report of an inspection of a designated centre for older people - … 2019-02-01 · convalescent/...

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Report of an inspection of a Designated Centre for Older People Name of designated centre:

St. Brigid's Hospital

Name of provider: Health Service Executive

Address of centre: Carrick on Suir, Tipperary

Type of inspection: Announced

Date of inspection:

23 and 24 October 2018

Centre ID: OSV-0000672

Fieldwork ID: MON-0022354

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About the designated centre

The following information has been submitted by the registered provider and describes the service they provide. The registered provider of the centre is the Health Service Executive (HSE) and the current premises was first designated as a workhouse in 1817. Over time it became a District Hospital providing general medical, dental, and maternity care. In more recent years the service has changed and now provides convalescence and respite care to the older Person, younger chronically ill and end of life care to those who require it. The centre can accommodate up to 16 residents, both males and females whose age range from 18 years upwards. The centre accepts level four (full dependency) to level one (low dependency) category. The centre provides short stay care and on admission an anticipated length of stay and potential discharge date is agreed with the resident and their family/carers. Discharges are planned in consultation with the resident, their General Practitioner (GP), family, public health nurses (PHN) and any other health professional required to ensure the ongoing safety of the resident once they return home. However, there are occasions where an individual’s care needs may dictate that a long term care option should be considered. A common summary assessment report (CSARs) is then completed on these individuals to allow their care needs to be considered at the Local Placement Forum. The 16 beds in the centre are allocated as follows: two respite care beds, 11 convalescent/ GP care beds and three palliative care beds. Respite Services; the two respite care beds are offered to individuals living at home. People availing of this service are placed on a waiting list. Residents requiring respite care are referred by their GP or through the PHN services. Resident are accepted for placement based on the common summary assessment, which has been completed by the PHN. Respite care is available on a regular rotational basis i.e. one week in every eight weeks. Emergency respite is also provided if required. Convalescent care; is offered to individuals transferred from acute medical services i.e. hospital or on referral by their GP in order to avoid acute hospital admission. For example, residents that have not yet met milestones for discharge from care to home or they may require additional period to recover health and strength after illness, injury or surgery. The anticipated length of stay for these residents is two weeks on average, but this may be extended if the medical officer deems the person to be medically unfit for discharge. The palliative care beds are for any adult, from 18 years upwards requiring this service. Residents requiring palliative care are referred from acute hospitals or by home care hospice teams in the community. They will have been assessed by a palliative care consultant and have met the criteria for palliative care. The expected length of stay for residents receiving palliative care is approximately three to four months or less, exceptions may be considered. Such residents agree to reassessment for alternative level of care if conditions stabilise and disease trajectory appears to exceed expected length of stay. Resident accommodation is provided as follows; on the ground floor there are three single bedrooms that are designated end of life suites with facilities for relatives to stay with the resident in a homely setting and each with direct access to the garden area. There is a passenger lift available for residents to access the first floor from the ground floor. There is also a small sitting room and dinning room, as

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well as showers, toilets, the director of nursing office, the kitchen and a sluice room located on the ground floor. The first floor consists of a five bedded male and five bedded female multi-occupancy bedrooms. There is also one twin bedded and one single bedroom on the first floor. In addition, there is a nurses station with treatment room, as well as showers, toilets, and a second sluice room also located on the first floor. The second floor does not have resident care areas however, there is a physiotherapy room, the secretary’s office, a staff room, staff changing room and a store room on this floor. The centre employs approximately 28 staff and there is 24-hour care and support provided by registered nursing and health care staff with the support of housekeeping, and catering staff. The following information outlines some additional data on this centre.

Number of residents on the

date of inspection:

14

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How we inspect

To prepare for this inspection the inspector or 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.

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This inspection was carried out during the following times:

Date Times of

Inspection

Inspector Role

23 October 2018 08:30hrs to 17:30hrs

Vincent Kearns Lead

24 October 2018 07:00hrs to 15:00hrs

Vincent Kearns Lead

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Views of people who use the service

Residents and their representatives spoke positively about the centre and felt safe and well looked after. Residents were very complimentary about all of the staff, particularly residents that had had more than one admission. Residents stated they felt well supported by all staff. Some residents spoke about the importance of the service to the local community in terms of the quality of the service provided, it's location near the town and ease of access. Residents spoke about their local connection to the centre and the sense of belonging within the local community. Many of the staff had worked for years in the centre and residents stated that they were well known to many residents. Residents expressed the importance of the service in the context of convalescing and respite as being hugely important in maintaining their independence and relieving carers at home. Residents informed the inspector that staff treated them with respect and dignity at all times.

