…………………… 22

Extract from the Directors’ Report and Financial Statements for Year Ended 31/12/2018……. 23-24

Development & Fund Raising……………………………………………………………………………………………………… 25

Human Resources Report…………………………………………………………………………………………………………… 26

Evaluation & Training Report……………………..…………………………………………………………………………. 27-29

Acknowledgements……………………………………………………………………………………………………………….…… 30

Western Care Association Board of Directors 2017/2018 Back Row: Ed Rose, Marie Munnelly, Paddy Geraghty, Bernard O’Regan Chief Executive Officer, Helen Mc Hugh. Front Row: Kieran McGloin, Frances Burke, Anthony McCormack and Annette Dillon. Unavoidably Absent: Pat O’Brien, Philip Mc Kiernan, Joe Gibbons and Pat Higgins.

Front Cover Artwork by Mairéad Coyne. Crann Mór Training Center, Ballinrobe. Back Cover Artwork by Noreen Naughton, Cluainin Day Service, Crossmolina.

1.1 Chairperson’s Report Chairperson’s Report This is my third and final guarantee, and as a result the organisation must opportunity as Chairperson to have company members. write directly to you as All those company members; present ones and members of the Association. As incoming members will have the opportunity to I said last year, I come very attend regional meetings that are being held in their much from a background of areas. They will also be entitled to exercise their volunteerism and have been democratic right to nominate and vote for incoming supporting Western Care services directors, who of course have the responsibility of through fundraising etc., in Ballinrobe and South governing and steering the path of the organisation. I Mayo since the mid 1990’s. would encourage all those interested to apply for membership. Since I became a director, our Articles of Association were reviewed and revised and state clearly that I welcome the continued development of no one can serve anymore than nine years as a individualised services, with supports tailored to director of the Association. I am now completing meet service users’ individual needs across all my ninth year as a director (3rd year as chair), sectors of Western Care. The new “Count Me In” and so I am required to step down from my project with GMIT, where people can access position at the upcoming AGM. education and explore options available to them, which is hugely beneficial to people using our I want to welcome all readers to this year’s Annual services. It’s great to see people engaging in their Report, new and old members, particularly those communities, participating in social farming, various who have been serving and supporting social roles, active citizenship and changing the way the organisation for many years now. communities view people accessing Western Care services. The organisation has faced a number of challenges during 2018. As I pointed out in last year’s Annual Western Care as an organisation is very responsive to Report, the organisation was and continues to be the needs of the individual it supports, and battling with shortfalls in funding. The demand proactively looks creatively at supporting and for services continues to grow and in the background developing opportunities for individuals to ensure of reductions to our allocation we struggled to that they have full and positive lives. reach a break even situation at the end of 2018. This was achieved pretty much as a result I take this final opportunity to reiterate my of the implementation of a cost containment appreciation to all those people who have been plan and prudent and careful management of supporting the organisation down through the years. the available resources. I want to thank the general public and particularly the people of Mayo for the enormous contribution The issue of regulation and the various they continue to make to the success of the regulatory authorities continues to place a large Association. I especially want to thank the many burden on our staff, and the regulatory volunteers who tour the highways and byways and environment as a whole continues to impact walk the streets of our towns in support of what we severely on us. There is a huge need for some do. Grateful appreciation also to all of the businesses joined up thinking, between all those who regulate who provide much needed sponsorship to the many the disability sector. Organisations like HIQA, The much needed fundraising events. I’m certainly not Housing Regulator, the HSE Compliance Unit, the forgetting all those members of the public who come Charities Regulator, all of whom have their own job out and attend our fundraising events and help us to to do, however at the same time there is an provide improved facilities and equipment for the enormous amount of duplication. If there were to be people using our services. more joined up thinking between these regulatory authorities the job would still get I want to say a very sincere thank you to all those done, and the burden on staff would be greatly directors I have served with over the last nine years, reduced. each and every one who have given so much of their time and energy to the Board. I would also like to An issue that continues to be close to my heart is the especially thank the directors who have served fact that the organisation is a company limited by during my tenure as Chairman.

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Your support to me personally is greatly appreciated. As I step down from my role with the Association I I also want to pay tribute to directors who serve on feel that the organisation continues to be in very the various sub committees of the Board. good hands. There are a team of directors who are experienced and committed, as well as a

Special thanks to all those who help the organisation Management team who between them hold a huge carry out its mission, the HSE, Mayo County Council, volume of knowledge in the disability sector and a development companies, community groups and huge team of extremely dedicated staff.

