report of an inspection of a designated centre for older ... 04 february 2020 centre id: osv-0000649...

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Report of an inspection of a Designated Centre for Older People Issued by the Chief Inspector Name of designated centre:

St Augustine's Community Nursing Unit

Name of provider: Health Service Executive

Address of centre: Cathedral Road, Ballina, Mayo

Type of inspection: Unannounced

Date of inspection:

04 February 2020

Centre ID: OSV-0000649

Fieldwork ID: MON-0028657

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About the designated centre

The following information has been submitted by the registered provider and describes the service they provide. St Augustine’s Community Nursing Unit is a 33 bedded community nursing unit which is under the management of the Health Service Executive (HSE). It is situated in the town of Ballina close to St. Muradech’s Cathedral. Nursing care is provided to long stay and respite residents who have increasing physical frailty, some living with dementia and others requiring assistance with mental health or palliative care needs. The environment is stimulating and friendly. The philosophy of care is to embrace positive ageing and place the older person at the centre of all decisions in relation to their care and support. The service promotes independence, health and wellbeing. Accommodation includes single and twin rooms. A internal courtyard garden and a further garden to the front of the building was available. A day care service is provided 5 days per week. Communal space is shared by day and residential residents. The following information outlines some additional data on this centre.

Number of residents on the

date of inspection:

33

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How we inspect

This inspection was carried out to assess compliance with the Health Act 2007 (as amended), the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (as amended), and the Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 (as amended). To prepare for this inspection the inspector of social services (hereafter referred to as inspectors) reviewed all information about this centre. This included any previous inspection findings, registration information, information submitted by the provider or person in charge and other unsolicited information since the last inspection.

As part of our inspection, where possible, we:

speak with residents and the people who visit them to find out their

experience of the service,

talk with staff and management to find out how they plan, deliver and monitor

the care and support services that are provided to people who live in the

centre,

observe practice and daily life to see if it reflects what people tell us,

review documents to see if appropriate records are kept and that they reflect

practice and what people tell us.

In order to summarise our inspection findings and to describe how well a service is

doing, we group and report on the regulations under two dimensions of:

1. Capacity and capability of the service:

This section describes the leadership and management of the centre and how

effective it is in ensuring that a good quality and safe service is being provided. It

outlines how people who work in the centre are recruited and trained and whether

there are appropriate systems and processes in place to underpin the safe delivery

and oversight of the service.

2. Quality and safety of the service:

This section describes the care and support people receive and if it was of a good

quality and ensured people were safe. It includes information about the care and

supports available for people and the environment in which they live.

A full list of all regulations and the dimension they are reported under can be seen in

Appendix 1.

This inspection was carried out during the following times:

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Date Times of

Inspection

Inspector Role

Tuesday 4 February 2020

08:30hrs to 18:30hrs

Una Fitzgerald Lead

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What residents told us and what inspectors observed

Feedback from residents was positive about their direct care delivery. Residents told the inspector that they felt they were well cared for by staff who knew their individual needs, likes and dislikes. When asked about the staff one resident replied ''they really are on the ball'' and ''all we have to do is ask''. A resident told the inspector that she had developed a leg ulcer and that as a direct result of the nursing team her wound had fully healed.

The inspector spoke with seven residents individually, spoke with residents in small groups and spent time sitting and observing staff and resident engagement. Residents said that they enjoyed a good quality of life and that staff were kind and caring to them. Residents described how they spent their day and said they were encouraged to be independent, to make choices for themselves and to be as mobile and active as possible. One resident described how she was encouraged to take up art and that while she was hesitant at first she now looked forward to the weekly art sessions. Residents had high praise for the activities team and the current schedule in place.

Residents told the inspector that their bedrooms were their own space. The inspector noted that residents bedrooms were personalised. Residents informed the inspector that their rooms were cleaned daily and that staff were very respectful of their personal belongings.