There was a weekly residents meetings and the minutes of these meetings were mainly positive. However, from a review of the minutes some residents would have liked more space in their bedrooms and access to WiFi was also identified as required by some residents.

Residents stated that they were also afforded choice for example, in relation to meals, activities or what time to got up or went to bed. Residents stated a range of activities were provided but their choice not to participate was also respected. A number of residents stated that they preferred to not participate in group activities.

Residents in shared accommodation said they could receive their visitors in the day room. Some residents said their sleep was disturbed at night due to noise from other residents in multi-occupancy rooms.

Residents questionnaire's were returned to HIQA as part of this announced inspection. These returned questionnaires were overwhelming very positive in their praise of the staff and the care provided in the centre. However, one respondent felt there was not enough space in the bedroom for personal belongings. A number of respondents was very complimentary about the garden but felt lunch was served too early.

Capacity and capability

Overall, there were suitable governance and supervision systems were in place which reflected the organisational structure described in the statement of purpose. The day to day management of the centre was lead by the person in

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charge who was the acting Director of Nursing (DON). She was an experienced manager having worked in the centre as a Clinical Nurse Manager 2 (CNM2) since 2015 and as person in charge since 2016. The inspector found improved levels of compliance with some improvements evident on this inspection. For example, most of the actions from the previous inspection had been completed. However, as identified on previous inspections the design and layout of some parts of the premises continued to be unsuitable to meet the needs of residents. The unsuitable premises continued to impact on residents privacy and potentially compromised some residents dignity. This issue is addressed further in this report. The provider representative was based in Clonmel town and spoke with the person in charge regularly by phone and was in daily email contact. They regularly met for example, at senior management meetings including quality and improvement meetings, health and safety meetings and fire safety meetings. There was evidence of appropriate arrangements for reporting, investigating and learning from serious incidents/adverse events which identified for example, residents who were at risk of falls and put in place appropriate measures to minimise and manage such risks. Each serious reportable event (SRE) was suitably recorded and escalated to senior management as per the HSE safety incident management policy January 2017 and reporting protocols. The effect of these arrangements was that the provider representative and person in charge were fully informed of any issues as they arose. They had good oversight of the centre and were therefore well positioned to provide suitable and timely managerial support, when required.

The inspector noted that the person in charge was proactive and responsive to the inspection process, and engaged positively throughout this inspection. Residents with whom the inspector spoke agreed that she was well known to them and both residents and staff confirmed that she was an effective manager and readily available to provide support.

The statement of purpose was available to residents in a folder in the day room and outlined the aims, objectives and ethos of the centre including the facilities and services that were to be provided for residents. However, some improvements were required in relation to the description of the centre's accommodation and the service that was provided.

The inspector noted that there were sufficient resources in place to ensure the delivery of safe and good quality care and support to the residents with the current skill mix and staffing levels. Staff files reviewed were complete and in compliance with the regulations. Staff were confident and knowledgeable of the centre's policies and procedures. Since the previous inspection, there had been improvements in staff training for example, in relation to end of life care and dementia care. There was also for example, appropriate assistive equipment available to meet residents’ needs such as electric beds, wheelchairs, hoists and pressure-relieving mattresses. The provider representative confirmed that the centre had adequate insurance and that there were sufficient resources to ensure on-going safe and suitable care provision.

There was a comprehensive complaints process in place should residents, relatives or visitors wish to raise any issues they might have, including an appeals process.

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There was the HSE national complaints policy ''Your Service Your Say'' and a centre specific complaints policy. There was a summary of these policies prominently displayed and met the regulatory requirements. However, some improvements were required in relation to the provider responding to some complaints.

Consultation with residents and or relatives in relation to the existing systems of monitoring quality of care was available. For example, there were weekly residents meetings to ascertain residents views and provide ongoing feedback. There was an annual review of the quality and safety of care for 2017 which informed ongoing continuous quality improvement in the centre for this year. The inspector viewed ongoing audits of key performance indicators for 2018, which included audits on falls, medication management, complaints and restraint. There was evidence of learning and action plans developed from these audits.