Chairperson’s Report Chairperson’s local politicians. I want to wish everyone in Western Care, families, I want to compliment all of the staff of the service users, staff and volunteers every success for organisation throughout the county and express the the future and assure you of my continued support appreciation of both myself and the Board for the to this great organisation over the coming years. wonderful contribution they are making to the lives of people with special needs and the organisation as Anthony Mc Cormack, a whole. I want to acknowledge and express my Chairperson. appreciation to the C.E.O., Bernard O’Regan and the Management Team, and also want to say a sincere thank you to our Director of Finance, Tia Crowley.

I offer my grateful appreciation to Mary O’Connell for her ongoing help as Secretary to the Board and Rita Lavelle, Secretary to the Executive Director.

Respite Services

Centre-Based Day Respite Service 3% 4% 20% Regular Part-Time Care - 2-3 Days P er Week

0% Crisis And Planned Respite

2% Overnight Respite In The Home

Shared Care Or Guardianship (Usually 5 Or 7 Days Per Week) 71% Home Sharing

3 C h i e f E x e c u t i v e O f fi c e r ’ s R e p o r t

The Annual report contains a needs. We have been fortunate to secure some range of reports on some of additional funding from the HSE in 2018 that has the work of the Association in allowed us to put in place additional services. However 2018, including initiatives and these have not been adequate to meet the ever developments. increasing and very urgent needs of people. I will, in this part of the report, seek to report on a I cannot stress enough that Western Care Association number of other areas to be can only put in place services and supports for which it read in conjunction with the is funded by the HSE. In order for us to manage within wider report. our existing resources, we can only respond in

circumstances where we are able to redirect funding CEO Report Throughout 2018, the Association continued to from other activity or where the HSE provide provide a range of services and supports to people additional funding. across the county. It’s not possible in a report such as this to capture the full and wide extent of everything It is clear from all of our engagements with the HSE at that is going on but I hope that this report will give you local, regional and national levels in 2019, that the some sense of the range and depth of activity even at level of funding available is entirely inadequate. We a time when financial pressures have tended to pre- are engaging with other organisations to make the occupy us. case on behalf of all people with disabilities that government must urgently allocate the level of funding Overview of the current position of the Association that is required to ensure that people have essential supports to live their best lives in the community. At the AGM in 2018, we reported to the members on the serious financial position that the organisation was Throughout 2018 we engaged in a number of reviews. in. This followed a deficit position of €800,000 at the An external consultant reviewed our strategies for end of 2017. The Association was spending money at responding to emergencies, our services and our a level beyond its budget and it was unsustainable. systems of governance and oversight. That report This followed on from the previous decade in which made a number of recommendations which the Board the Association had accumulated deficits, albeit at a of Directors has considered and has agreed to much lower level in each year, but which, implement in full over the coming two years. incorporating the result at the end of 2017, meant that the Association had accumulated deficits of €2 In addition we engaged PwC to work with us to million. develop a business plan to assist the organisation in getting on a sound financial footing over the coming In the course of 2018 the Board of Directors approved years. The recommendations of that report have been a cost containment plan, which was subsequently considered by the Board of Directors and again will be agreed with the HSE, and which was a primary focus implemented over the next three years or so. At the for the management of the Association throughout same time, the HSE undertook an internal audit of 2018. You will see from the audited accounts for 2018 Western care Association. that we ended the year with a small deficit which, in This highlighted some significant work that is required light of the overall budget to the Association, is very to do with the oversight and controls in place within close to a breakeven position. This was achieved the organisation. It effectively points in the direction of through careful management of all income and bringing the organisation into a strong business-like expenditure. I want to acknowledge the hard work by way of working. The management team, reporting to all budget holders for their efforts in achieving this the Board of Directors, is implementing these position which is essential to putting the organisation recommendations in full over the next eighteen on a firm financial foundation. months. This will ensure the compliance of the organisation with all of its contractual and legal However there are other costs to a strategy such as obligations under its service agreement with the HSE. this, even though it is essential that we do it. Our ability to respond to the new and changing needs HIQA of people that we support or who urgently need the support of the organisation have been impacted. We HIQA continue to inspect our designated centres and have often not had the flexibility to be able to engage staff in those services have been working hard to with people in a way that allows us to meet their achieve and maintain their registration.

