Det vil helst gå bra... Oppsummering av landsomfattende tilsyn i 2009 med kommunale sosial- og helsetjenester til barn i barne- og avlastningsboliger

Abstract

NORSK SAMMENDRAG: Kort sammendrag av Rapport fra Helsetilsynet 2/2010

I 2009 ble det gjennomført tilsyn i 75 kommuner/bydeler som har barne- og avlastningsboliger. Fylkesmannen og Helsetilsynet i fylket undersøkte sammen om kommunene sikrer forsvarlige sosial- og helsetjenester til barn i barne- og avlastningsboliger. Tilsynet ble gjennomført i virksomheter som gir heldøgns omsorgstjenester til barn under 18 år etter lov om sosiale tjenester.

Tilsynet avdekket brudd på regelverket i tre av fire virksomheter. Funnene viser at mange kommuner har mangelfull faglig styring, og er for lite opptatt av kvaliteten på tjenestene. Mye overlates til et engasjert personell, som sørger for at barna får mye god omsorg. Men mangelfulle skriftlige rutiner og mangelfull opplæring, kombinert med mange deltidsansatte og sårbare barn som flytter fram og tilbake, er blant det som gir grunn til bekymring.

Legemiddelhåndtering er en utfordrende oppgave som krever klare prosedyrer og tydelig ansvarsplassering. Tilsynet fant at en av to kommuner hadde brutt regelverket på dette området. Legemiddelhåndteringsforskriften gjelder når helsepersonell er involvert. Innholdet i forskriften var ikke godt nok kjent og etterlevd. Avvik kan i verste fall føre til uheldige hendelser med helsemessige konsekvenser.

Regelverket er ikke godt tilrettelagt for drift av barne- og avlastningsboliger. Det er dels mangelfullt og dels vanskelig tilgjengelig og komplekst. Statens helsetilsyn anbefaler en gjennomgang av regelverket med spesiell tanke på barn som oppholder seg i barne- og avlastningsboliger, deres særskilte situasjon og behov.

SUMMARY IN ENGLISH: 1 Summary The Offices of the County Governors and the Norwegian Board of Health Supervision in the Counties together investigated whether the municipalities ensure that children in residential accommodation and respite care accommodation receive health and social services of an adequate standard. The results show that professional management in many municipalities is inadequate, and that not enough attention is paid to the quality of the services. Much is dependent on individual staff, who ensure that children are given adequate care. But lack of written procedures and inadequate training, combined with many part-time staff and vulnerable children who move back and forth between their home and residential care, gives cause for concern.

Administration of medication is an area that presents challenges, and for which clear procedures and clear allocation of responsibility are important. In this area, the supervision authorities found breaches of the legislation in one out of two municipalities. The regulations relating to medicinal products apply when health care personnel are involved. Knowledge about the regulations was inadequate and the requirements in the regulations were not always met. In the worst cases, breach of the regulations can lead to adverse events and damage to health.

In 2009, countrywide supervision of health and social services for children in residential accommodation and respite care accommodation was carried out in 75 municipalities and urban districts that provide services for children under 18 years of age in accordance with the Social Services Act. These children have reduced function, often have health problems, and need special care adapted to their individual needs. Their needs are often complex and demanding, and the consequences of inadequate services can be serious. This area was chosen for supervision because these children are vulnerable, because the risks associated with inadequate services are high, and because little supervision of these services has been carried out during the last few years. The municipalities were chosen on the basis of the supervision authorities’ local knowledge, including information about risk. Thus these municipalities are not necessarily representative for the country as a whole.

The aim of this countrywide supervision was to investigate whether the municipalities had a management system that ensures that children in residential accommodation and respite care accommodation receive health and social services of an adequate standard. Supervision was limited to five areas. The supervision authorities examined whether the municipalities organize services for children in residential accommodation and respite care accommodation in such a way as to ensure that:

children’s rights for contact with others, a meaningful daily life, and participation in leisure activities are met the needs of children with special nutritional needs are met the care that is provided is specially adapted to the health status of the children administration of medication is adequately dealt with the residences are specially adapted for the children. Many of the staff in residential accommodation and respite care accommodation are part-time staff, temporary staff and staff who have no professional qualifications. They cooperate with many other people, such as regular medical practitioners, teachers and support persons, in addition to parents. The municipality has responsibility for continuity of care, and that the quality of all the services provided for each individual child is adequate. Given the nature of the services, and the vulnerability of the children, sound management systems are required.