Registration Regulation 4: Application for registration or renewal of registration

Application and required documents were submitted as per regulation 4.

Judgment: Compliant

Regulation 14: Persons in charge

The person in charge was suitably engaged in the governance, operational management and administration of the centre on a regular and consistent basis.The person in charge was a suitably qualified registered nurse who had been involved in the governance and management of the centre since 2015. She had many years experience of nursing care of the older person and had completed a number of relevant post graduate courses including a management qualification. The person in charge demonstrated comprehensive knowledge of residents, their care needs and a strong commitment to ongoing improvement of the quality of the services provided. She was seen and reported to be visible, accessible and effective by staff, residents and relatives. The person in charge demonstrated good knowledge of the relevant legislation and her statutory responsibilities. Arrangements were in place for deputizing in the absence of the person in charge. The person in charge was supported by a clinical nurse manager who were actively involved in the day to day running of the centre.

Judgment: Compliant

Regulation 15: Staffing

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The person in charge was supported in her role by an experienced Clinical Nurse Manger (CNM), experienced staff nurses and care staff. The inspector noted that many of the staff had worked in the centre for some time and many were well experienced and knew the residents, the management and operating systems in the centre well. The number of staff matched the roster on the days of inspection. Following a review of the staff rosters, and feedback from residents, the inspector were satisfied that, at the time of inspection, there were sufficient staff on duty to meet residents' needs. The majority of the staff in the centre had been working there for many years and were observed interacting positively with residents and visitors throughout the inspection. The inspector was informed that at times there was need for agency staff in the centre. However, the person in charge outlined a robust induction system to orientate such staff to residents needs. Staff demonstrated good knowledge of residents' care and support needs and there was good levels of supervision and assistance to residents observed. Staff were also knowledgeable about individual residents' needs for social engagement and all care staff were involved in providing meaningful activities to the residents.

Judgment: Compliant

Regulation 16: Training and staff development

The training matrix was viewed and a comprehensive list of mandatory training was provided to all staff appropriate to their role and included, training on fire, safeguarding, safe moving and handling techniques, basic life support, sharps management, open disclosure, medication management and hand hygiene. There was for example 100% compliance in fire training and in safeguarding. Refresher training was available in a timely manner to ensure staff knowledge remained up to date.

Judgment: Compliant

Regulation 19: Directory of residents

The directory of residents was viewed and contained all of the information specified in paragraph 3 of schedule 3.

Judgment: Compliant

Regulation 21: Records

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Overall records were seen to be maintained and stored in line with best practice and legislative requirements. Residents' records were made available to the inspector who noted that they complied with Schedule 2, 3 and 4 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013.

Judgment: Compliant

Regulation 22: Insurance

Current insurance certification/documentation in relation to the centre was viewed by the inspector.

Judgment: Compliant

Regulation 23: Governance and management

There was evidence of effective communication in place between the person in charge, the provider representative and all staff. There was evidence of suitable clinical governance and oversight in the centre. For example, the person in charge outlined how ongoing clinical auditing, incident reporting and improvements in care planning documentation contributed to improved resident care provision. There were records of completed audits in areas such as falls, hygiene and infection control, and medication management. These management and governance arrangements were effective, as evidenced by the improved level of compliance identified on this inspection and the ongoing improvements within the centre. However, in relation to the on-going premises issues; the provider confirmed that there were no planned premises building works.

Judgment: Substantially compliant

Regulation 24: Contract for the provision of services

The inspector found that residents’ contracts of care had been signed by the residents and or their relatives and the contracts were clear, user-friendly and outlined the services and responsibilities of the provider representative to the resident and the fees to be paid. Since the previous inspection the contracts also identified details in relation to the residents bedroom accommodation.

Judgment: Compliant

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Regulation 3: Statement of purpose

The statement of purpose detailed the aims, objectives and the facilities and services that were to be provided for residents. The statement of purpose was made available for residents, visitors and staff to read and had been most recently reviewed in October 2018. However, the statement of purpose did not adequately detail all items listed in Schedule 1 of the Regulations including the following:

an adequate description (either in narrative form or a floor plan) of the rooms in the designated centre including their size and primary function

more detail was required in relation to the criteria used for admission to the designated centre, including the designated centre’s policy and procedures for emergency admissions.


