Following are the recommendations from the Review of the Oaklands Regional Centre and the Independent Manager's Review of safety, security and overall patient care:

• Oaklands should implement a comprehensive and consistent approach to monitoring the use of both exterior doors (i.e., doors leading to the outside) and interior doors (i.e., bedroom doors) across its residences. Instructions on how to use the monitoring system should be posted next to the central panel in the residence office.
• The monitoring system should include the following characteristics:

1. All exterior and interior doors should be fitted with devices that are connected to a central monitoring panel in the office;
2. The alarm system for interior doors should allow for the activation of only those doors where there is a need to monitor resident movement;
3. The opening of any exterior or interior door should be signalled by both auditory and visual cues at the central monitoring station;
4. The opening of an activated interior door should provide a non-intrusive auditory signal that is different from the one used for exterior doors;
5. The opening of any exterior door should provide a non-intrusive auditory signal that can be heard throughout the house;
6. The auditory signal should be shut off only by resetting the signal at the monitoring station, not by closing of the door;
7. There should be no way to shut down the monitoring system for exterior doors
8. There should be a battery back-up for the monitoring system, in case of a power outage;
9. The system should be checked once a day by one staff opening each of the monitored doors and another resetting the alarm at the central monitoring station;
10. The daily check of the monitoring system should be recorded as part of the daily records for the house.

• The agency should have a written protocol regarding what to do when a resident has been returned to a house after leaving unannounced (e.g., wandering/eloping/running).

1. The protocol should include expectations with regard to

• Communication of the incident of unannounced leaving to all shift members;
• Documentation of the incident;
• Reporting of the incident to appropriate managers;
• Assessment of the level of risk of the resident leaving again;
• Development of strategies to reduce the risk of the resident leaving again.

1. The protocol should also include the expectation that after a first incident of unannounced
2. leaving, the resident be kept in the sight of a staff member at all times until a decision has been made and documented to discontinue visual monitoring.
3. The protocol should be posted in the office of all residences.
4. All current staff (full-time, part-time and casual) should be oriented to this protocol as soon as possible.
5. All new staff (full-time, part-time and casual) should be oriented to the protocol and assessed for accurate understanding of it before working in a residence.

• The agency should post the procedures for reporting missing persons in the office of each residence, including

1. The steps to be completed;
2. The telephone extension numbers of potential participants in a search;
3. The areas to be searched, along with a map of the grounds and surrounding areas;
4. A form to be used for the recording of steps – searches, times and lead responsibilities;

• The agency should develop a form to record an inventory of each resident's clothing.
• The agency should add 'wandering/elopement' to the section 'Type of Incident' on its incident report.
• The agency should ensure that its policy and procedures for missing persons includes the expectation that all staff who have knowledge of the missing person's movements and clothing on the day of the disappearance are interviewed during the investigative process.
• The agency should perform unscheduled drills of the missing persons procedures at least every six months, and review the accuracy and speed with which the procedures are carried out.
• The agency should ensure that all policies and procedures related to the personal safety of residents, including those pertaining to missing persons and emergency procedures.

1. Be reviewed and updated as necessary on an annual basis to reflect current standards, practices and technology;
2. Indicate clearly on each page, the title and source of the policy, the date it was approved/reviewed, and the page number along with the number of pages (e.g., 2 of 8);

• The agency should reintroduce a centralized client filing system in order to ensure the security and confidentiality of client records.

• The agency should review the use of the Confinement Time-Out room in House 1, and subsequent recording and reporting for consistency with agency policies and procedures.
• The agency should review the recording and reporting of wandering in House 1 for consistency with agency policy and procedures.
• The agency should review the recording of the Mood Chart in House 1 for consistency with agency policy and procedures.
• The agency should ensure the levels of supervisory support recorded in section 2 'Levels of Support' of the Personal Support Plan include the numerical rating and descriptor (e.g. Level Two – Close Supervision), and that the levels of supervisory support for each resident are posted in the office within the house.
• The agency should reinforce a consistent approach to recording times for shift reports, incident reports and other practice-related documents, using either a 12-hour or 24-hour approach, not a mixing of the two.
• The agency should review its approach to selecting staff to cover shifts in order to ensure that

1. There are written criteria for assessing whether a staff member has the required level of familiarity with a house in order to work there;
2. There is a roster indicating which staff have satisfied the criteria to work in specific houses;
3. No staff member is assigned to work alone in a house for which they have not met the criteria.

The agency should engage in consultation with residents, families and staff regarding the advantages and disadvantages of a voluntary program using personal locator devices for residents at risk of wandering or running.