Residents told the inspector that they are unhappy with the main sitting room. The dissatisfaction is specific to the curtains and the need for the walls to have a fresh coating of paint applied. This has been discussed at resident meetings. Residents have been reviewing and discussing the color that they wish the room to be painted. Residents have informed the senior management team of the Health Service Executive (HSE) and told the inspector that no action has been taken. In addition, thirty four residents and relatives signed a petition that was submitted to the senior management team requesting that the walls of the internal gardens be painted. The inspector concluded that while there was good evidence that residents were consulted with on the running of the centre, there was poor evidence that any action was taken as a result of the resident opinion and wishes voiced.

Capacity and capability

Overall, the inspector found the centre was delivering a good standard of care to the residents. The nursing management team had systems in place to ensure that they have oversight and governance to oversee the quality of care received by residents. The person in charge was organised in her approach and engaged with the

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inspector throughout the day. The person in charge is supported in her role by a clinical nurse manager. The responsibilities and the lines of authority of both managers were clearly defined. The structure was understood by staff who knew who to report any concerns to.

This inspection was unannounced. The information requested was made available in a timely manner and presented in an easily understood format. The inspector followed up on the last inspection action plan form April 2018. While progress had been made in most areas there are restated non compliance found under five of the regulations. Namely regulation 23 Governance and management, regulation 17 Premises, regulation 31 notifications of incidents, regulation 28 fire precautions and regulation 9 Residents rights.

The management hold a variety of meetings on a weekly and monthly basis to discuss all operational matters and clinical issues. Statistical information was gathered. There was sufficient oversight of the service that included incident management, number of falls, restraint usage and staff training. There was an auditing schedule in place. While areas of improvement were identified as required there was no evidence of appropriate follow up that ensured that appropriate action was taken and that there was a person made responsible for the actions to be completed. For example; a detailed comprehensive care plan audit had been completed that had identified gaps in resident files. There was no evidence if follow up had occurred. The audit did not assign or identify who had responsibility to address the findings to ensure better outcomes for residents.

There were measures in place to safeguard residents from abuse. A policy was available to inform management of any suspicions, allegations or incidents of abuse. Residents told the inspector that they felt safe in the centre. From a review of the incident log the inspector identified 3 incidents that were not submitted to the chief inspector. The inspector acknowledges the management team had completed a full investigation and all reasonable measures had been taken to protect residents form further incidents.

The inspector spoke with multiple staff. The staff confirmed that the nursing management team have a presence in the centre and were readily available for support. During conversations with residents the inspector observed that the residents knew the staff well. This impacted positively on residents as staff knew their individual needs. Staff informed the inspector that they would not hesitate to bring any issue concerning a resident to the attention of the person in charge and had full confidence in management to take action if required. The inspector reviewed the complaints log. Overall, there was good evidence that appropriate steps are taken in the management of complaints received with the exception of matters relating to requests by residents for painting to parts of the premises. The documentation in place evidenced that the management engaged with the complainant to ensure that all reasonable measures were taken to ensure a satisfactory outcome.

The inspector found that a review of fire management and precautions was required. The management of fire safety and the systems is discussed further under

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the quality and safety section of this report.

Regulation 15: Staffing

Sufficient numbers of staff with appropriate skills were available to meet the assessed individual and collective needs of residents in the centre. A planned and actual staff rota was available. The roster reflected the staff on-duty on the day of inspection.

The person in charge had identified a gap in the staffing compliment on duty for the evening from 17.30-2100. This risk had been added to the risk register. The person in charge is managing the risk locally and so there was no direct negative impact on the residents. The person in charge has escalated the risk to the senior management team within the CHO area and is awaiting a reply.

Judgment: Substantially compliant

Regulation 16: Training and staff development

Staff had access to appropriate training and records reviewed evidenced that staff had received training in safeguarding and safety, manual handling and fire safety. While there were some gaps this was as a result of the need to cancel training due to an infection control concern that has now passed. All gaps that were identified have a booked date for staff to attend.

The inspector found that training in other areas such as infection control, challenging behaviour, cardio pulmonary resuscitation (CPR), and medication management was also in place. Staff were supported and facilitated to attend training.

All new staff complete an induction programme to ascertain competency in their assigned role.