Regulation 31: Notification of incidents

The inspector followed up on a number of notifications received from the person in charge and saw that suitable actions had been taken regarding each accident or any adverse event.

Judgment: Compliant

Regulation 34: Complaints procedure

Complaints could be made to any member of staff and the person in charge was the designated complaints officer. The procedure for making a complaint was displayed on the wall near the front entrance to the centre. Residents stated they knew how to voice a complaint if needed. Documented evidence was adequate and indicated a suitable approach to managing complaints. Complainants were notified of the outcome of their complaint and the complaint log recorded whether or not they were satisfied. However, some improvements were required. For example, the inspector noted from complaint records viewed, that residents and or their representatives had complained about the unsuitability of one of the five bedded bedrooms and expressed concern regarding the lack of personal storage space. In addition, complaints had been received in relation to the absence of any WiFi or Internet connection. The person in charge had highlighted and escalated these issues as per HSE policy. However, the provider had not put in place adequate measures required for improvement in response to these complaints, as required by

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regulation.


Regulation 4: Written policies and procedures

Polices and procedures as set out in Schedule 5 of the Regulations were viewed by the inspector and were available to all staff to guide care practice.

Judgment: Compliant

Quality and safety

The premises was generally clean, bright, warm and well ventilated and there had been on-going improvements in the décor of the centre since the previous inspection. For example, a number of areas had been repainted including the outside of the building, some residents' bedrooms and corridors, and the palliative care suites. Residents spoken to expressed satisfaction with the bright corridors and bedrooms following the repainting. However, the design and layout of the premises continued to be largely reflective of a small hospital from the period in which it was built. As identified on previous inspections the design, size and layout of some of the bedrooms continued to be unsuitable to meet the needs of residents. For example, the size, design and layout of the two five bedded bedrooms continued to be inadequate to protect residents’ privacy and potentially compromised residents' dignity. The provider representative acknowledged these ongoing failings. The inspector noted that the impact from the inadequate premises was somewhat mitigated by the short average length of stay for residents in the center. The inspector was informed that during the first nine months of 2018 the average length of stay for residents was 12 days. This short duration of residents admissions was also confirmed by the provider representative, the statement of purpose and the admission policy. The person in charge stated that any resident requiring a longer period of admission had generally required palliative care.

Overall, the inspector were satisfied that residents’ health and social care needs were met to a good standard. There were effective systems in place for the assessment, planning, implementation and review of health and social care needs of residents. Residents with whom the inspector spoke felt that they received very good care from all staff, including nurses, doctors and allied health care staff. The inspector observed that residents had good access to GP services. Since the previous inspection, there had been improvements in the care planning documentation and care plans were generally person-centred and individualised. The centre had a total bed capacity for 16 residents and only

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provided short stay care for residents requiring respite, convalescence and palliative care. The person in charge confirmed that the centre could not cater for residents who had dementia, were mobile and at risk of unexpectedly leaving the centre. On the days of inspection there were 14 residents who had been assessed as having the following levels of dependency needs: three residents had low dependency needs, three residents had medium dependency needs, and a further five residents had high dependency needs. There were three residents that had been assessed as having maximum dependency needs. All residents were recently admitted for short term care and each had a clear discharge plan in place which had been initiated either prior to admission or on admission to the centre.

Suitable communication arrangements were in place to ensure safe and suitable care. For example, there was regular clinical handover meetings each day, there was evidence of meetings with staff and regular meetings were held with residents and or their representatives. The inspector noted that the person in charge was well known to residents to whom the inspector spoke with. With the frequent change in the resident population, the person in charge stated that she made getting to know all residents a priority. She described how she spoke to all residents and attended the morning handover meeting each day. The person in charge stated that the chair of the residents' committee meetings was rotated to encourage residents’ participation. From a review of the minutes of these meetings it was clear that issues identified were addressed in a timely manner and that the person in charge was proactive in addressing any concerns or issues raised.