The supervision authorities identified breaches of the regulations (nonconformities) in about three out of four services. In 59 services there were one or more nonconformities. The extent and nature of the nonconformities varied a lot. Seven services had neither nonconformities nor observations about areas with potential for improvement. The areas with breaches of the regulations that are presented in this report only show tendencies, and do not apply to all the municipalities. Sound management to ensure services of high quality Many municipalities do not have adequate internal control systems. Management systems must be used systematically to ensure that children receive adequate health and social services. For example, when many of the staff have no professional qualifications, many work part-time, and there are no guidelines, this can adversely affect the services that children receive. In addition to lack of written procedures, three of the institutions had not ensured that staff received systematic training. Lack of training applied to the following areas: medication, daily care of the children, diseases and disabilities, and methods of communication. The need for professional staff must be assessed on the basis of the children’s functional abilities and need for assistance. In several municipalities, no such assessment had been made. When many staff have neither professional qualifications nor professional skills, the services are vulnerable. Many municipalities lacked systems for dealing with nonconformities 1, and systems for evaluating and improving the services. If adverse events are not identified and made known, the organization has no basis for correcting deficiencies or for preventing similar incidents from happening again.

A meaningful daily life and adequate care for each child Many municipalities lacked routines for systematic assessment of the children’s needs for activities and health care. Lack of assessment makes it difficult to assess the needs for professional staff and skills. Not all the residences had personnel with adequate skills. Duty rotas and the need for training were often not adequately assessed in relation to the children’s needs. Individual adaptation requires planning, but one service in four lacked plans, or had inadequate activity plans, care plans or other types of plans. The greatest number of nonconformities were for lack of activity plans, particularly individual plans. The result can be that activities are only provided according to the skills of the personnel who happen to be present. This is particularly unfortunate for children who live permanently or for long periods in the residences, and can limit their functional abilities. Very few cases of inadequate nutrition were detected. Administration of medication Administration of medication is an area where there was particular need for improvement. Breaches of the regulations relating to medication were identified in about half of the municipalities. This is an area where there is a great danger of deficiencies occurring. It is clearly necessary for residential accommodation and respite care accommodation to have written procedures. These procedures should describe sound, adequate practice, so that the children are given the correct medication in the correct way. Nonconformities most often included lack of procedures or incorrect procedures, that procedures were not followed, that it was unclear who had responsibility for medication, and lack of professional personnel. These are serious deficiencies, which in the worst cases can have serious consequences for the health of children who are dependent on medication. The most common type of unsound practice with regard to dealing with medication was inadequate preparation of medication, in particular medicines. Preparation of medication shall normally be carried out by health care personnel with adequate qualifications, such as nurses or social educators. Adaptation of the residences for all the children Nonconformities were detected in one out of ten residences regarding adaptation of the residences for children with physical disabilities. In addition, twenty per cent of the municipalities received notification about physical conditions identified as areas with potential for improvement. Although the seriousness of these conditions varied, this is a worrying situation. A large proportion of children in residential accommodation and respite care accommodation have physical disabilities, which means that they have problems in moving around freely. Many of the findings related to conditions that created limited access for these children, particularly children in wheelchairs. This limits their possibilities to participate in activities with others. The recommendations of the Norwegian Board of Health Supervision The municipalities must monitor and follow up the quality of the services provided in each residence for children in residential care and respite care. Many municipalities have an inadequate overview of the services, and must improve their management in order to reduce the risk of inadequate services. The leadership cannot delegate responsibility to the staff without monitoring and following up the services systematically.

As a result of supervision, several deficiencies in management of the services have been detected, and the municipalities must: identify areas where there is a high risk of deficiencies occurring, in order to be able to prevent adverse events ensure that essential routines and procedures are developed to ensure that services for children are sound and adequate ensure that there are sufficient staff with adequate qualifications, skills and training to care for the children identify deficiencies and carry out work to improve the services. Experience gained from supervision in other municipalities can be used to assess routines and discuss areas of high risk. Breaches of the regulations must be corrected.

Supervision was carried out for services that are provided according to the Social Services Act. But most children in residential accommodation and respite care accommodation also need health services. This means that municipalities must pay special attention to the need for qualified staff, and ensure that they know which legislation is applicable. When health care personnel provide services, health legislation will usually be applicable, including the regulations regarding medication. The legislation is not well adapted for running residential accommodation and respite care accommodation. It is incomplete, and it is complex and difficult to interpret. In some areas, it is difficult for the municipalities to know what standards the authorities require. The Norwegian Board of Health Supervision recommends that the legislation should be reassessed in the light of the special situation and needs of these children.

1. When service providers observe deficiencies in the services, these should be registered. This is called registration of nonconformities.