Judgment: Compliant

Regulation 21: Records

The person in charge confirmed that all staff had been vetted by An Garda Síochána (police). These documents were made available for review. Staff files were reviewed. Minor gaps were found in the documentation that is required by Schedule 2 requirements. For example: there was no documentary evidence of the relevant

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qualifications for one staff member. Immediate action was taken on the day of inspection to address the gap.


Regulation 23: Governance and management

The nursing management team were monitoring the service delivered. This included audits with regard to nutritional care, infection control, care documentation, health and safety and hygiene audits. While the inspector could see that deficits were identified there was no formal quality improvement plan enacted following audits which showed the timescale and the persons responsible for close out of actions required. This would ensure that improvements made are sustained for the benefit of residents. This action is restated since the last inspection.


Regulation 24: Contract for the provision of services

Contracts were signed and dated and detailed all services and fees payable. The contracts of care detailed the room to be occupied by the resident and specified if the room was a single or shared occupancy as required by the 2016 regulations.

Judgment: Compliant

Regulation 3: Statement of purpose

The statement of purpose was reviewed and found to contain all the requirements under Schedule 2 of the Regulations.

Judgment: Compliant

Regulation 31: Notification of incidents

On review of the incident log the inspector found three incidents of allegations of financial abuse that had occurred within the centre. The centre had not informed the Chief Inspector of the incidents as is required by the regulations. The inspector acknowledges that internal measures and appropriate actions were taken at the

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time and each incident had been investigated.

This is a restated non compliance found on the last inspection.

Judgment: Not compliant

Regulation 34: Complaints procedure

A policy and procedure was in place in the centre to inform management of complaints received. A summary of the complaints procedure was prominently displayed for information for residents and their relatives in the main reception foyer. Details included the nominated complaints officer in the centre and the appeals process.

A record of complaints raised by residents and relatives was maintained in the centre. The records included details of the investigations carried out in relation to the complaints and of the prompt actions taken to resolve the complaint. Details of communication with the complainant and their level of satisfaction with the measures put in place to resolve the issues were also included.

The person in charge had identified a gap in the management of complaints. It was found that when residents voiced dissatisfaction it was not always recorded and recognised as a complaint. As a result additional training had been provided to staff.

There was one complaint logged in 2020. The documentation in place was comprehensive. All appropriate measures were taken and the satisfaction level of the outcome for the complainant was also documented.

Judgment: Compliant

Quality and safety

The centre had arrangements in place to manage risk and protect residents. The systems in place for the management of regulation 28 fire precautions required review. On a walkabout of the premises the inspector found that a number of the fire compartment doors did not seal when closed and so this was a high risk in the event of a fire. This was discussed with the management team. Immediate action was taken and the person in charge arranged for this concern to be addressed. The day following the inspection the registered provider representative was issued with an urgent compliance plan.

The centre is purpose built. Residents move freely around the centre. The main sitting room, lounge room and dining rooms are close to the main entrance. These

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rooms were a hub of activity throughout the day. In addition, there was a separate oratory and a visitors room available for resident use. Residents have access to enclosed gardens but as previously highlighted in resident feedback the garden area is uninviting and in a poor state of repair.

Overall, the design and delivery of the service maintains and supports physical and psychological well being for residents. However, the number of assisted bathrooms with a bath and showering facilities requires review. When operating at full capacity there are 31 residents sharing a total of three communal bathroom/shower facilities. The inspector reviewed resident care plans specific to how resident personal hygiene care needs are met. Records evidenced that despite the limitations of the availability of bathroom facilities the staff ensure that the care needs of current residents are met in line with the care plans.

Residents' assessed needs were addressed by person-centred care plans that reflected their individual preferences and care choices. The documentation in place was easily understood. Direct provision of care was found to be of a high standard. For example; there was clear pictorial evidence found on wound management. A resident told the inspector that she had a wound that had fully healed due to the intervention of the nursing team. The inspector reviewed the file. The care plan that was in place prior to the healing process was detailed, comprehensive and guided care.

On admission, all residents had been assessed by a registered nurse to identify their individual needs and choices. A personalised care plan was then developed. Each care plan reviewed had the life history of the resident documented. Resident and family members spoken with had a good understanding on what a care plan was and confirmed that the nursing team consulted with them on all changes to their plan.