The suitable provision of scheduled activities for residents remained an on-going challenge for staff as the majority of residents stayed in the centre for very short periods. The inspector was informed by a number of residents that they were happy with the activities on offer and a number of residents were seen reading the paper or in one case using a computer tablet to play games. Some residents were also seen enjoying the lovely weather in the garden on both days of the inspection. All staff were responsible for providing activities and some were observed taking time especially in the afternoon to sit and chat with residents and play cards or board games, if the resident was interested in same.

Within the limitations of the premises; management and staff within the centre respected residents' rights, choices and wishes, and supported them to maintain their independence, where possible. In relation to residents' financial transactions, the inspector noted that the centre did not manage any monies on behalf of any resident. Overall, there appeared to be a warm and friendly atmosphere between residents and staff. For example, residents were observed calling staff by their first names and interacting with them in a relaxed and friendly way. Staff were also seen to also be very supportive, positive and respectful in their interactions with residents.

Regulation 11: Visits

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The person in charge confirmed that the centre implemented an open visiting policy. The inspector noted that visitors were complimentary about the care and support provided by staff to their loved ones. Some visitors who visited the centre at different times every day confirmed that they felt that the care provided was excellent.

Judgment: Compliant

Regulation 12: Personal possessions

The design and layout of the two five-bedded bedrooms and the one twin bedded bedroom continued to be inadequate to meet the individual or collective needs of residents in these bedrooms. For example, there continued to to be a lack of storage space in these bedrooms for residents' personal clothing or belongings. The inspector noted that residents in these bedrooms had access to only a small bedside locker and did not have any access to wardrobes for storing their clothes or belongings. In addition, there were no lockable storage space for the safe-keeping of residents’ personal money and valuables. The provider representative acknowledged that these bedrooms were not adequate. The inspector noted that the impact from the limited space for furniture or personal memorabilia that could be accommodated in the multi-occupancy bedrooms was somewhat mitigated by the short average length of stay for residents in the center.

Judgment: Not compliant

Regulation 13: End of life

On the days of this inspection, there were no residents receiving end of life care. However, there was evidence of appropriate end of life care and comfort was provided to residents which addressed their physical, emotional, social, psychological and spiritual needs. Staff who the inspectors spoke with demonstrated an empathetic understanding of the needs of residents and their families in relation to the provision of end of life. There were three single occupancy bedrooms with en suite facilities available for palliative care provision. In each of these rooms there were facilities for families to stay and a small kitchenette room available for families use if they wished to stay overnight. Staff confirmed that family members who wished to remain overnight were supported and made as comfortable as possible.

Judgment: Compliant

Regulation 17: Premises

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As already identified in this report there were on-going non-compliance's in relation to the premises that had been identified in a number of previous inspections and had not been satisfactorily progressed. The design and layout of the two five-bedded rooms continued to be inadequate to meet the individual or collective needs of residents in these bedrooms. For example, in these two five bedded bedrooms, three beds were arranged against one wall and two beds against the opposite wall. The space between the three beds in both five bedded wards was very limited. The inspector noted that there was approximately only 76cms space between these three beds. This limited space also posed a restriction on movement for staff delivering care at the bedside. The lack of space also reduced the amount of furniture or personal memorabilia that could be accommodated. The person in charge stated that only residents that had low dependency needs, who were mobile occupied the middle of these three beds. The inspector noted that this was the case on the days of inspection. The provider representative acknowledged that these bedrooms were not adequate. However, the provider representative also stated that they did not have any further information or definite plans at this time regarding this on-going non-compliance in relation to these bedrooms. In addition, the inspector noted that there was a number of further improvements required in relation to the premises. For example, there was no call bell facility in the sitting room and the telephone exchange box located in this sitting room required review to ensure that it was not excessively noisy. In addition, the inspector noted that there was a hole in the ceiling of one of the sluice rooms and there were no bath including any assisted bath, available in the centre.


Regulation 18: Food and nutrition

Overall residents nutritional and hydration needs were adequately met. Residents weights were monitored on a regular basis as appropriate. A recognised nutritional assessment tool was used and there were corresponding nutritional care plans in place. Appropriate referrals to allied health services were documented. For example, there was evidence of referrals to dietitian, speech and language therapy and GP services. Residents were complementary about the food provided which was cooked on site and served in the dining room or in residents bedrooms. There was ample drinks available to all residents and inspectors noted that jugs of water and fruit juice were available in all residents bedrooms and the sitting room. Residents confirmed that snacks and drinks were provided at regular intervals and also available on request, at any time.

