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Health Information and Quality Authority Social Services Inspectorate Inspection report Designated centres for older people

Centre name:

Ballygar Nursing Home

Centre ID:

0319 Ballygar

Centre address:

County Galway

Telephone number:

0906624818

Fax number:

Not available

Email address:

[email protected]

Type of centre:

Private Voluntary Public

Registered provider:

Tom Thomas

Person in charge:

Tom Thomas

Date of inspection:

7 July and 8 July 2010

Time inspection took place:

7 July Start: 10:30hrs Completion: 17:30hrs 8 July Start: 09:00hrs Completion: 14:30hrs

Lead inspector:

Nan Savage

Support inspector:

Vicky Blomfield

Type of inspection:

Registration Scheduled Announced Unannounced

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About inspection The purpose of inspection is to gather evidence on which to make judgments about the fitness of the registered provider and to report on the quality of the service. This is to ensure that providers are complying with the requirements and conditions of their registration and meet the standards; that they have systems in place to both safeguard the welfare of service users and to provide information and evidence of good and poor practice. In assessing the overall quality of the service provided, inspectors examine how well the provider has met the requirements of the Health Act 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland under the following topics:

1. Governance and leadership: how well the centre is organised.

2. The quality of the service.

3. How well the healthcare needs of residents are met.

4. Premises and equipment: appropriateness and adequacy.

5. Communication: information provided to residents, relatives and staff.

6. Staffing: the recruitment, supervision and competence of staff.

This report summarises the findings of the inspection under some or all of these topics, highlighting areas of good practice as well as areas where improvements were required as follows: Evidence of good practice – this means that an acceptable standard was reached and the provider demonstrated a culture of review and improvement and aimed to drive forward best practice. Some improvements required – this means that practice was generally satisfactory but there were areas that need attention. Significant improvements required – this means that unacceptable practice was found. The report also identifies minor issues, where applicable, to which the provider should give consideration to enhance the quality of the service. Registration inspections are one element of a process to assess whether providers are fit and legally permitted to provide a service. The registration of a designated centre is for three years. After that the provider must make an application for registration renewal at least six months before the expiration date of the current registration. New providers must make an application for first time registration 6 months prior to the time the provider wishes to commence.

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In controlling entry to service provision, the Chief Inspector of Social Services is fulfilling an important regulatory duty under section 40 of the Health Act 2007. Part of this duty is a statutory discretion to refuse registration if the Chief Inspector is not satisfied about a provider’s fitness to provide services, or the fitness of any other person involved in the management of a centre. The registration inspection is one element for the Chief Inspector to consider in making a proposal to the provider in respect of registration. Other elements of the process designed to assess the provider’s fitness include the information provided in the application to register, the Fit Person self-assessment and the Fit Person interviews. Together these elements are used to assess the provider’s understanding of, and capacity to, comply with the requirements of the Regulations and the Standards. Following assessment of these elements, a recommendation will be made to the Chief Inspector and the formal legal process for registration will proceed. As a result, this report does not outline a final decision in respect of registration. The report is available to residents, relatives, providers of services and members of the public, and is published on our website www.hiqa.ie.

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About the centre

Description of services and premises

Ballygar Nursing Home is a single-story purpose-built facility which first opened in May 1997. There are places for 16 residents providing long-term, palliative and respite care. At the time of inspection, there were 11 residents including some with dementia. All residents were over 65 and receiving long-term care. The entrance leads to a hall which opens onto a main corridor extending the full length of the building. Residents’ bedrooms are located off this corridor. The nurses’ station is located in the entrance area and is also used by the person in charge. Communal accommodation consists of a day-room, dining room, a small reception room and visitors’ room. The reception room is located in the entrance hall while the day-room and visitors’ room are off the main corridor. The kitchen is next to the dining room and a large hatch area connects the dining room to the kitchen. The laundry room and the sluice room are accessed through the assistive shower room on the main corridor. In total there are eleven bedrooms, six single and five twin bedrooms. There are no en suite shower and toilets however they all have hand-washing facilities. There are two shower rooms with assisted shower, toilet and hand-washing facilities and a separate additional toilet for residents’ use. There is a toilet for catering and non catering staff beside the laundry. Car parking for relatives, staff and visitors is available to the side of the building. An outdoor space with some seating is available for residents’ use.

Location

Ballygar Nursing Home is located in Ballygar, Co Galway and is approximately 62 kilometres from Galway city.

Date centre was first established:

29 May 1997

Number of residents on the date of inspection

11

Number of vacancies on the date of inspection

5

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Dependency level of current residents

Max High Medium Low

Number of residents

1

3

3

4

Management structure Ballygar Nursing Home is owned by Tom and Bernadette Thomas. Tom Thomas is both the Provider and Person in Charge. Bernadette Thomas is the senior staff nurse and deputises for the Person in Charge. Four nurses including Bernadette Thomas support the Person in Charge and report directly to him. Care assistants report to the nurse in charge. Catering staff report to the Person in Charge or nurse in charge. Maintenance work is the responsibility of the Person in Charge.

Staff designation

Person in Charge

Nurses Care staff

Catering staff

Cleaning and laundry staff

Admin staff

Other staff

Number of staff on duty on day of inspection

1 1 1 1 0 0 1*

* An extra member of staff was on duty for the inspection but was not part of the planned roster.

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Summary of findings from this inspection This was the first inspection carried out by the Health Information and Quality Authority (the Authority) and it was an announced registration inspection. The provider had applied for registration under the Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2009 and the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations (as amended). As part of the registration process, the provider and the person in charge have to satisfy the Chief Inspector of Social Services that they are fit to provide the service and that the service will comply with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended). This registration inspection took place over two days. Inspectors met with residents, relatives, the provider and person in charge, staff nurses, the administrator, the chef, and other members of staff. Records were examined including care plans, medical records, accident and incidents log, complaints register, fire safety records, staff records and the policies and procedures. The provider had submitted an application to be registered for older person (over 65 years of age). Discussions were held with the provider about the category of care applied for and he confirmed in his application was for older persons only. There was no statement of purpose to reflect the category of care as defined by the provider or the service being provided. Separate fit person interviews were carried out with the provider for his dual role as provider and person in charge. The provider had completed the fit person self assessment document in advance of the inspection and this was reviewed by inspectors, along with all the information provided in the registration application form and supporting documents. The provider had completed extensive works to the internal facilities in order to enhance the quality of life for residents. There was a homely atmosphere and the building was nicely decorated with domestic style furniture. The premises were maintained in a clean condition and was odourless. Due to the small size of the centre, residents and staff knew each other very well and many were on first name terms. The provider had an informal approach to governance which resulted in a lack of management systems. Adequate risk management measures were not in place and the clinical leadership of the person in charge was not built on evidenced based nursing care. Training records and interviews held with staff indicated that they had received limited continuous training and education. Inspectors were seriously concerned about inadequate staffing levels during the day to meet the needs of residents. Care assistants worked as multi task attendants and changed from different roles such as personal care to household duties which meant that there were not enough staff to attend to residents at times.

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Following the inspection the provider was required to take immediate action and submit a plan to address the inadequate staffing levels during the day. The fit person entry programme self assessment was not adequately completed and as a result the provider was also requested to resubmit this self assessment. On foot of this immediate action plan the provider submitted a satisfactory written response outlining the action taken. The provider sought further information from the Authority in relation to staffing levels. Residents’ basic healthcare needs were being met. General practitioners (GPs) called to residents on a regular basis and nursing assessments were completed for all residents. However, significant improvements were required to some aspects of medication management and residents’ care plans. Peripatetic services were not readily available to residents. Inspectors also identified some improvements that were required regarding residents’ quality of life. Inspectors observed very limited activities for residents and the midday mealtime was disorganised and unsociable. There were insufficient staff during mealtimes to supervise and assist residents and supervision in the day-room was also intermittent. These and other improvements are detailed in the body of the report and included in the Action Plan at the end of the report.