4 A number of themes have arisen for us in the course the market. The sale of these has progressed and the of the year that have been a focus of our attention Board is considering a number of options in relation including the development of a local risk management to the use of the proceeds. These represent policy and system that is integrated into the important opportunities for us, especially in light of corporate risk register. This is being further the absence of capital funding. However we also progressed in 2019 and it is anticipated that by the have to bear in mind our overall financial position end of the year our policy and system will be which needs to be a consideration in any decision on sufficiently robust to ensure effective local risk the use of this funding. management and effective connection to the corporate risk register, which is overseen by the We also secured Clár funding in 2019 which allowed Board of Directors. for the purchase of three vehicles which have made a significant improvement to the aging transport fleet

Service Developments of the organisation. In addition, the continued fundraising efforts have benefited the Association Funding was received from the HSE in 2 018 to meet and a number of projects as set out in our newsletter CEO Report the needs of a number of school leavers who wanted this year have been possible as a result of this to be supported by the Association, and to facilitate fundraising. the transfer of a number of people from Aras Attracta

to Western Care day services, along with some Housing funding for residential services for a small number of

people. We are grateful to the HSE to have secured We have continued to engage with the housing this funding and these services have been put in regulator in relation to our obligations as an place. approved housing body. We had an engagement meeting with the regulator in 2018 in which they Management Structures noted and acknowledged the substantial progress Some changes to the structures of the organisation that had been achieved by the organisation in the were further implemented throughout 2018 and as year since its previous engagement with us. However we moved to the end of the year we were in a they highlighted a number of continuing areas for us position to ensure an effective management team to progress, with particular emphasis on our structure for the organisation. This new management obligation to have a sinking fund in place. This is team came into place in January 2019 and has been something that we are a exploring and will again, in working hard to lead the organisation in what are 2019, be meeting with the housing regulator to somewhat turbulent times. report on our progress in relation to this.

Progress in Children’s Disability Services In addition, we have had some constructive engagement with Mayo County Council on the We engaged constructively with the HSE at local and housing needs of people with disabilities in the

national level in relation to progressing and county and are exploring potential projects and

implementing the national strategy for children’s collaborations. disability services. This has involved an engagement in a national mediation process which reached The Role of the Community Sector agreement on a management structure and it was There was significant optimism throughout 2018 that agreed as part of this that Western Care Association the imminent publication of the Report of the would be the lead agency for the provision of children’s services in the West area, which is broadly Independent Review Group on the Future of from Ballinrobe to Achill. Work on progressing this Voluntary Organisations in Publicly Funded Health has been ongoing in 2019. This will secure the future and Personal Social Services would point the way to of Western Care Association in leading and providing secure the future of voluntary organisations such as services to children at least in part of the county and Western Care Association. will maintain the long tradition of the organisation in The report was finally published in February 2019 and providing support and services to both children and has a number of very significant recommendations to adults. State and the voluntary sector on the future relationship between both parties. Capital Primarily, the report highlights the extraordinary The Board of Directors made the decision in 2019 to contribution that the voluntary sector can make to put a number of properties which were unused on the personal social services and makes the case for the market. This has resulted in the sale of Beehive and State to nurture, support and partner with the the former residential service at Castle Court in Ballina on

5 voluntary sector. It also challenges the voluntary legal and contractual obligations. This will require a sector to ensure that it maintains the trust of the further review of the Articles of Association. wider community, that it demonstrates effective and Compliance transparent governance, and that it makes contributions as a partner in the development of The organisation has completed its compliance national policy and its implementation. statement to the HSE for 2018. We have

incorporated as appropriate the recommendations We are engaging at an individual organisation level and actions from a number of reviews in our and in conjunction with the wider network of compliance statement. The areas that we will organisations, to engage with government to progress continue to focus on in the current year include: the implementation of the recommendations, CEO Report commencing with the establishment of a forum of • procurement systems and processes State and voluntary organisations to agree how best to • internal financial controls progress and implement these recommendations. • segregation of duties within the Finance Staff Recruitment and Retention Department and between Finance and Human Resources Staff recruitment and retention has been extremely • ensuring adequate oversight and sign off in problematic for the organisation throughout 2018 and relation to all key decisions, into the early part of 2019. The improving economy, • continued training and development of the the absence until relatively recently of a program to Board of Directors restore pay to Section 39 staff as has happened with • a review of the Code of governance for the the wider public service, some increased competition Association and preparing for the from other providers in Mayo and in neighbouring implementation of the Code of Governance counties, and the increase in choice for potential for Charities which come into effect on 1 employees of seeking employment in other parts of January 2020 and for which 2019 is a year of the economy, have resulted in delays in establishing preparation. services and have made it difficult for us to recruit and retain staffing. The Board of Directors has approved a monitoring

The HR Department and management team have been and oversight system, in which the CEO will be reporting to the Board on a monthly and quarterly working on a strategy to address this and we are exploring innovations in how we recruit and retain basis as appropriate.