The centre had residents who had responsive behaviours (how people with dementia or other conditions may communicate or express their physical discomfort, or discomfort with their social or physical environment) due to their medical condition. A positive approach was taken to support these residents' care needs. Compassionate, sensitive and supportive care from staff positively impacted on the wellbeing and quality of life for residents in the centre.

The management team actively promoted a restraint free environment. The ethos and delivery of care was focused on eliminating the use of restrictive practices.

Residents' rights to privacy and dignity was respected. Staff sought consent for care procedures and were observed to be kind and caring in their interactions with residents. Residents availed of a varied activity programme. Activities developed for people with cognitive impairments formed part of this programme, and this had a positive impact on those who participated. Residents' links with the community were maintained where possible, and this was supported by access to local media, national daily newspapers and telephone services. Residents had been accommodated to vote in the recent election.

Resident meetings were scheduled monthly. There was a high numbers of residents

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in attendance. The inspector reviewed previous meeting minutes and spoke with residents about their requests. While there was good evidence of consultation at the meetings the inspector found that the residents requests were not followed up. Residents had clearly voiced their dissatisfaction with the upkeep of the gardens, the need for repainting in multiple areas and the request to upgrade the communal sitting room decor. One resident told the inspector that they had communicated directly with the senior management team on the last visit and to date the residents have not been given any feedback or update on their requests.

Regulation 13: End of life

There was a system in place to identify the resuscitation status of each resident. This decision was recorded in the medical file. Staff spoken with were clear on how to access this information in a timely manner to ensure the most appropriate outcome for the resident. The management team committed to ensure that there was a member of the team with current CPR (cardio pulmonary resuscitation) training on duty 24 hours.

Staff provided end of life care to residents with the support of their GP and community palliative care services. The inspector reviewed the file of a resident that was receiving end of life care. The care plan identified the expressed preferences regarding the preferred setting for the delivery of care at the end of life. Not all relevant information relevant to the care plan was updated. For example: the resident had received pain medication. There was no pain assessment completed. The inspector could not ascertain where the resident had pain and if the pain medication given had been effective. This meant that the team could not clarify if the dose given had been effective and was the most appropriate intervention management to take should the resident have another episode of pain. The inspector acknowledges that immediate action was taken on the day. The care plan was updated and the nurse management confirmed that going forward an assessment will be completed for all incidents of pain before and after the administration of pain medication.


Regulation 17: Premises

A bathroom and two accessible shower rooms are available for 31 residents. This does not comply with current national standards. A further 5 additional toilets are available. A review of the number of resident bath and shower facilities is required. The person in charge informed the inspector that some discussion has occurred in relation to two of the single bedrooms that are smaller in size being converted into shower rooms for residents. The actions that the registered provider representative

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will take will be addressed in the compliance plan response.

Following on from the last inspection the dining room door was widened to ensure that all residents could access all parts of the dining room. The decor in the dining room has had some minor changes to make the room more homelike. For example, a wooden kitchen cupboard has replaced the stainless steel style storage unit that was in place on the last inspection.

However, there are parts of the centre that are in poor state of repair. The residents have clearly voiced their dissatisfaction to the management team but to date no action had been taken. For example: the internal courtyard is not fit the purpose. The wheelchair ramp that exits onto the courtyard has a raised level that is a trip hazard. In addition the garden walls are in a very poor state and in immediate need of some fresh paint. The area is dull and uninviting.


Regulation 26: Risk management

The person in charge had good oversight of risk within the centre. For each risk identified it was clearly documented what the hazard was, the level of risk, the controls in place and the person responsible. This document was kept live and updated when needed.

Judgment: Compliant

Regulation 27: Infection control

The centre was found to be clean. The procedures in place for managing the prevention and control of infection were in line with National Standards. The inspectors spoke with the staff responsible for the cleaning of the centre. Staff were knowledgeable on the cloth color coded system in place. Staff were observed to wash hands between resident contact. There was hand hygiene soap dispensers strategically placed throughout the centre corridors for resident, relative and staff use.