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Comments by residents and relatives Prior to the inspection the Authority received no completed questionnaires from residents and relatives. At the outset of the inspection the provider gave inspectors two questionnaires he had received from relatives which were subsequently reviewed. Inspectors met and spoke with residents and relatives during the course of the inspection. Some residents told inspectors that a lot of improvements were recently completed. One resident said “… They did a lot in the last couple of months like painting the place”. This resident also mentioned that “The place was always clean”. One relative described the place as “…Lovely and very welcoming” and told an inspector that her family member “…Did not settle but she was won around”. One resident was concerned that about the cost of living in the centre and was worried if he/she had enough money to pay for it. Many of the residents spoken to felt safe living there and one resident said “I feel very safe; there is a lot of protection”. Relatives who completed questionnaires and talked to inspectors considered that their family members were safe which was important to them. Both residents and relatives identified the person in charge or senior nurse as someone they would approach if they required information or had a concern. Inspectors asked residents about how day-to-day life was fulfilled. One resident told an inspector that there was “Not that much to do”. Some residents mentioned how they watched television, read papers and magazines. Another said that he played skittles and liked to watch sport on the television. Some of these residents told inspectors that they occasionally went outside in the fine weather. Both residents and relatives mentioned how residents went for walks within the building. One relative said that “There was not much communal space” and that It would be nice if there was a safe garden and residents could sit out. Residents and relatives were generally positive about the laundry service. One relative said that clothes were not lost and described the laundry as okay. A resident mentioned to an inspector that “They look after my clothes well. Residents spoke highly of staff and some described them with compliments such as “…They are looking after me well” and “They have good personalities”. Other residents told inspectors that staff were very good to them. This feedback received from residents and relatives was examined during the inspection.

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Overall findings 1. Governance: how well the centre is organised Outcome: The centre is well organised and managed and complies with the requirements of the Health Act 2007, the Regulations and standards. Good governance involves the effective and efficient deployment of resources in accordance with the stated purpose and function of the centre. Governance includes setting clear direction for the service, a commitment to continual improvement and having a system in place to effectively assess and manage risk. Evidence of good practice The provider who is also the person in charge demonstrated good leadership skills and had a positive attitude to quality improvement. He was knowledgeable of residents’ life histories and was well known to residents. The provider outlined to inspectors many of the changes he had made to the service following the publication of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland. For example, parts of the building were upgraded and some additional facilities were provided in order to comply with the Regulations including a sluice room. In his role as person in charge he introduced a new care planning process, formalised an activities programme and developed a number of policies and procedures. Fire equipment maintenance records and test certificates were available and up-to- date. Fire equipment was serviced on the 1 July 2010 along with testing of the alarm system and emergency lighting. Formal fire training of all staff and a fire drill was also completed on this date. Procedures to be followed in the event of a fire were displayed prominently in the entrance area. When questioned, staff demonstrated a clear understanding of these procedures and were able to describe the use of the fire doors and compartmentalising in the event of a fire. The insurance certificate was reviewed and found to be up-to-date. Insurance cover was in place against loss or damage to the property of residents. During the fit person interview the provider was questioned on his business plan. He explained that his accounts were independently audited by an accountant on a yearly basis and outlined arrangements he had in place for emergency expenditure and other significant expenditure.

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Some improvements required The person in charge was aware of the Regulations and the Standards; however he did not demonstrate an adequate knowledge of the Health Act 2007. Consequently his lack of knowledge impacted on how the service was governed and there was a potential risk that the provider would be unable to meet some of his legal responsibilities. All of the policies and procedures required were not in place and some of the policies available were not implemented. Inspectors reviewed the policies and procedures and found that while a number of policies required in Schedule 5 of the Regulations were in place some were absent including the provision of information to residents, missing persons and the creation, access, retention and destruction of records. Inspectors reviewed a sample of the policies and found that they were concisely written. However, aspects of some polices were not fully implemented into practice. When questioned some staff were not aware of and had not read the policies relevant to their duties. While the complaints procedure was prominently displayed it did not meet the Regulations. Inspectors found that there were two complaints policies and neither fully complied with the Regulations. One of the policies made incorrect reference to the Authority and the Health Service Executive (HSE) as bodies to which residents could complain and the other policy did not identify an independent person as part of the appeals process. The person in charge told inspectors that there were no complaints received to date. A complaints log was in place for the recording of any complaints but no complaints had been received to date. Contracts of care were available for each resident however they did not fully comply with the Regulations. Some contracts did not list the fee charged to the resident and a full list of additional fees were not detailed. Contracts reviewed by inspectors were signed by the resident or his/her representative. Inspectors read the emergency plan and found that it contained the majority of the information that staff need in an emergency. The plan outlined procedures to be followed in the event of emergencies including power outage and disruption to water supply and identified alternative accommodation which residents could be transferred to in the event of evacuation. However, information such as the provider’s telephone number, contact details of utility providers and other relevant organisations were not documented. Adequate controls were not in place to ensure that all persons in the centre had been evacuated in an emergency. There were no measures, such as a visitors’ book, to identify who had entered or left the premises. Inspectors found that the directory of residents was well maintained and up-to-date. However, details of the name and address of any authority, organisation or other body that arranged the resident’s admission as required in the Regulations was not included.

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Whilst the provider produced the required documentation in a timely manner, inspectors noted that the health care documentation was fragmented. For example, information pertaining to the same resident was held in a number of different files which may lead to confusion and poor continuity of care. The provider informed inspectors that he did not manage residents’ finances. He reported that a statement of each resident’s account of fees paid was issued to the resident or his/her representative on a yearly basis. However, these accounts and copies of all receipts for any additional fees charged to residents were not available. Adequate controls were not in place to ensure that all persons in the centre had been evacuated in an emergency. There were no measures, such as a visitors’ book, to identify who had entered or left the premises. Significant improvements required Staffing levels were inadequate during the day to assist and supervise residents, particularly during meal times. Care assistants worked as multi task attendants and performed a number of tasks including laundry, cooking and cleaning. As a result of this system, one care assistant was deployed as the cook each day while another was responsible for cleaning and doing the laundry in the morning in addition to her care assistant role. In the afternoon from 3.00 pm one nurse and one care assistant were on-duty. This care assistant also prepared the residents’ evening meal from 3.30 pm to 5.00 pm. The amount of time available for care assistants to spend meaningful time with residents and to facilitate stimulating activities for them was limited. An immediate action plan was served on the provider requiring him to address this serious matter. A risk management policy had not been developed and implemented. Inspectors reviewed the health and safety statement which was updated in March 2010. It included information on workplace safety and the responsibilities of the employer, employees and visitors. Inspectors found that there were no policies on missing persons and managing assaults, as required by the Regulations. While some risk assessments were carried out and control measures were identified, inspectors noted hazards during the inspection which were not managed. For example, the hot water supply from some hand-wash basins in residents’ bedrooms and in an assistive shower room was scalding hot. This was brought to the attention of the person in charge during the inspection and he rectified the matter immediately. A statement of purpose was not available. There was a mission statement which was presented to inspectors as the statement of purpose however this did not meet the requirements listed in Schedule 1 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended). When questioned, staff were not familiar with the policy on the prevention of elder abuse which was implemented in May 2010. Some staff were not aware of the different types of elder abuse and there was a risk that they would not be able to protect residents from the risk of abuse. There were no formal arrangements in place to educate staff in this area.

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Inspectors reviewed training records which indicated that mandatory training in moving and handling of residents was completed by all staff. Despite this, staff were unable to demonstrate their knowledge and were unsure if they had received training. This lack of knowledge was reflected in practices observed which posed a risk to residents’ and staff safety. Inspectors noted that the qualifications of the trainer were not substantiated and course content was not available. The system for the management of accidents and incidents was not comprehensive and the procedure for investigating accidents as outlined in the health and safety statement did not reflect practice. For example, it was recorded in the statement that “The cause of the accident must be established, corrective action identified and controls put in place to prevent reoccurrence”. This was not happening in practice. A duplicate book was used to record a brief narrative on each fall that occurred and inspectors noted that the last entry was in 2006. There was no system in operation to record incidents, accidents and near misses and inspectors found it difficult to ascertain if the resident’s next of kin and/or general practitioner (GP) were contacted. There was no auditing and monitoring of incidents, accidents and near misses to inform learning and improve practice. The person in charge did not understand the importance of auditing and did not collect data to monitor trends in order to improve the quality of residents’ lives. Written confirmation from a competent person was not available to confirm that all the requirements of the statutory fire authority were met.