staff through more effective use of social media, reviewing our recruitment campaign and Acknowledgements The growth of the Association and the continuation endeavouring to secure proper pay and entitlements for staff to reflect the work that they are doing. of the work that it does is, as ever, entirely reliant on the people who are associated with it. I can never Western Care Association wants to be an employer of thank enough our staff, managers, the Board of choice but to do this we need to implement a strategy Directors, the HSE and other statutory agencies and that ensures that this is what is experienced by staff the wider community and voluntary network, along who, in turn, through word-of-mouth, will be evidence with the people of Mayo for their continued support to other potential employees that this is a good to the Association. What we are able to achieve is organisation to work for. only possible through the involvement and This requires that management provide the adequate engagement of all stakeholders. and effective supports to people in all circumstances and that staff know that they are valued. We are I want in particular to thank Anthony McCormack as working on our induction process to ensure that this is he steps down both as director and as Chair of the set out from the very beginning as people commence Board of Directors at the end of his term. Anthony their employment with the organisation. has been a steadfast supporter of the Association in his time on the Board and has been a great personal Governance support to me in recent years, in particular in his role The Board is currently reviewing how it recruits and as Chair of the Board. I know that he is keen and engages people onto its governance structures, willing to maintain his involvement with the whether that is the Board of Directors or its various organisation in other capacities and I look forward to committees. It’s clear to the Board that the widest working with him in those. possible range of skills, experience, and diversity on the Board of Directors will position the organisation to Bernard O’Regan be effectively governed into the future and to meet its Chief Executive Officer

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CEO Report Organisation Report N = 25 Not Inspected Not Compliant Compliant Substantially Compliant Inspections 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Compliant Substantially Compliant Compliant Compliant Substantially Purpose Statement of REG 3 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant 19 3 0 3 Procedures Policies and REG 4 Written Compliant Compliant Compliant 22 3 0 0 registration renewal of registration or Application for REG 5: REGISTRATION Compliant Compliant Compliant Compliant Compliant Compliant 19 6 0 0 In Charge REG 14 Person Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 21 4 0 0 Not Compliant REG 15 Staffing Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 22 0 1 2 Not Compliant Development and Staff REG 16 Training Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Substantially Compliant Compliant Substantially 21 0 1 3 of Residents REG 19 Directory Compliant Compliant Compliant Compliant Compliant Compliant Compliant Capacity and Capability 18 7 0 0 Not Compliant REG 21 Records Compliant Compliant Compliant Compliant Compliant Compliant Compliant 7 17 1 0 7 REG 22 Insurance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 17 8 0 0 Not Compliant Not Compliant Not Compliant Management Governance and REG 23 Not Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Compliant Compliant Substantially Compliant Substantially Compliant Compliant 15 0 4 6 Services Provision of Contract for the Admissions and REG 24 Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Substantially 18 0 2 5 REG 30 Volunteers Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant 17 0 1 7 Incidents Notification of REG 31 Compliant Substantially Compliant Compliant Substantially Compliant Substantially Compliant Substantially Compliant Substantially Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Western Care Association - 2018 HIQA Inspections 10 9 0 6 Absent Person in Charge is Periods when Notification of REG 32 25 0 0 0 Absent Person in Charge is Periods when Arrangements for Procedures and Notifications of REG 33 25 0 0 0 Procedure Complaints REG 34 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 12 13 0 0 Personal Plan Assessment and REG 5 Individual Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant 20 3 2 Not Compliant Not Compliant REG 6 Healthcare Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 17 6 2 Not Compliant Not Compliant Behaviour Support REG 7 Positive Compliant Compliant Compliant Substantially Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Substantially Compliant Compliant 14 4 2 5 Not Compliant Not Compliant REG 8 Protection Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant 20 2 2 1 Rights REG 9 Residents' Compliant Compliant Compliant Compliant Substantially Compliant Compliant Substantially 19 0 2 4 Communication REG 10 Compliant Compliant Compliant Compliant Compliant Compliant 19 0 0 6 REG 11 Visits Compliant Compliant Compliant Compliant Compliant 20 0 0 5 Not Compliant Possessions REG 12 Personal Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Quality and Safety 11 12 1 1 Development Welfare and REG 13 General Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 15 10 0 0 REG 17 Premises Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant 19 4 0 2 Nutrition REG 18 Food and Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially 16 0 1 8 Residents Information for REG 20 Compliant Compliant Compliant Compliant Compliant Compliant 19 0 0 6 Patients Discharge of Transition and Absence, Temporary REG 25 Compliant 24 0 0 1 Not Compliant Not Compliant Not Compliant Procedures Management REG 26 Risk Not Compliant Compliant Substantially Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Substantially 14 3 4 4 Infection Protection against REG 27 Not Compliant Compliant Compliant Compliant 21 1 0 3 Precautions REG 28 Fire Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Substantially Compliant Compliant Compliant 22 0 0 3 Services Pharmaceutical and REG 29 Medicines Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Substantially Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Compliant 15 5 0 5 CEO Report 5 0 5 15 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Substantially Compliant Compliant Compliant Compliant REG 29 Medicines and Pharmaceutical Services 3 0 0 22 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Substantially Compliant Compliant Compliant Compliant REG 28 Fire Precautions 3 0 1 21 Compliant Compliant Compliant Not Compliant REG 27 Protection against Infection 4 4 3 14 Substantially Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Not Compliant Not Compliant REG 26 Risk Management Procedures Not Compliant Not Compliant 1 0 0 24 Compliant REG 25 Temporary Absence, Transition and Discharge of Patients 6 0 0 19 Compliant Compliant Compliant Compliant Compliant Compliant REG 20 Information for Residents 8 1 0 16 Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant REG 18 Food and Nutrition 2 0 4 19 Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant REG 17 Premises 0 0 8 10 15 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant REG 13 General Welfare and Development 1 1 12 11 Quality and Safety Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant REG 12 Personal Possessions Not Compliant 5 0 0 20 Compliant Compliant Compliant Compliant Compliant REG 11 Visits 6 0 0 19 Compliant Compliant Compliant Compliant Compliant Compliant REG 10 Communication 4 2 0 19 Compliant Substantially Compliant Compliant Compliant Compliant Substantially Compliant REG 9 Residents' Rights 2 1 2 20 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant REG 8 Protection Not Compliant Not Compliant 5 2 4 14 Compliant Compliant Compliant Substantially Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Compliant Compliant Compliant Substantially Compliant Not Compliant Not Compliant REG 7 Positive Behaviour Support 2 6 17 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Not Compliant REG 6 Healthcare Not Compliant