Judgment: Compliant

Regulation 28: Fire precautions

Daily checks on exits were carried out throughout the premises. Fire training specific

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to the centre was delivered on the day of inspection that simulated night time staffing conditions of the largest compartment. Staff spoken with were clear on what action to take in the event of the fire alarm being activated. Each resident had a completed personal emergency evacuation plan (PEEP) in place to guide staff.

The management of fire safety in the centre required further action. The fire alarm was activated weekly by staff. The inspector released multiple fire compartment doors and observed that the doors did not seal. The inspector was able to see through the gap between the fire doors. This meant that in the event of a fire the smoke would not be contained in the compartment.

Findings were discussed with the management team and an urgent compliance plan was issued the following day.


Regulation 5: Individual assessment and care plan

Each resident's needs were comprehensively assessed within 48hours of their admission and at regular intervals thereafter. Staff used a variety of accredited assessment tools to complete a comprehensive assessment of each resident's needs, including risk of falling, malnutrition, pressure related skin damage and mobility assessments. These assessments informed care plans to meet each resident's needs. The interventions needed to meet each resident's needs were clearly described in person-centred terms to reflect their individual care preferences. Staff spoken with were very familiar with the care planning system in place and could navigate the system with ease and retrieve all information requested in a timely manner.

Where possible, residents were consulted with regarding their care plan development and subsequent reviews. The families of residents unable to be involved in this process were consulted on behalf of individual residents. Records were maintained of this consultation process.

Judgment: Compliant

Regulation 6: Health care

Residents were provided with timely access to medical and allied health professional services as necessary. There was good systems in place that evidence that advice received was followed which had a positive impact on the resident.

Physiotherapy, occupational therapy, speech and language therapy, tissue viability, optical and dietitian services were available to residents as necessary. Community

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palliative care services were also available to residents as appropriate.

Judgment: Compliant

Regulation 7: Managing behaviour that is challenging

The inspector reviewed the file of a resident who exhibited responsive behaviours and found that the care plan in place was detailed and person centered. The staff were familiar with the resident and were knowledgeable on the triggers that may cause any distress. In addition the staff knew how to deescalate any behaviour in a manner that was not restrictive. Incidents of responsive behaviours were clearly documented in the records which meant that a clinician reviewing the detail of the behaviour could make informed decisions on the best intervention management approach to take to ensure the best outcome for the resident.

The management team was seen to be actively promoting a restraint-free environment. There was a total of two residents who had bedrails in use. The inspector reviewed the resident files and found that appropriate assessment of need had been completed. The resident files were compliant with regulation requirements.

Judgment: Compliant

Regulation 8: Protection

The centre acted as a pension agent for a number of residents. Management confirmed that the systems in place were in line with the department of social protection guidelines.

Residents felt safe in the centre. There were internal systems in place to support the identification, reporting and investigation of allegations or suspicions of abuse. All staff had received training in the prevention, detection and response to abuse. All staff had a Garda vetting disclosure on file.

Judgment: Compliant

Regulation 9: Residents' rights

Residents were aware of their rights, including, civil, political and religious rights. Residents within the centre had been accommodated to vote in the recent elections.

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Advocacy services were available to assist residents where required. At the time of inspection there was one resident who was actively receiving support form the advocacy services.

Resident meetings were held and there was evidence of discussion that was of importance to the residents. Following the last meeting the residents had requested that the resident meetings be held monthly and the person in charge had scheduled in a monthly date for same. While there was good evidence that residents were consulted with on the running of the centre there was poor evidence that any action was taken as a result of the resident opinion and wishes voiced. This was evidenced by:

The failure of the provider representative to take action on resident requests for new curtains in the sitting room,

The repainting of the sitting room The upkeep work required in the external gardens to make the gardens

inviting and a place of comfort for residents to sit. The painting of the external building.