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2. Quality of the service Outcome: Residents receive a good standard of service, appropriate treatment and are treated with courtesy and respect. A quality service is one where residents are protected from harm or abuse, where practice is person-centred, where rights are protected, where residents are enabled to play an active part in the centre and where management, staff and residents work together towards continuous improvement. Evidence of good practice A residents’ committee had been established and the first meeting was held on the 20 June 2010. A note of this meeting was recorded in a residents’ committee book. This forum gave residents an opportunity to bring forward suggestions, provide feedback and contribute to decision making. The person in charge told inspectors that he intended to have the meeting on a regular basis and maintain formal minutes of these meetings. He also recognised the value in having an independent person facilitating the meetings and said that a visitor who was from the local community and well known to the residents had been approached and appointed as the residents’ advocate and would facilitate future meetings. The provider acknowledged that this person may require some training to fulfil the post. Residents’ religious and spiritual needs were being met. Residents’ religious preferences were identified on admission. Mass took place at least fortnightly and communion was administered each Sunday. Inspectors were informed by staff that the rosary took place in the day-room and residents confirmed that this was a daily occurrence. At the time of inspection all residents were Roman Catholic. The person in charge had a detailed list of contacts available for any future resident admitted who may be from a different religion. The dining room was nicely presented for residents. The room was bright and airy and soft music was playing in the background. There was a variety of condiments on the table including mustard, salt, pepper and sauces. Staff were attentive to residents’ personal appearance. Residents spoken to were satisfied with how personal clothing was looked after and some commented that they enjoyed a recent visit by a beautician. Inspectors viewed the ‘beauticians work list’ which indicated that the beautician service was recently introduced on the 6 July 2010. Reference was made to six residents receiving massage and nail care.

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Some improvements required The activities schedule was extremely limited with little meaningful stimulation for residents. Some activities had been introduced recently and inspectors saw residents taking part in skittles and ball games while others played cards with a staff member. Residents were encouraged to join in with the activities and became very animated when they did so. However, the schedule cited some parts of the daily routine such as ‘Mid Morning Snack’ and ‘Afternoon cuppa’ as activities. Activities were not informed by residents’ interests which were comprehensively recorded in residents’ social participation assessments. For example, some residents expressed an interest in music and ceili sessions however this was not incorporated into the activities schedule. Inspectors noted that some of the more independent residents did not participate in the activities which were provided. Instead these residents spent most of the day in their bedrooms. Inspectors saw that the television was on all day and at times the volume was loud. This did not encourage residents to engage with each other as the background noise made it difficult to communicate. The mealtime experience for residents required improvement. The dining experience was not sociable and there was very little conversation between residents and staff. Inspectors sampled the food which was hot and saw that residents were served adequate portion sizes. Residents’ independence was not sufficiently promoted. For example, gravy was added to all dishes and all residents wore plastic bibs although some did not appear to need one. When asked about the quality of the food, residents made little comment. The modified meals for some residents who required a pureed diet were not presented in an appetising way. All the ingredients of these meals were pureed together and served in a bowl. The cook demonstrated knowledge of residents’ special dietary requirements and food preferences. However, there was no record maintained in the kitchen of residents’ special dietary requirements, preferences, likes and dislikes. The seven day menu cycle did not present residents with adequate choice and variety at all mealtimes. Inspectors noted that there was no choice of lunch dish available. While there were two meat options available, both were served together on one plate. An assistive bathroom was not available to allow residents choice in having a bath or shower. Inspectors found that residents were not afforded complete privacy and dignity in their daily routines. For example:

some residents who shared bedrooms were not given sufficient privacy when personal care was being delivered. Inadequate screening was provided in some shared rooms and the screen did not extend fully around either bed

one resident was observed in the communal areas with his/her catheter bag visible which did not safeguard this resident’s dignity. The person in charge informed inspectors that they had tried a more discreet leg bag but it was not suitable for the resident however other alternatives had not been explored

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there was no system in place to indicate when the assistive shower room or residents’ toilet was in use. There was no lock on some of these doors which meant that someone could walk in on the resident and compromise his/her privacy.

Significant improvements required Some residents who required assistance during meal times did not receive it when required. Inspectors saw dependent residents waiting for their meals whilst others were eating. Inspectors noted while one resident was waiting for his/her meal another resident was giving him/her food from his/her plate. One maximum dependency resident needed assistance and was seen reaching for his/her cup on a number of occasions but was not able to lift it without assistance. Inspectors drew this to the attention of staff members. Another resident needed additional support to eat his/her meal independently and would have benefited from the use of a plate guard to preserve his/her dignity and assist him/her with eating. Minor issues to be addressed There was no access to a professional hairdresser. As a result unqualified staff cut, coloured and styled residents hair. One resident’s hair colour needed attention.

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3. Healthcare needs Outcome: Residents’ healthcare needs are met. Healthcare is integral to meeting individual’s needs. It requires that residents’ health, personal and social care needs are assessed and reviewed on an ongoing basis, within a care planning process that is person centred. Emphasis is firmly placed on health promotion, independence and meaningful activity. Evidence of good practice There was some evidence that residents’ health and well-being was monitored and promoted. Inspectors saw residents being encouraged and assisted by staff members to walk and continuously mobilise throughout the day. Ample supplies of fluids were available in residents’ bedrooms, the day-room and during meal times. Residents’ files reviewed indicated that blood sugars levels were being monitored on a regular basis for diabetic residents. The person in charge had recently introduced a new assessment and care planning system which was structured and easy to use. Inspectors found that the quality of nursing assessments carried out were of a good standard. One part of the nursing assessment included ‘a key to me’ which was being used to gather personal information about residents’ previous history. All residents had access to GP services and an out-of-hours service was available. One resident told an inspector how the GP “Was near at hand if you wanted to see him”. The person in charge promoted a restraint free environment with the result that there were no forms of restraint in use. An inspector read the policy on restraint and noted that the person in charge had implemented positive alternatives to the use of restraint which was in accordance with the policy. An inspector accompanied the person in charge on the midday medication round and saw medications being administered in accordance with residents’ prescriptions. The person in charge explained to the residents what each medication was and remained with the resident until it was taken. Medications were suitably stored and inspectors were informed by the person in charge that the medication trolley had been recently purchased. Medications requiring strict controls were well managed and stored appropriately.

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Some improvements required Residents had limited access to peripatetic services. Despite residents with medical cards having an entitlement to access services such as dentistry, ophthalmology and audiology, the person in charge had not made these services available. Inspectors observed that some residents had no dentures and others had difficulty hearing. Speech and Language Therapy (SALT) had been accessed for one resident who required assessment however there was no access to occupational therapy. Some residents were observed in specialised seating and the person in charge informed inspectors that chairs provided were based on an assessment carried out by him in consultation with the supplier. The person in charge confirmed that he had no training in this area. He also informed inspectors that a chiropodist attended to residents on a fortnightly basis however there were no records to confirm these visits. An inspector viewed the end-of-life policy which was not dated and found that it did not contain adequate guidelines on end-of-life care including procedures around communication with the resident, family and allied health professionals. Information was available on the care of the body after death. The person in charge highlighted to inspectors the importance of respect and dignity when caring for a resident at end-of-life and demonstrated consideration for family and relatives by offering overnight accommodation. Significant improvements required There were significant gaps in the assessment and monitoring of residents’ health which potentially put residents’ wellbeing and safety at risk. Inspectors saw little evidence to confirm that residents had been weighed regularly and that weight loss or gain was being monitored. There was no record of residents’ weight in the new residents’ care plans and vital signs such as blood pressure were not monitored on a regular basis. The person in charge said that residents’ blood pressure would only be monitored if this was clinically indicated as necessary. Additional risk assessments were not carried out to determine if residents were at potential risk of developing pressure ulcers. Inspectors examined some of the pressure-relieving mattresses and noted that the pressure settings on the mattresses did not correlate with residents’ weight. Consequently this increased the risk of some residents developing pressure ulcers. Staff confirmed that they had not received guidance or training on the use of these mattresses. Some information gathered in the nursing assessments and additional risk assessments did not link to the residents’ care plans. As a result some residents’ care plans did not contain interventions for all of the residents’ needs. For example, one resident in a specialised chair was unable to independently mobilise from the chair and yet there was no direction or specific instructions in the resident’s care plan for exercise and mobilisation. Inspectors did not observe this resident being mobilised during the inspection.