Judgment: Compliant

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Regulation 20: Information for residents

In this small centre, the person in charge outlined how she met and spoke to most residents each day. There was a general information leaflet available for residents and visitors that gave an overview of the centre including directions on how to get to the centre. In addition, there was a residents' guide which included a summary of the services and facilities provided, terms and conditions relating to residence, procedure respecting complaints and the arrangements for visits. This guide was found to meet the requirements of legislation.

Judgment: Compliant

Regulation 26: Risk management

Overall, there were suitable arrangements in place in relation to the management of risks in the centre. For example, there was a risk management policy and risk register which detailed and set control measures to mitigate risks identified in the centre. These included risks associated with residents such as fire, falls, and residents leaving the centre unexpectedly. An accident and incident log was kept in line with the HSE National Information Management System (NIMS). These records were retained in relation to any accidents regarding residents, staff and visitors, and regular health and safety reviews were arranged to identify and respond to potential hazards. However, some improvements were required in the hazard identification and assessment of risks in the centre. For example, risk assessments were required in relation to residents the absence of hand or grab rails in some toilets, the unrestricted access to the kitchen area and the unsecured garden.


Regulation 27: Infection control

The person in charge outlined how since the previous inspection, staff had implemented a new cleaning system which included using new cleaning equipment such as a new cleaning trolley. The inspector noted that premises appeared to be clean and there were appropriate infection prevention and control procedures being practiced throughout the centre which were found to be in line with relevant national standards.

Judgment: Compliant

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Regulation 28: Fire precautions

There was evidence that suitable measures to protect residents, staff and the premises against the risk of fire were in place. For example, suitable fire fighting equipment and means of escape were available, and these were regularly tested, serviced and maintained. All staff had up-to-date fire safety training including attendance at fire evacuation drills in the centre.

Judgment: Compliant

Regulation 29: Medicines and pharmaceutical services

Overall, medications were stored, administered and disposed of appropriately in line with An Bord Altranais and Cnáimhseachais na hÉireann's Guidance to Nurses and Midwives on Medication Management (2007). For example, medicines were stored in a locked cupboard, medication trolley or within a locked room only accessible by nursing staff. Medicines requiring refrigeration were also stored securely and appropriately. The temperature of the medication fridge was monitored and recorded daily. Controlled drugs were stored and generally managed in accordance to best practice guidelines. For example, two nurses were checking the quantity of medications at the start of each shift. However, improvements were required to these records, as the inspector noted that not all controlled drugs stock records contained the two nurses signatures, as required by the centres' medication policy.


Regulation 5: Individual assessment and care plan

The inspector reviewed a sample of residents care plans which reflected the overwhelming majority of residents' assessed needs. Comprehensive nursing assessments of each resident's health, personal and social care needs were carried out by an appropriate health care professional following admission to the centre. The person in charge outlined how on-going improvements in the residents care planning system was being implemented. Given the short stay nature of the service, care plans were frequently reviewed as required.

Judgment: Compliant

Regulation 6: Health care

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There was evidence of appropriate medical and health care, including a high standard of evidence-based nursing care provided for residents in accordance with professional guidelines issued by An Bord Altranais agus Cnáimhseachais. Many residents were complementary about the kindness and high standard of care provided to them by all staff. Some residents had been admitted for respite care and said that they were well known to all staff. While other residents were recently transferred from acute hospital and required more nursing care, monitoring and support. There was also evidence of good access to other specialist and allied health care services to meet the care needs of residents. For example, speech and language therapist, occupational therapy, physiotherapy, psychiatry, and chiropody services.

Judgment: Compliant

Regulation 7: Managing behaviour that is challenging

There were no residents with behaviours that challenge on the days of inspection however, there were suitable arrangements and supports in place in the centre such as suitable staff training, knowledge and guiding policies for the management of behaviours that challenge.