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Appendix 1 - Full list of regulations considered under each dimension This inspection was carried out to assess compliance with the Health Act 2007 (as amended), the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (as amended), and the Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 (as amended) and the regulations considered on this inspection were:

Regulation Title Judgment

Capacity and capability

Regulation 15: Staffing Substantially compliant

Regulation 16: Training and staff development Compliant

Regulation 21: Records Substantially compliant

Regulation 23: Governance and management Substantially compliant

Regulation 24: Contract for the provision of services Compliant

Regulation 3: Statement of purpose Compliant

Regulation 31: Notification of incidents Not compliant

Regulation 34: Complaints procedure Compliant

Quality and safety

Regulation 13: End of life Not compliant

Regulation 17: Premises Not compliant

Regulation 26: Risk management Compliant

Regulation 27: Infection control Compliant

Regulation 28: Fire precautions Not compliant

Regulation 5: Individual assessment and care plan Compliant

Regulation 6: Health care Compliant

Regulation 7: Managing behaviour that is challenging Compliant

Regulation 8: Protection Compliant

Regulation 9: Residents' rights Not compliant

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Compliance Plan for St Augustine's Community Nursing Unit OSV-0000649 Inspection ID: MON-0028657

Date of inspection: 04/02/2020 Introduction and instruction This document sets out the regulations where it has been assessed that the provider or person in charge are not compliant with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013, Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 and the National Standards for Residential Care Settings for Older People in Ireland. This document is divided into two sections: Section 1 is the compliance plan. It outlines which regulations the provider or person in charge must take action on to comply. In this section the provider or person in charge must consider the overall regulation when responding and not just the individual non compliances as listed section 2. Section 2 is the list of all regulations where it has been assessed the provider or person in charge is not compliant. Each regulation is risk assessed as to the impact of the non-compliance on the safety, health and welfare of residents using the service. A finding of:

Substantially compliant - A judgment of substantially compliant means that the provider or person in charge has generally met the requirements of the regulation but some action is required to be fully compliant. This finding will have a risk rating of yellow which is low risk.

Not compliant - A judgment of not compliant means the provider or person in charge has not complied with a regulation and considerable action is required to come into compliance. Continued non-compliance or where the non-compliance poses a significant risk to the safety, health and welfare of residents using the service will be risk rated red (high risk) and the inspector have identified the date by which the provider must comply. Where the non-compliance does not pose a risk to the safety, health and welfare of residents using the service it is risk rated orange (moderate risk) and the provider must take action within a reasonable timeframe to come into compliance.

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Section 1 The provider and or the person in charge is required to set out what action they have taken or intend to take to comply with the regulation in order to bring the centre back into compliance. The plan should be SMART in nature. Specific to that regulation, Measurable so that they can monitor progress, Achievable and Realistic, and Time bound. The response must consider the details and risk rating of each regulation set out in section 2 when making the response. It is the provider’s responsibility to ensure they implement the actions within the timeframe. Compliance plan provider’s response:

Regulation Heading Judgment

Regulation 15: Staffing

Substantially Compliant

Outline how you are going to come into compliance with Regulation 15: Staffing: This compliance plan response from the registered provider did not adequately assure the chief inspector that the actions will result in compliance with the regulations. Management is continuing to work with staff representatives so that the existing roster can be modified to enable an additional Carer to be allocated to the evening shift. A meeting is scheduled for the 18th March 2020

Regulation 21: Records


Outline how you are going to come into compliance with Regulation 21: Records: The staff member has contacted the awarding body and asked them to provide further evidence of their qualification. A current Annual Retention Certificate is held on file.

Regulation 23: Governance and management


Outline how you are going to come into compliance with Regulation 23: Governance and management: This compliance plan response from the registered provider did not adequately assure the chief inspector that the actions will result in compliance with the regulations.

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The care plan audit template has been modified so the Named Nurse can confirm that the issues identified in the audit have been addressed within the agreed time frame.

Regulation 31: Notification of incidents

Not Compliant

Outline how you are going to come into compliance with Regulation 31: Notification of incidents: This compliance plan response from the registered provider did not adequately assure the chief inspector that the actions will result in compliance with the regulations. Future incidents of missing money will be notified to HIQA on a NF06.

Regulation 13: End of life

Not Compliant

Outline how you are going to come into compliance with Regulation 13: End of life: Nursing staff are aware of the need to assess and document responses both pre and post administration of analgesia to ensure that analgesia administered is effective for managing pain.