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Inspectors reviewed the medication management procedures and found that a number of significant improvements were required. Concerns identified included:

a medication policy was not in place to inform and guide practice. The person in charge showed inspectors reference material which he used instead of a policy

there was no photograph of each resident attached to the residents’ medication prescription charts

the time of administration was not detailed or pre-printed on the residents’ prescribing and administration charts. Sufficient space was not available on the administration charts to record comments if a medication was withheld or refused

residents medications were transcribed onto the prescription chart, the transcribing nurse did not sign the transcribed medications

with the exception of medications requiring strict controls other medications returned to the pharmacist were not recorded and were not signed by the pharmacist as having been returned

medical records reviewed indicated that some residents’ did not receive regular medication reviews

residents’ prescription charts were re-written, however new corresponding administration charts were not started which increased the possibility of drug errors

there was no system in place for recording medication errors adequate storage arrangements were not in place for medications. Inspectors

were informed by the person in charge that a medication fridge was not provided but that he would purchase one if required.

Daily nursing notes did not comprehensively reflect the residents’ condition on a daily basis. An inspector read nursing notes maintained for some residents and noted that they were very brief and did not comment on areas such as the resident’s food intake during the day, bowel movements and participation in activities. The nursing notes for one resident were not available.

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4. Premises and equipment: appropriateness and adequacy Outcome: The residential care setting provides premises and equipment that are safe, secure and suitable. A good physical environment is one that enhances the quality of life for residents and is a pleasant place to live. It meets residents’ individual and collective needs in a comfortable and homely way, and is accessible, safe, clean and well-maintained. Equipment is provided in response to the assessed needs of each of the residents and maintained appropriately. Evidence of good practice There was a homely and relaxed, welcoming atmosphere. Inspectors observed the building to be warm, bright and nicely furnished. The corridors were wide and uncluttered which enabled residents to mobilise in a safe environment. The provider had made many improvements to the building in order to comply with the Standards and the Regulations. For example, a sluice room and cleaning room were provided. Some existing facilities were upgraded including the laundry room and reception room. The floor covering in parts of the building was replaced and new furniture was provided in some residents’ bedrooms. A visitors’ room was available for residents to meet visitors in private. The room was nicely decorated with domestic style furniture. All residents’ bedrooms had a lockable storage space for residents’ personal belongings. Some residents mentioned that they were pleased with a locked drawer in their bedrooms. Some of the bedrooms were personalised with residents’ belongings including photographs and radios and residents told inspectors that they were encouraged to bring in personal belongings. Adequate assistive equipment was available and the equipment-servicing records were reviewed and found to be up-to-date. Some new equipment had been recently purchased including high/low hydraulic beds. Inspectors viewed the maintenance records for equipment such as beds, hoists and pressure relieving mattresses and noted that they were serviced within the last year. A maintenance log was also maintained to record any day-to-day faults. Adequate laundry facilities were provided. New cupboards were fitted and counter space provided for the segregating and sorting of soiled and clean laundry. Staff told inspectors that the washing machine was recently purchased and installed. A new cleaning room was provided in an outside building. This room was fitted with a hand-wash basin and adequate space for cleaning chemicals and equipment. A cleaning sink was installed for the filling and emptying of mop buckets. Cleaning chemicals were stored under locked conditions in this room.

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Hand sanitisers were prominently sited throughout the building and staff were observed being vigilant in their use. Some improvements required The outdoor area was not secure which meant that residents who were confused were not allowed to access the garden. A relative commented in a questionnaire that it would be nice to have an outdoor area that residents could use. The provider informed inspectors that he planned to provide a secure garden area for residents with dementia within the next six months. Inspectors observed that some parts of the centre were inadequate in size and layout and did not comply with all the requirements of the Standards. For example, the layout of the day-room did not promote conversation and interaction amongst residents, visitors and staff as the armchairs were positioned along the walls. The size of some residents’ bedrooms was not adequate for the needs of those residents with the result that sufficient private accommodation was not provided. While adequate laundry facilities and equipment were available adequate laundry processes were not in place. There was no procedure for segregating and sorting laundry. As a result staff were unsure about how they organised residents’ laundry. Significant improvements required Infection control practices were reviewed by inspectors and some serious concerns were identified as posing a risk:

an inspector reviewed the infection control policy and found that there were no specific procedures or clear guidelines to minimise the risk of cross contamination for care assistants who worked as multi-task assistants and changed between different roles such as personal care duties to household or kitchen duties

hot water was not available to the hand-wash basin in the cleaners’ room and paper towels were not available. Materials for hand-washing were not provided in the sluice room. As a result staff were unable to hygienically wash their hands

inspectors observed staff who were not disinfecting commode basins and instead were rinsing them under luke warm water which did not sterilise or disinfect these basins

catering and non catering staff used the same staff toilet increasing the risk of cross contamination. A wheelchair accessible visitors’ toilet was not available which meant that visitors also used this toilet

suitable staff changing facilities were not provided. Access to the laundry with soiled linen was through the staff changing area which meant that there was an increased risk of infection

inspectors were told that care assistants who completed cleaning duties used the same mop in both residents’ bedrooms and toilets increasing the risk of cross contamination.

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open weaved basins were used to store all soiled laundry. Soiled linen including tea towels were stored amongst personal clothing and not segregated

inspectors were informed that the process for washing heavily soiled linen was to soak the linen in bleach which was not in-line with best practice in infection control.

Some hazards were identified within the premises which posed a risk to residents’ safety:

during some periods of the inspection, access and egress was not controlled from one part of the building which meant that residents with dementia could leave the building and be at risk

grab rails were not fitted beside the shower in one assistive shower room and in the residents’ toilet which potentially compromised the safety of residents.

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5. Communication: information provided to residents, relatives and staff Outcome: Information is relevant, clear and up to date for residents. Information is accessible, accurate, and appropriate to residents’ and staff needs. Feedback is actively sought from residents and relatives and this informs future planning and service provision. Information is recorded and maintained in accordance with legal requirements and best practice and is communicated to staff on a need to know basis to ensure residents’ privacy is respected. Evidence of good practice An inspector observed a staff handover between two nurses, one of whom was coming on-duty and the other going off-duty. The handover was comprehensive and each resident’s current condition was discussed. There were different forms of communication in place. A stand was prominently displayed at the entrance area which included a variety of information leaflets on such areas as the ‘Drugs Payment Scheme’ and beauty treatments available to residents. Information on planned activities and upcoming events were posted for residents’ attention. Residents had access to television, radio and a plentiful supply of newspapers and age appropriate magazines. The person in charge told inspectors that the flat screen television and CD player were recently bought and this enhanced residents’ entertainment. Residents had access to the hand held phone to make and receive calls in private. Inspectors saw a resident being given this phone to receive a call in the privacy of his/her bedroom. Staff and residents confirmed this was normal practice. Friendly interaction was observed between residents, staff and visitors. Residents and staff knew each other well and many were on first name terms. Staff on-duty wore name badges and uniforms to distinguish the different grades of staff. Some residents commented on how this was a useful reminder to them. Inspectors noted that residents and staff files were maintained confidentially. Some improvements required The Residents’ Guide was not made available to residents. Inspectors reviewed the Guide and found that it did not fully comply with all of the requirements listed in the Regulations. For example, the terms and conditions of accommodation and the address and telephone number of the Chief Inspector were not detailed. Some information documented in the Guide did not reflect the actual staff roster. It stated that there was a nurse on-duty along with two care staff in the mornings however