Judgment: Compliant

Regulation 8: Protection

There were clear systems in place to support identifying, reporting and investigating allegations or suspicions of abuse. Residents spoken with stating that all staff in the centre made them feel as relaxed and as comfortable as possible. Staff spoke confidently about arrangements in the centre for safeguarding residents and were knowledgeable of the indicators of abuse and how to respond if they witnessed or suspected abuse.The inspector heard staff addressing residents by their preferred names and speaking in a clear, respectful and courteous manner. Training records indicated that all HSE staff had completed initial or up-to-date training in the prevention, detection and response to abuse.

Judgment: Compliant

Regulation 9: Residents' rights

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As already identified in this report, the unsuitable design and layout of the multi-occupancy bedrooms impacted on the privacy and potentially dignity of residents. The inspector observed that in both of these multi-occupancy bedrooms, residents had various levels of care needs and levels of mobility. Some residents required bed rest, some had cognitive impairment and a number of residents required support with personal care including for example, the use of a commode. It was evident that having up to five residents with such diverse health and social care needs sharing the same bedrooms inevitably impacted on residents' privacy and potentially on their dignity. Even with the use of bed screens provided; the inspector formed the view that some residents with reduced capacity, mobility and or high care needs could not undertake personal activities in private. In addition, residents could not exercise choice so far as such exercise did not interfere with the rights of other residents. For example, there was only one television in each of these five bedded bedrooms and residents did not have access to other media such as WiFi or Internet connectivity.


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Appendix 1 - Full list of regulations considered under each dimension

Regulation Title Judgment

Capacity and capability

Registration Regulation 4: Application for registration or renewal of registration

Compliant

Regulation 14: Persons in charge Compliant

Regulation 15: Staffing Compliant

Regulation 16: Training and staff development Compliant

Regulation 19: Directory of residents Compliant

Regulation 21: Records Compliant

Regulation 22: Insurance Compliant

Regulation 23: Governance and management Substantially compliant

Regulation 24: Contract for the provision of services Compliant

Regulation 3: Statement of purpose Substantially compliant

Regulation 31: Notification of incidents Compliant

Regulation 34: Complaints procedure Substantially compliant

Regulation 4: Written policies and procedures Compliant

Quality and safety

Regulation 11: Visits Compliant

Regulation 12: Personal possessions Not compliant

Regulation 13: End of life Compliant

Regulation 17: Premises Not compliant

Regulation 18: Food and nutrition Compliant

Regulation 20: Information for residents Compliant

Regulation 26: Risk management Substantially compliant

Regulation 27: Infection control Compliant

Regulation 28: Fire precautions Compliant

Regulation 29: Medicines and pharmaceutical services Substantially 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. Brigid's Hospital OSV-0000672 Inspection ID: MON-0022354

Date of inspection:23 and 24/10/2018 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 23: Governance and management

Substantially Compliant

Outline how you are going to come into compliance with Regulation 23: Governance and management: Consideration has been given by Hospital Management in conjunction with Technical Services regionally to add an extension to St. Brigid’s Hospital with a view to meeting HIQA Environmental standards. However the building itself and the surrounding grounds and parking area does not allow for an extension of sufficient size to meet HIQA Environmental Standards. There is thus a requirement to build a new hospital on a green field site in Carrick on Suir. A cost estimate for such a proposal would be in the region of €5 million. No capital funding has been identified nationally to meet this cost Intermin measures are in place to manage as follows. 1. In the multi occupancy rooms three of five residents are fully independent with mobility and they can leave this area to ascess the sitting room and dinning room and have ascess to the garden areas. 2. Residents are provided with head phones for TV and radio 3. Ear plugs are also provided for Residents should noise be a problem 4. Independent residents can leave the multi occupancy areas to a quiet area if they wish 5. Bed management will monitor that only three of five Residents will be independent In the multi occupancy area. .

Regulation 3: Statement of purpose Substantially Compliant

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Outline how you are going to come into compliance with Regulation 3: Statement of purpose: The Statement of Purpose will be updated to include 1. A more detailed description of the rooms, their function and size. 2. A robust admission criteria

Regulation 34: Complaints procedure


Outline how you are going to come into compliance with Regulation 34: Complaints procedure: St. Brigid’s Hospital will continue to maintain a complaints log and clarifying with residents their satisfaction or otherwise with the management of a complaint. With regard to a resident’s suitability for admission to the 5 bedded ward, all residents will be assessed on admission and placed in the available bedroom that best meets their clinical; and social care needs. Internet access for residents will be available going forward.

