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:
Page 1 of 38
[email protected]
January 2014
Contents
Introduction
1.0
Registered Provider
1.1
Registered Manager
2.0
Number and relevant Qualifications & Experience of Staff
3.0
Philosophy of Care
Aims of the Facility
Aims and Objectives
4.0
Status and constitution
5.0
Organisational Structure of the Facility
6.0
Number of Members to be provided with Services
7.0
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 Pursuits
10.0 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
14.0 Review Procedure
15.0 Number and size of Rooms in the Beacon Day Support Setting
16.0 Details of any specific therapeutic techniques used in the day
care setting and arrangements made for their supervision
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January 2014
17.0 The arrangements made for respecting the privacy and dignity
of Members
Introduction
About Niamh
Niamh, 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 Beacon
Beacon 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 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-today 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.
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January 2014
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.
 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.
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January 2014
The NIAMH originally opened Hope (Then known as Twinbrook dropin 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:
Monday
10am to 4pm
Wednesday
10am to 4pm
Thursday
10am to 4pm
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January 2014
The Registered Provider is:
Northern Ireland Association for Mental Health (Niamh)
Business Address: Beacon House
Central Office
80 University Street
Belfast
BT7 1HE
Company Number: ni 25428
Charity 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
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 Assessor
Accredited Trainer - Train the Trainer
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January 2014
Experience:
17 years management experience in the Social Care Sector
2010 – Present –
Quality Manager, Niamh
Devising, 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.
2004-2005 (UCHT)
Manager, Mental Health Day Hospital, Newtownards
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 -
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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.
January 2014
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
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.
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January 2014
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, online training, and scheme level training. Niamh also promote staff
development through access to QCF’S at Level’s 3,4 &5.
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.
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January 2014
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:
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:
-
Page 10 of 38
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
January 2014
-
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 Members
Niamh staff
Niamh volunteers
Representatives of local statutory mental health team
Representatives from local community and voluntary sector
There will be a maximum of two from any group represented.
.0 Niamh Philosophy of Care/Support
Beacon
Social Care Model
for Flourishing Mental Health
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January 2014
Beacon
Supporting Mental
Wellbeing
believe that
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 well-being are
essential components
No illness or
disorder and
positive mental
health.
Is aware and
independent
Has diagnosis of
No diagnosable
a serious illness
illness or disorder
but copes well
but has poor
and has positive
mental health.
mental health.
Is aware and
Is aware and
dependant
interdependent Has diagnosis of
a serious illness
and has poor
mental health.
Is unaware and
dependant
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 Hope
2. Re-establish a Positive Identity
3. Build a Meaningful Life
4. Take Responsibility and Control
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November 2010
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
To provide a range of constructive
options promoting positive mental
health within the community and
facilitating the individuals
recovery
To help support and maintain the
individuals recovery
To encourage and enhance each
individuals quality of life
To provide person centered
provision where care and support
is based on individually assessed
needs
To promote a holistic approach to
mental health care.
Page 13 of 38
Objectives
- 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
- 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 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 actively provide opportunities for
individuals to engage in user led
activities and promote the
individuals right to choose their
input
- to provide age specific activities
that meets the individuals needs
- to provide a range of activities that
enhance each individuals physical,
emotional & psychological wellbeing
November 2010
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 work in partnership with other
helping agencies which support the
individual
To promote integration thus
minimizing social isolation
- to consult with members regularly
in planning and implementing the
service programme
- to actively establish links with
community and Statutory
Organizations to meet the
requirements of individual areas of
need, such as tailored outreach
activities
- to provide access and regular use of
community / social facilities for
groups and individuals through the
centre Programme
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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November 2010
5.0 Organizational Structure of the Organisation and Facility.
NIAMH Board
Chief Executive
Director
Director
Of Services
Of Resources
Service Team
Manager
Service Manager
Scheme
Manager
Project Workers
Support Worker
Peripatetic Staff
Page 15 of 38
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)
b)
Or
c)
Aged 18-65 years
Those with a recognised form of mental illness
those who have successfully completed rehabilitation
Programme for an addiction problem
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 accompanied by the Referral Agent/Keyworker. 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.
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November 2010
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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November 2010
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 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
Page 18 of 38
November 2010
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.
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
Page 19 of 38
November 2010
risk/vulnerability, for example as a result of a review, an incident or to reflect a
change in circumstances. A new
Risk 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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November 2010
SERVICE USER RISK/VULNERABILITY REPORT
SCHEME:
Code –
(initials
/ age /
gender)
Willowtree House
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
Where available a copy of
SE Trust Risk and
Vulnerability ‘Screening
Tool’ will be obtained.
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.
Signature:
Page 21 of 38
Designation:
Issues for
Managers/CO
Date:
November 2010
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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November 2010
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 emergency
Procedures (general), a medical emergency, fire, accident and potential
Self-harm, as well as guidelines for dealing with untoward incidents.
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November 2010
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
The 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.
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November 2010
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
1.2
1.3
1.4
1.5
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.