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this was not reflected in the staff roster as one nurse and one care assistant were on-duty in the morning. Inspectors viewed the communication policy. The policy did not contain adequate guidelines for staff on how to communicate effectively with residents who had communication difficulties or those with dementia. While a number of staff had signed the policy to confirm they had read it, some staff were not familiar with the policy. Other staff were able to describe appropriate techniques they used when communicating with residents with dementia including distraction techniques. They also highlighted the importance of following the residents’ conversation and reassuring these residents. Adequate signage was not displayed in the building for residents with dementia. This did not aid orientation of these residents and promote independence. Minor issues to be addressed The laminated menu displayed on the kitchen door facing the dining room was not clearly visible to all residents sitting in the dining room.

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6. Staff: the recruitment, supervision and competence of staff Outcome: Staff are competent and recruited in sufficient numbers to meet residents’ needs Staff numbers and skill-mix are determined by the size and complexity of the service and there should be sufficient competent staff on duty, both day and night, to meet the needs of residents. Robust recruitment and selection procedures ensure the appointment of suitably qualified and experienced staff. Staff are supported in their work by ongoing training and supervision. Evidence of good practice Staff told inspectors that the person in charge was supportive and was very approachable. The person in charge was seen continually interacting with residents and staff throughout the inspection. Staff records reviewed showed a low staff turnover. No staff member had left the service during the previous 24 months. Some improvements required Inspectors reviewed the recruitment, selection and vetting policy. The policy was detailed and included information on job descriptions and personal specifications, recruitment methods and the interview process. However, it did not specify some information required prior to appointment such as evidence of mental and physical fitness and three written references. There were no definitive job descriptions or guidelines in place for staff. The job description in place for care assistants did not include guidelines for staff who worked as multi task attendants and changed from giving personal care to working in the kitchen or undertaking dining duties. There was no specific job description for nursing staff. The person in charge informed inspectors that the care assistant job description was also used for nurses. A sample of staff personnel files were reviewed by inspectors who found that some information was obtained from staff including photographic identification and a CV. However, there was no evidence of mental and physical fitness or three written references. The person in charge informed inspectors that Garda Síochána vetting had been applied for all staff.

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Significant improvements required There was no formal programme of training and education for all staff based on the assessed needs of residents and service requirements. There was no process in place to allow staff to identify their specific training needs. The person in charge told inspectors that he was currently completing a degree in psychology. However, he was unable to provide evidence that he had undertaken continuous clinical training to provide care in accordance with contemporary evidence based practice. Staff were not adequately trained in areas such as dementia care and infection control. Some care assistants who also worked as cooks had not received adequate food hygiene training or supervision. Minor issues to be addressed Staff meetings had recently commenced however these meetings did not take place on regular basis and minutes were not maintained.

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Closing the visit At the close of the inspection visit a feedback meeting was held with the provider and assistant person in charge to report on the inspectors’ findings, which highlighted both good practice and where improvements were needed.

Acknowledgements The inspectors wish to acknowledge the cooperation and assistance of the residents, relatives, provider and staff during the inspection.

Report compiled by: Nan Savage Inspector of Social Services Social Services Inspectorate Health Information and Quality Authority 10 July 2010

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Provider’s response to inspection report

Centre:

Ballygar Nursing Home

Centre ID:

0319

Date of inspection:

7 July and 8 July 2010

Date of response:

21 September 2010 Revised: 14 October 2010 Revised: 16 November 2010

Requirements These requirements set out what the registered provider must do to meet the Health Act 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland.

1. The provider is failing to comply with a regulatory requirement in the following respect: Staffing levels and skill-mix were inadequate having regard to the needs of residents. There were inadequate staffing levels during the day to assist and supervise residents and the time available for care assistants to spend with residents and facilitate activities was limited. Action required: Put in place adequate numbers of staff that are appropriate to the assessed needs of all residents. Reference:

Health Act, 2007 Regulation 16: Staffing Standard 23: Staffing Levels and Qualifications

Health Information and Quality Authority Social Services Inspectorate Action Plan

Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: One extra care staff have been roistered from 9.00 am to 1.00 pm each day to assist with resident activity and meal times. These care staffs are solely for residents needs as distinct from kitchen or cleaning duties.

Already in place

2. The provider is failing to comply with a regulatory requirement in the following respect: Residents’ weight was not being adequately monitored and there was no record of their weight in the residents’ care plans. Vital signs such as blood pressure were not monitored on a regular basis. Care plans did not reflect all of the residents’ current needs and care plans were not in place for some residents with specific needs. For example, additional risk assessments were not carried out to ensure residents were not at potential risk of developing pressure ulcers. There was no record of consultation and agreement with the resident or his/her representative when the resident’s care plan was developed or reviewed. Action required: Ensure that all of the residents’ healthcare needs are assessed and monitored. Action required: Set out each resident’s needs in an individualised care plan, developed and agreed with each resident. Make the care plan available to residents and formally review the care plan with residents or their representative as required. Reference: Health Act, 2007 Regulation 8: Assessment and Care Plan Standard 11: The Resident’s Care Plan Please state the actions you have taken or are planning to take with timescales:

Timescale:

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Provider’s response: More frequent monitoring of weights and vital signs will be carried out and recorded. Additional risk assessments will be included in care plans and consent obtained from resident/representative with regard to discussion and implementation of care plan. Residents’ weight will be monitored recorded on a monthly basis in resident’s files. We are already doing this. Vital signs are now being recorded on a weekly basis and documented in resident’s files. We are already implementing this. Care plans are now developed that are specifically designed for residents needs and include risk assessments tools for potential for developing pressure ulcers e.g. Waterlow scale. Each care plan has been agreed and signed by the resident or their next-of-kin.

3 months Nov. 2010 Completed

3. The provider is failing to comply with a regulatory requirement in the following respect: There was no evidence that the residents’ weight was being used to determine pressure settings on mattresses and this increased the risk of developing pressure ulcers. Staff had not received guidance or training on the use of these mattresses. Action required: Review the pressure settings on all pressure-relieving mattresses to ensure that they are appropriately and suitably set. Action required: Provide training and guidance to staff to ensure that they are aware of how to correctly set mattresses. Reference:

Health Act, 2007 Regulation 17: Training and Staff Development Standard 24: Training and Supervision Please state the actions you have taken or are planning to take with timescales:

Timescale:

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Provider’s response: Guidance and training will be provided to staff on the setting of mattresses, and risk of developing pressure ulcers. We have instructed and shown all staff the pressure settings that are appropriate to resident’s weight. (A company representative will give instruction also.) Company representatives have been contacted and have given us instructions and labels for each mattress with regard to settings.

Completed

Completed

4. The provider is failing to comply with a regulatory requirement in the following respect: Aspects of the medication management process were not sufficient. For example:

There was no medication management policy in place there was no photographic identification of each resident attached to his/her

prescription chart administration times were not detailed on the residents’ prescription charts residents’ medications were transcribed onto the prescription chart. The

transcribing nurse did not sign the transcribed medications. medications returned to the pharmacist were not recorded and were not been

signed as such by the pharmacist medical records reviewed indicated that some residents’ did not receive regular

medication reviews residents’ prescription charts were re-written however corresponding

administration charts were not started which increased the possibility of drug errors increased

a system was not in place for recording medication errors provide adequate storage arrangements for specific medications which may be

required refrigeration. Action required: Put in place appropriate and suitable practices and written operational policies relating to the ordering, prescribing, storing and administration of medicines, the handling and disposal of unused or out of date medicines. Ensure that staff are familiar with such policies and procedures. Action required: Arrange for medications reviews to be completed by the GP on a regular basis. Action required: Arrange for each individual transcribed medication to be signed by the transcribing nurse.