Regulation 12: Personal possessions

Not Compliant

Outline how you are going to come into compliance with Regulation 12: Personal possessions: An area has been identified within St. Brigid’s Hospital where wardrobes can be placed to accommodate resident’s personal belongings. Objects of value will be stored on behalf of the resident in the Hospital safe.

Regulation 17: Premises

Not Compliant

Outline how you are going to come into compliance with Regulation 17: Premises: Consideration has been given by Hospital Management in conjunction with Technical Services regionally to add an extension to St. Brigid’s Hospital with a view to meeting HIQA Environmental standards. However the building itself and the surrounding grounds and parking area does not allow for an extension of sufficient size to meet HIQA

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Environmental Standards. There is thus a requirement to build a new hospital on a green field site in Carrick on Suir. A cost estimate for such a proposal would be in the region of €5 million. No capital funding has been identified nationally to meet this cost. The telephone call system within the sitting room will be modified to reduce the noise emission. A mobile call bell will be placed in an accessible area within the sitting room. The hole in the ceiling in the sluice room will be repaired.

Regulation 26: Risk management


Outline how you are going to come into compliance with Regulation 26: Risk management: Risk management will be improved by: 1. Ensuring all toilets and bathroom areas accessed by residents have hand rails in place 2. Ensuring that the Kitchen and garden area are fitted with locks to allow monitoring and control of access. 3. A formal health and safety walk around is carried out every three monthly where all hazards and risks identified are risk rated and our risk register is updated accordingly ,the effectiviness of this walk around has helped mitigate risks,this is evaluated on a ongoing basis

Regulation 29: Medicines and pharmaceutical services


Outline how you are going to come into compliance with Regulation 29: Medicines and pharmaceutical services: The requirement for having two signatures on all control drugs stock records has been highlighted to clinical nursing staff at the staff meeting in November. Documentation records will be audited on a monthly basis going forward to ensure compliance with this requirement.

Regulation 9: Residents' rights

Not Compliant

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Outline how you are going to come into compliance with Regulation 9: Residents' rights: Consideration has been given by Hospital Management in conjunction with Technical Services regionally to add an extension to St. Brigid’s Hospital with a view to meeting HIQA Environmental standards. However the building itself and the surrounding grounds and parking area does not allow for an extension of sufficient size to meet HIQA Environmental Standards. There is thus a requirement to build a new hospital on a green field site in Carrick on Suir. A cost estimate for such a proposal would be in the region of €5 million. No capital funding has been identified nationally to meet this cost. Internet access for residents will be available going forward.

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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 12(c) The person in charge shall, in so far as is reasonably practical, ensure that a resident has access to and retains control over his or her personal property, possessions and finances and, in particular, that he or she has adequate space to store and maintain his or her clothes and other personal possessions.

Not Compliant Orange

31/01/2019

Regulation 17(2) The registered provider shall, 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.


31/01/2019

Regulation 23(a) The registered provider shall


Yellow

30/11/2018

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ensure that the designated centre has sufficient resources to ensure the effective delivery of care in accordance with the statement of purpose.

Regulation 26(1)(a)

The registered provider shall ensure that the risk management policy set out in Schedule 5 includes hazard identification and assessment of risks throughout the designated centre.


Yellow

31/01/2019

Regulation 29(4) The person in charge shall ensure that all medicinal products dispensed or supplied to a resident are stored securely at the centre.


Yellow

30/11/2018

Regulation 03(1) The registered provider shall prepare in writing a statement of purpose relating to the designated centre concerned and containing the information set out in Schedule 1.


Yellow

30/11/2018

Regulation 34(1)(h)

The registered provider shall provide an accessible and effective complaints procedure which includes an


Yellow

30/11/2018

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appeals procedure, and shall put in place any measures required for improvement in response to a complaint.

Regulation 9(3)(a) A registered provider shall, in so far as is reasonably practical, ensure that a resident may exercise choice in so far as such exercise does not interfere with the rights of other residents.

Not Compliant Yellow

30/11/2018

Regulation 9(3)(b) A registered provider shall, in so far as is reasonably practical, ensure that a resident may undertake personal activities in private.


30/11/2018

report of an inspection of a designated centre for older people - … 2019-02-01 · convalescent/...

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