Regulation 17: Premises

Not Compliant

Outline how you are going to come into compliance with Regulation 17: Premises: This compliance plan response from the registered provider did not adequately assure the chief inspector that the actions will result in compliance with the regulations. This unit was refurbished in 2015 in line with the then National Quality standards for residential care settings at a ratio of 1 assisted bathroom/shower to 11 residents. At present we feel we are conforming to regulation 17(2) schedule 6 in regards to providing a sufficient number of assisted bathrooms/showers to meet the needs of our current residents. We are satisfied that the operational plan for bathing can satisfactorily achieve the bathing of all residents within an acceptable timeframe. There have been no complaints or incidents around the bathing/showering of residents. We will continue to review this situation as new residents are admitted . Following discussion with Local maintenance department we will refer the wheelchair

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ramp to HSE estates for design advice to ensure that current building regulations around external wheelchair access is complied with.

Regulation 28: Fire precautions

Not Compliant

Outline how you are going to come into compliance with Regulation 28: Fire precautions: This compliance plan response from the registered provider did not adequately assure the chief inspector that the actions will result in compliance with the regulations. The issues identified on the urgent compliance plan have been remedied and now meet requirements. The staff responsible for weekly checks are now clear on the requirements for cross corridor doors. HSE maintenance department will be responsible for twice yearly checks on fire doors.

Regulation 9: Residents' rights

Not Compliant

Outline how you are going to come into compliance with Regulation 9: Residents' rights: This compliance plan response from the registered provider did not adequately assure the chief inspector that the actions will result in compliance with the regulations. Maintenance Dept is currently obtaining quotes for internal painting, when colour scheme is picked curtains will be obtained through the current supplier on HSE contract. Quotes to do the external painting and the garden area will be obtained with a view to commencing work in Q3 this year.

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Section 2: Regulations to be complied with The provider or person in charge must consider the details and risk rating of the following regulations when completing the compliance plan in section 1. Where a regulation has been risk rated red (high risk) the inspector has set out the date by which the provider or person in charge must comply. Where a regulation has been risk rated yellow (low risk) or orange (moderate risk) the provider must include a date (DD Month YY) of when they will be compliant. The registered provider or person in charge has failed to comply with the following regulation(s).

Regulation Regulatory requirement

Judgment Risk rating

Date to be complied with

Regulation 13(1)(a)

Where a resident is approaching the end of his or her life, the person in charge shall ensure that appropriate care and comfort, which addresses the physical, emotional, social, psychological and spiritual needs of the resident concerned are provided.

Not Compliant Orange

29/02/2020

Regulation 15(1) The registered provider shall ensure that the number and skill mix of staff is appropriate having regard to the needs of the residents, assessed in accordance with Regulation 5, and the size and layout of the designated centre concerned.


Yellow

30/06/2020

Regulation 17(2) The registered provider shall,


31/12/2020

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having regard to the needs of the residents of a particular designated centre, provide premises which conform to the matters set out in Schedule 6.

Regulation 21(1) The registered provider shall ensure that the records set out in Schedules 2, 3 and 4 are kept in a designated centre and are available for inspection by the Chief Inspector.


Yellow

30/04/2020

Regulation 23(c) The registered provider shall ensure that management systems are in place to ensure that the service provided is safe, appropriate, consistent and effectively monitored.


Yellow

29/02/2020

Regulation 28(2)(i) The registered provider shall make adequate arrangements for detecting, containing and extinguishing fires.

Not Compliant Red

12/02/2020

Regulation 31(1) Where an incident set out in paragraphs 7 (1) (a) to (j) of Schedule 4 occurs, the person in charge shall give the Chief Inspector notice in writing of the incident within


29/02/2020

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3 working days of its occurrence.

Regulation 9(3)(d) A registered provider shall, in so far as is reasonably practical, ensure that a resident may be consulted about and participate in the organisation of the designated centre concerned.

Not Compliant Yellow

30/09/2020

report of an inspection of a designated centre for older ... 04 february 2020 centre id: osv-0000649...

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