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Action required: Provide photographic identification of each resident. Action required: Record administration times on the residents’ prescription charts. Action required: Ensure all medications returned to the pharmacist are recorded and signed as such by the pharmacist. Action required: Put in place a system for recording and reducing the risk of medication errors. Reference:

Health Act, 2007 Regulation 33: Ordering, Prescribing, Storing and Administration of Medicines Standard 14: Medication Management Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response:

1. We are using new medication policy in our centre and all staff are familiarizing themselves with it and adhering to it. Clear guidelines regarding the handling, storing and administration of medicines and disposal of unused or out of date medicines are being implemented

2. photographic Identification of each resident has been attached to each administration recording sheet to prevent any danger of drug administration error

3. medication reviews of each resident will be conducted by G.P. and documented on resident’s medical file

4. an administration time for each medication is clearly shown on Medication Administration sheet

5. there is a part in our Administration records for returned medication and for signature of Pharmacist

6. prescriptions now adhere to Administration charts and are signed by the nurse administrating the medication at the corresponding time

7. we are now adhering to Medication an error report form that provides a recording system for medication errors

8. a small fridge for storage of Medications that require refrigerated storage is now provided.

3 Months November 2010 Completed

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5. The provider is failing to comply with a regulatory requirement in the following respect: The risk management system in place does not control the risk of accidental injury to residents, staff or visitors in that:

there was no documented risk management policy and the health and safety statement did not contain policies on missing persons and managing assaults

the system for managing accidents and incidents was not comprehensive and adequate details were not recorded on each accident that occurred. Incidents and near misses were not being recorded

access and egress was not continuously controlled from one exit of the building which meant that residents with dementia could leave the building and be at risk

the hot water supply from some hand-wash basins was scalding hot grab rails were not provided to the shower in one assistive shower room and the

residents’ toilet the outdoor area was not secure which meant that residents who were confused

were unable to access the garden the emergency plan did not contain contact details for relevant organisations in

the event of an emergency.

Action required: Develop and implement a comprehensive risk management policy throughout the centre and put in place policies including missing persons and managing assaults. Action required: Provide adequate security measures to ensure the safety of residents. Action required: Take all reasonable measures to prevent accidents to any person by putting in place a system for effectively managing the risk and ensure that wash-basins are fitted with a hot water supply which incorporates thermostatic control valves or other suitable anti-scalding protection. Action required: Provide grab rails in shower and toilet areas. Action required: Provide external grounds which are suitable for, and safe for use by residents. Action required: Put an emergency plan in place that provides adequate contact details which may be required in the case of identified emergencies.

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Reference: Health Act, 2007 Regulation 31: Risk Management Procedures Standard 26: Health and Safety Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response:

1. We have already employed services of health and safety officer to develop a risk management policy that will contain policies on missing persons and managing assaults by December 2010.

2. A more comprehensive system for managing

accidents/incidents and a more detailed recording of them will be commenced and developed as part our risk management system by December 2010.

3. Constant control of each exit to our centre is now being

adhered to. Each door is located for the safety and well-being of our Residents. We are doing this already.

4. A plumber has been contacted and has advised us of the need

for installation of thermostatic control valves on hand basins. This will be completed before the end of 2010.

5. Grab rails will be installed in the assistive shower rooms and

residents toilets by the end of November 2010. 6. Our current outdoor garden provides for the residents an

outdoor environment when supervised and a member of staff accompanies them. We will provide a secure section in the garden before June 2011.

7. We have added additional contact details of relevant

organisations in our Emergency Plan. This is done already.

February 2011

February 2011

Completed

December 2010

Completed

June 2011

Completed

6. The provider is failing to comply with a regulatory requirement in the following respect: Some peripatetic services were not available to residents including occupational therapy. Action required: When a resident requires occupational therapy or any other services as may be required, access to such service must be facilitated by the provider or by arrangement with the HSE.

Reference: Health Act, 2007 Regulation 9: Health Care Standard 13: Healthcare Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: We have accessed optical care for our residents and some have received glasses chiropody services have been obtained and residents needs in this area attended to. Audiology referrals have been sent to HSE in Galway for some of our residents. An Occupational Therapist has also been accessed and this service will be facilitated by the provider. Peripatetic services will be accessed and offered to residents if they require them.

December 2010

7. The provider has failed to comply with a regulatory requirement in the following respect: The following practices were not in-line with best practice in infection control and posed an infection control risk in that:

tThe infection control policy did not contain specific procedures or clear guidelines for care assistants who worked as multi-task assistants and changed from different roles such as personal care duties to household or kitchen duties

hot water was not available to the hand-washing basin in the cleaners room, paper towels were not provided to the hand-wash basin in the cleaning room and materials for hand washing were not available in the sluice room

commode basins were not disinfected and instead were rinsed under luke warm water which did not sterilise these basins

catering and non catering staff used the same staff toilet. A wheelchair accessible visitors’ toilet was not available and resulted in visitors using this toilet

suitable staff changing facilities were not provided. Access to the laundry was through the staff changing area which meant that there was an increased risk of infection

the same cleaning mop was used in both residents’ bedrooms and toilets open weaved basins were used to store all soiled laundry and soiled linen

including tea towels were not segregated and instead were stored among personal clothing

the process for washing heavily soiled linen was not in-line with best practice in infection control.

Action required: Amend the infection control policy to include clear guidelines for staff who work as multi task attendants and change between roles. Implement a good standard of evidence based nursing practice to eliminate the risk of cross infection to residents and staff.

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Action required: Provide adequate staff changing and toilet facilities for catering and non catering staff. Action required: Provide an adequate supply of hot water, hand washing and drying materials at all hand-wash basins. Action required: Put in place appropriate systems to control the risk of cross contamination during laundry and cleaning. Action required: Implement suitable procedures to adequately disinfect commode basins. Reference:

Health Act, 2007 Regulation 19: Premises Standard 25: Physical Environment Please state the actions you have taken or are planning to take following the inspection with timescales:

Timescale:

Provider’s response: We are amending and setting out clear guidelines for infection control for staff in the nursing home.

Policies will be amended and staff educated with regulars to same.

Hot water and paper towels will be available in sluice rooms and cleaning room.

We will amend infection control policy to contain procedures for care assistants who also may work in other roles by December 2010.

We will provide hot water in cleaning rooms and paper towels which is already in place.

We will provide disinfectants for commode to be sterilized. Which we have completed. Extra staff toilets will be provided and engineer is presently drawing up plans with regard to same. As well as wheelchair accessible toilets. Plans will be completed by February 2011.

December 2010 December 2010 Completed Completed Completed Completed February 2011

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Different mops and Buckets are presently being used for different areas in the Nursing Home.

Closed linen buckets are now being used for laundry.

Heavily soiled linen is now segregated, washed and separately at 80 degree centigrade.

Completed Completed Completed

8. The provider has failed to comply with a regulatory requirement in the following respect: There was no formal training and education programme for staff based on the assessed needs of residents and service requirements. For example, staff were not adequately trained on areas such as dementia care and infection control. Some care assistants who also worked as kitchen assistants had not undertaken adequate food hygiene training. The person in charge had not undergone continuous clinical training to provide care in accordance with contemporary evidence based practice. Action required: Provide access to education and training for all staff to enable them to provide care in accordance with contemporary evidence based practice. Reference: Health Act, 2007 Regulation 17: Training and Staff Development Standard 24: Training and Supervision Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: We will ensure that all staff is educated in areas commensurate with their role and this will be documented. We have already developed Infection control policies and procedures and will educate and train staff on infection prevention methods. Food Hygiene Training courses accessed for staff and training commenced on it.