All staff must be aware of, and comply with, the requirements of the complaints procedure
within their level of responsibility.
Scheme Managers / Registered Managers are responsible for ensuring compliance with
complaints procedures at scheme level.
Complaints handling will be included in Beacon’s performance measurement framework and
within Niamh’s corporate objectives.
The Quality Manager will quality assure complaints handling arrangements.
2. Accessibility
2.1
2.2
2.3
2.4
2.5
2.6
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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’.
Where possible, arrangements will be made to accommodate the specific needs of Members,
such as information in a variety of formats, languages, etc
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.
In single occupancy supported housing or Home Support, complaints information will be
provided to Members at the point of introduction to services.
Members, or their representatives will be made aware that they have the right to make their
complaint through the local HSC Trust.
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’
November 2010
3. Receiving Complaints
3.1
3.2
3.3
3.4
3.5
3.6
3.7
All complaints will be welcomed as an opportunity for improvement.
All complaints will be treated confidentially.
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.
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.
Every attempt will be made to achieve local resolution of complaints, where possible.
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.
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
4.2
4.3
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.
All staff will receive training and guidance on complaints procedures and effective
complaints handling.
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
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
Page 26 of 38
Not all complaints will need to be investigated to the same degree, however the same
principles will apply in terms of timescales and responses.
Anyone has the right to make a complaint within six months of the event.
All complaints will be acknowledged within two working days of receipt.
Investigations of complaints will normally be undertaken within 10 working days
A response will normally be made within 20 working days of receipt.
The nature of the complaint will determine the degree of investigation required
and the appropriate person to undertake the investigation.
All investigations will be robust and proportionate and the findings will be supported by
evidence.
Where appropriate, joint investigations will be undertaken (HSC Trust, NIHE (SP), Housing
Association).
The complainant will be fully informed regarding the investigatory process.
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.
Responses will be clear, accurate, balanced, fair and easy to understand.
All issues raised in the complaint will be responded to and, where appropriate, the response
will contain an apology.
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).
November 2010
6. Recording Complaints
6.1
6.2
6.3
6.4
6.5
All complaints will be recorded appropriately. The scheme manager is responsible for
ensuring this at scheme level.
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).
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.
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.
All completed ‘Beacon Complaints Records’ must be copied to the Quality Manager.
7. Monitoring
7.1
7.2
7.3
7.4
7.5
The number and type of complaints will be monitored by each scheme manager and recorded
on the scheme monthly report.
Monitoring compliance with complaints procedures will be undertaken by the nominated
service manager.
The Quality Manager will conduct an annual review of arrangements for complaints handling
and responsiveness.
The Quality Manager will report annually on complaints received. This report will be made
available to all staff and service users.
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
8.2
8.3
8.4
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Learning will take place at different levels within Beacon: individual, team and
organisational level.
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.
The Quality Manager will monitor the nature and volume of complaints at organisational
level, to ensure that trends are identified and acted upon.
Learning from complaints will be shared across services through managers’ forums, in
support of ‘best practice’.
November 2010
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 1HE
Tel: 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
Page 28 of 38
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;
3. 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
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November 2010
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.
Page 30 of 38
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
Page 31 of 38
November 2010
Appendix 4
REGISTER OF COMPLAINTS
Date
Complaint
Received
Name of person
making
complaint
Name of
person
receiving
complaint
SAMPLE
Beacon
Complaints
Record form
completed
Yes / No
(Example)
1 Jan 2010
Ms Smith
Joe Wright
No
(Example)
Mr Jones
rd
3 Jan 2010
Page 32 of 38
Joe Wright
Yes – see Beacon
Complaint records
Description of complaint Other relevant
Please state whether
documentation ie
Verbal/Written
statements, reports
Tumble Dryer is
frequently broken down
(verbal)
Daily Notes
(31/12/09)
Maintenance Request
(2/1/10)
Action taken,
date resolved
and by whom
Repair arranged
and completed.
Joe Wright
(4/1/06)
November 2010
REGISTER OF COMPLAINTS
Date
Complaint
Received
Page 33 of 38
Complainant
Name of person
making
complaint
Name of
person
receiving
complaint
Beacon
Complaints
Record form
completed:
Yes / No
Description of complaint
Please state whether
Verbal/Written
Other relevant
documentation ie
statements, reports
Action Taken,
date resolved
and by whom
Pg 34 of 10
Beacon Complaints Procedure SP 21 May 2010
Appendix 5
Beacon Complaints Record
Scheme: __________________________
Verbal
Written
Date: _______________
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?
Page 34 of 38
Yes
No
Pg 35 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
Page 35 of 38
Date _________________
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
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.
Page 36 of 38
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 nonattendance 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.
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.
Page 37 of 38
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.
Reviewed September 2013 – Copies to RQIA, Scheme & Niamh.
Reviewed January 2014
At request of RQIA
- Copies to RQIA, Scheme & Niamh
Reviewed May 2014
Reviewed February 2015
Reviewed July 2015
- Copies to RQIA, Scheme & Niamh
-
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