2 3

20

Compliant Compliant

Compliant Compliant

Compliant Compliant

Compliant Compliant

Compliant Compliant

Compliant Compliant Compliant Substantially Compliant

Compliant Compliant

Compliant Compliant

Compliant Substantially

Compliant Compliant

Compliant Personal Plan Assessment and REG 5 Individual 0

0 12 13 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant REG 34 Complaints Procedure 0 0 0 25 REG 33 Notifications of Procedures and Arrangements for Periods when Person in Charge is Absent 0 0 0 25 REG 32 Notification of Periods when Person in Charge is Absent 6 0 9 10 Western Care Association - 2018 HIQA Inspections Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Substantially Compliant Substantially Compliant Substantially Compliant Substantially Compliant REG 31 Notification of Incidents 7 1 0 17 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant REG 30 Volunteers 5 2 0 18 Compliant Compliant Compliant Substantially Compliant Substantially Compliant Compliant Compliant REG 24 Admissions and Contract for the Provision of Services 0 6 4 15 Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Substantially Compliant Compliant Substantially Compliant Compliant Not Compliant REG 23 Governance and Management Not Compliant Not Compliant Not Compliant 0 0 8 17 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant REG 22 Insurance 7 0 1 17 Compliant Compliant Compliant Compliant Compliant Compliant Compliant REG 21 Records Not Compliant 0 0 7 18 Capacity and Capability Compliant Compliant Compliant Compliant Compliant Compliant Compliant REG 19 Directory of Residents 3 1 0 21 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Substantially Compliant Compliant Substantially Compliant Compliant Compliant Compliant REG 16 Training and Staff Development Not Compliant 2 1 0 22 Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant REG 15 Staffing Not Compliant 0 0 4 21 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant REG 14 Person In Charge 0 0 6 19 Compliant Compliant Compliant Compliant Compliant Compliant REGISTRATION REG 5: Application for registration or renewal of registration 0 0 3 22 Compliant Compliant Compliant REG 4 Written Policies and Procedures 3 0 3 19 Compliant Compliant Compliant Compliant Compliant REG 3 Statement of Purpose Substantially Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Substantially Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 1 2 3 4 5 6 7 8 9 17 18 19 20 21 22 23 24 25 10 11 12 13 14 15 16 Inspections Compliant Substantially Compliant Not Compliant Not Inspected N = 25 Services Report

Day Services He is really proud telling people about it and looks forward to every rehearsal. It has given him a huge 2018 saw the introduction of