March 2011

9. The provider is failing to comply with a regulatory requirement in the following respect: Staff were unable to demonstrate their knowledge in moving and handling of residents. Inspectors observed practices which posed a risk to residents’ and staff safety. The qualifications of the trainer were not substantiated and course content was not available.

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Action required: Provide appropriate training for all staff in moving and handling of residents and ensure that this training is implemented into practice. Reference:

Health Act, 2007 Regulation 31: Risk Management Procedures Standard 26: Health and Safety Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: We plan to provide new manual handling/ training for all staff. We have contacted patient Handling trainer and plan to renew and update our manual handling training for all our staff. This will be completed by January 2011. In the meantime the person in charge has addressed and spoken with staff regarding techniques in the moving and handling of residents and has conducted demonstration at training sessions.

January 2011

10. The provider is failing to comply with a regulatory requirement in the following respect: There were no formal arrangements in place to educate staff on elder abuse. Some staff were not aware of the different types of abuse or familiar with the policy on the prevention of elder abuse which was implemented in May 2010. Action required: Make all necessary arrangements by training staff or by other measures, aimed at preventing residents being harmed or suffering abuse or being placed at risk of harm or abuse. Reference:

Health Act, 2007 Regulation 6: General Welfare and Protection Standard 8: Protection Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: We have already commenced education of staff regarding elder abuse different types through visual DVD workbooks and verbal feedback. We already have a session of this done and plan to have regular updates and education sessions with our staff. This was done on 11 September 2010. All staff have now read policy and signed it and are function with procedures in dealing with it.

November 2010

11. The provider is failing to comply with a regulatory requirement in the following respect: A statement of purpose which met with the requirements listed in Schedule 1 of the Regulations was not available. Action required: Develop and implement the statement of purpose to include all of the information as required by the Regulations. Reference: Health Act, 2007 Regulation 5: Statement of Purpose Standard 28: Purpose and Function Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: We will develop comprehensive statement of purpose as required by the Regulations. We have already completed this.

November 2010 Completed

12. The provider is failing to comply with a regulatory requirement in the following respect: Written confirmation from a competent person that all the requirements of the statutory fire authority was not available. Action required: Provide written confirmation from a competent person to verify that all the requirements of the statutory fire authority have been complied with. Reference:

Health Act, 2007 Regulation 32: Fire Precautions and Records Standard 26: Health and Safety

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Timescale:

Provider’s response: We have contacted a qualified person and he is going to inspect our Nursing home and provide us with relative fire certificate. We have already completed this and submitted same. We will submit further letter of verification from competent person that all the requirements of the statuary fire authority have been complied with.

November 2010

13. The provider is failing to comply with a regulatory requirement in the following respect: Daily nursing notes did not comprehensively reflect the residents’ current condition on a daily basis and the nursing notes for one resident were not available. Action required: Maintain an adequate daily nursing record of the person’s health and condition and treatment given. Reference: Health Act, 2007 Regulation 25: Medical Records Standard 32: Register and Residents’ Records Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: More comprehensive recording of resident’s notes will be implemented and recorded. We are doing this now and implementing care plans. We are recording and implementing notes on resident’s condition from a daily basis.

November 2011

14. The provider is failing to comply with a regulatory requirement in the following respect: There was limited meaningful stimulation for residents and the residents social participation assessments did not inform the activities schedule.

Action required: Provide opportunities for meaningful social interaction and a range of activities appropriate to residents’ interests and capabilities. Reference: Health Act, 2007 Regulation 6: General Welfare and Protection Standard 18: Routines and Expectations Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: New activities programmes with more participation and opportunity for socializing developed. We have already done this.

October 2010

15. The provider is failing to comply with a regulatory requirement in the following respect: The layout and size of some parts of the building were not suitable to comfortably meet residents’ individual and collective needs. For example:

the layout of the day-room did not promote interaction between residents, visitors and staff

some residents bedrooms were not adequate in size a wheelchair accessible visitors’ toilet was not available adequate signage was not displayed in the building for residents with dementia.

Action required: Provide a suitable layout in the day-room that accommodates the specific needs of residents. Action required: Provide adequately sized rooms occupied by residents which are suitable for their needs. Action required: Provide a wheelchair accessible visitors’ toilet. Action required: Provide adequate signage to meet the needs of residents with dementia.

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Reference:

Health Act, 2007 Regulation 19: Premises Standard 25: Physical Environment Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: From 3 months to 5 years for construction of wheelchair accessible toilets

We will change the layout of the day-room to facilitate needs of the residents

We are drawing up plans to provide wheelchair accessible toilet and hope to have them by January 2011

We have already put up new signs on various rooms bedrooms, lounge doors to facilitate residents with Dementia

We are in the process of measuring bedrooms to ascertain their suitability for residents needs Adequate floor space will be provided for each resident.

2012 January 2011 January 2011 Completed February 2011

16. The provider is failing to comply with a regulatory requirement in the following respect: Some practices were observed which compromised the privacy and dignity of residents:

Some residents who shared bedrooms were not afforded sufficient privacy during the delivery of personal care as screening curtains did not fully extend around each resident’s bed

one resident was seen in the communal areas with his/her catheter bag visible which did not afford this resident dignity

a system was not in place to indicate when the assistive shower room or residents’ toilet was in use.

Action required: Review arrangements and provide facilities to ensure that residents’ are able to undertake personal activities in private and that his/her dignity is protected.

Reference: Health Act, 2007

Regulation 10: Residents’ Rights, Dignity and Consultation Standard 4: Privacy and Dignity Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: Extension of screening curtains to afford residents more privacy. Prevision of system to indicate occupancy of toilets/ shower rooms. We plan to extend Curtains around residents beds to provide more privacy for each resident them by January 2011. We will discuss with residents the possibility of acquiring a leg bag for this comfort. We will install system to indicate occupancy of shower rooms, toilets by January 2011.

March 2011 November 2011.

17. The provider is failing to comply with a regulatory requirement in the following respect: The dining experience for residents was not satisfactory and residents’ independence was not promoted. For example:

assistance was not provided to some residents who required it in a timely manner during meal times in order to promote residents independence and dignity

the seven day menu cycle did not offer residents adequate choice and variety at all mealtimes. Records of residents’ dietary requirements, preferences, likes and dislikes were not recorded in the kitchen the modified meals for some residents who required a pureed diet were not presented in an appetising way as all the ingredients of these meals were pureed together and served in a bowl

residents’ choices were limited with gravy being added to all dishes and all residents wearing plastic bibs.

Action required: Provide appropriate assistance to residents who require such assistance with eating and drinking. Action required: Provide each resident choice at each mealtime while taking account of any special dietary requirements; and is consistent with each resident’s needs.

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Reference: Health Act, 2007

Regulation 20: Food and Nutrition Standard 19: Meals and Mealtimes Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: Residents like/dislike and preferences will be highlighted in the kitchen. The need of wearing bibs will be limited to those residents that require them We have one extra care staff on-duty now to facilitate and assist residents in the dining room. Residents are provided with more personal choices now as we have displayed a list in the kitchen of their favourite personal choices at mealtimes We have extended our menu to cover 2 weeks and also provided more variety in the menu Modified diets are now presented and prepared in a more appetizing fashion Bibs are provided to residents that require or request them. Condiments, sauces and gravy offered to resident at meal times.

November 2010 Completed Completed Completed Completed Completed

18. The provider is failing to comply with a regulatory requirement in the following respect: Adequate laundry processes were not in place. There was no procedure for segregating and sorting laundry. As a result staff were unsure about how they organised residents’ laundry. Action required: Provide adequate arrangements for the segregating and sorting of laundry. Reference:

Health Act, 2007 Regulation 13: Clothing Standard 25: Physical Environment


Timescale:

Provider’s response: The separating and segregating of laundry/ linen will take place and infection control procedures with regard to same implemented and staff educated. We already have introduced laundry segregating procedures with covered laundry bins and separate bins for different linen

A new system of separating and segregating laundry has been implemented already taking into account infection control and staffs have been instructed on procedures for carrying out same. We already have this in place.

Completed

Completed

19. The provider is failing to comply with a regulatory requirement in the following respect: The recruitment, selection and vetting policy in place did not detail all the information required prior to appointment such as evidence of mental and physical fitness. Staff files did not contain all the documentation required such as three references and evidence that staff are physically and mentally fit. Adequate job descriptions, procedures and guidelines were not in place for nurses and for staff who multi tasked and changed roles. Action required: Amend the recruitment, selection and vetting policy to reflect all the requirements of the Regulations. Action required: Ensure all information maintained on staff files meet the requirements of schedule 2 of the Regulations. Action required: Implement adequate job descriptions, procedures and guidelines for staff to adhere to when multi tasking and changing roles. Reference: Health Act, 2007 Regulation 18: Recruitment Standard 22: Recruitment

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Timescale:

Provider’s response: The policy on recruitment has been amended to include all relevant information

We are in the process of obtaining evidence of mental/ physical fitness certificates and extra references for staff and job

Mental physical evidence of competency from staff has been obtained Staff references have been obtained already

Job descriptions will be clearly documented for different roles within the care setting by January 2011.

Completed Completed Completed Completed

20. The provider is failing to comply with a regulatory requirement in the following respect: An assistive bathroom was not available to offer residents with choice in having a bath or shower.

Action required: Provide an operational assistive bath for resident use. Reference:

Health Act, 2007 Regulation 10: Residents’ Rights, Dignity and Consultation Standard 4: Privacy and Dignity Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: We will provide an assistive bath for residents.

September 2011

21. The provider is failing to comply with a regulatory requirement in the following respect: There was no formal auditing and monitoring process of accidents, incidents and near misses or other key information therefore there was no evidence of learning and improving practice as a result of monitoring incidents, accidents and near misses.

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Action required: Establish and maintain a system for reviewing the quality and safety of care provided to, and the quality of life of, residents in the centre. Reference:

Health Act, 2007 Regulation 31: Risk Management Procedures Standard 30: Quality Assurance and Continuous Improvement Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: We have commenced medicine audits, complaints audits and monitoring. We also have commenced monitoring of incidents, accidents and near misses and will submit our quarterly returns and notifiable events on the relevant forms to the Authority. We will review the quality and safety of care and the quality of life of the residents in our care or an ongoing basis. We will implement system for the review of incidents/ accidents in our risk management policy. We are already in the process of drawing this up.

January 2011

22. The provider is failing to comply with a regulatory requirement in the following respect: The provider did not demonstrate adequate knowledge of the Heath Act, 2007 and his responsibilities under this legislation. Action required: The provider must be knowledgeable of his legal obligations under the Health Act, 2007. Reference: Health Act, 2007 Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: The provider has reviewed his responsibilities and will ensure he is more knowledgeable and more familiar with the Health Act, 2007 and relevant legislation.

Completed

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The provider will learn and understand the Health Act 2007 in a more comprehensive way. The provider is endeavouring to become more knowledgeable about the Health Act 2007. We have it at our centre.

23. The provider is failing to comply with a regulatory requirement in the following respect: All of the policies and procedures required in the Regulations were not available including the provision of information to residents, missing persons, communication policy and the creation, access, retention and destruction of records. Aspects of some polices were not fully implemented into practice and the end-of-life policy was not dated and did not contain adequate guidelines on end-of-life care. Some staff were not aware of the policies relevant to their duties and had not read them. Action required: Develop all the written operational policies and procedures in accordance with Schedule 5 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) in order to inform practice. Put in place arrangements to ensure staff are knowledgeable of all policies commensurate with their role. Reference: Health Act, 2007 Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: The development and implementation of policies will take place and all staff will become knowledgeable with regard to them. Most staff have already read our policies and signed same

Policies in missing persons, provision of Information to residents, Communication and creation access retention and destruction of records will be drawn up and implemented by March 2011

End-of-life care policy has already been amended, dated and new guidelines added

All staff has now read and is implementing our policies. They have also signed off on the policies.

March 2011

March 2011 Completed Completed

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24. The provider is failing to comply with a regulatory requirement in the following respect: Two complaints policies were in place and neither fully complied with the Regulations. Action required: Put in place a complaints policy in-line with the Regulations. Reference: Health Act, 2007 Regulation 39: Complaints Procedure Standard 6: Complaints Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: We have changed our complaints policy to include the appeals process and recording process in-line with Regulation 39 of the complaints procedures of Health Act, 2007. We are reviewing our complaints policy in order that it complies with the Health act 2007.

Complete

25. The provider is failing to comply with a regulatory requirement in the following respect: Contracts of care were available for each resident however they did not fully comply with the Regulations as some contracts did not list the fee charged to the resident and a full list of additional fees were not outlined. Copies of all receipts were not available for any additional fees charged at the time of payment. Action required: Amend all contracts to ensure that fees are listed. Action required: Maintain records of any additional fees charged to residents. Reference: Health Act, 2007 Regulation 28: Contract for the Provision of Services Standard 7: Contract/Statement of Terms and Conditions

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Timescale:

Provider’s response: Contracts of care will be reviewed and amended to include any additional charges or to include fee chargeable to the particular resident Receipts book has been commenced and will be available for inspection for additional charges and fees. We have completed this action.

Completed

Completed

26. The provider is failing to comply with a regulatory requirement in the following respect: Some required information was absent in the Residents’ Guide including the terms and conditions of accommodation to be provided and the address and telephone number of the Chief Inspector were not detailed. It was documented incorrectly that there was a nurse on-duty along with two care staff in the mornings. However this was not evident in practice as one nurse and one care assistant were on-duty in the morning. This document was not available to residents. Action required: Amend the Residents’ Guide to include all the items listed in the Regulations. Action required: The Residents’ Guide must be made available to residents. Reference: Health Act, 2007 Regulation 21: Provision of Information to Residents Standard 1: Information Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: Residents guide will be amended and additional information will be documented. We already have completed this action.

Complete

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27. The provider is failing to comply with a regulatory requirement in the following respect: The directory of residents did not contain the name and address of any authority, organisation or other body that arranged the resident’s admission as required in the Regulations. Action required: Maintain a record of all the matters listed in Schedule 3 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) in the directory of residents. Reference: Health Act, 2007 Regulation 23: Directory of Residents Standard 32: Register and Residents’ Records Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: Additional information regarding resident’s admission will be documented in residents Directory. We are already operating this action.

Complete

28. The provider is failing to comply with a regulatory requirement in the following respect: In the event of an evacuation adequate controls were not in place to monitor all visitors to the premises. Action required: Maintain a record of all visitors to the designated centre, including the names of visitors. Reference: Health Act, 2007 Schedule 4: Other records to be kept in a designated centre Standard 26: Health and Safety Please state the actions you have taken or are planning to take with timescales:

Timescale:

Provider’s response: Visitors control measures will be put in place in our nursing home. We have commenced a visitor’s book and will maintain it for evacuation purposes.

Complete

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Recommendations These recommendations are taken from the best practice described in the National Quality Standards for Residential Care Settings for Older People in Ireland and the registered provider should consider them as a way of improving the service. Standard Best practice recommendations Standard 24: Training and Supervision

Maintain formal minutes of staff meetings which had recently commenced and make available to staff who may have not been able to attend. Hold staff meetings on a regular basis. Provider’s response: We will hold regular staff meeting and keep minutes of names. We have already commenced this.

Standard 1: Information

Display the daily menu in a format which is clearly visible to residents. Inform residents in advance what choices are available for each mealtime. Provider’s response: We will display and amend our menu in a more visible location. We have already commenced this.

Standard 17: Autonomy and Independence

Offer residents the choice of attending a professional hairdresser. Provider’s response: We already have a professional hairdresser coming into our nursing home on a regular basis as requested.

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Any comments the provider may wish to make: Provider’s response: None received Provider’s name: Tom Thomas (Provider) Date: 21 September 2010

health information and quality authority social services inspectorate ... - nursing...

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