Report of an inspection of a Designated Centre for Older People

Transcription

1 Report of an inspection of a Designated Centre for Older People Name of designated centre: Name of provider: Address of centre: Sheelin Nursing Home Sheelin Nursing Home Limited Mountnugent, Cavan Type of inspection: Announced Date of inspection: 21 March 2018 Centre ID: OSV Fieldwork ID: MON Page 1 of 13

2 About the designated centre The following information has been submitted by the registered provider and describes the service they provide. The designated centre provides nursing care and support over a 24 hour period to meet the needs of up to 36 older persons, male and female for both long term and short term care. The centre is a converted building, on three levels over looking an expanse of water. It is situated in a rural area. The philosophy of care is to provide a caring environment that promotes residents health, independence, dignity and choice. The holistic approach aims to provide a quality service with the highest standard of care. The following information outlines some additional data on this centre. Current registration end date: Number of residents on the date of inspection: 12/06/ Page 2 of 13

3 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. Page 3 of 13

4 This inspection was carried out during the following times: Date Times of Inspection Inspector Role 21 March :00hrs to 19:30hrs 21 March :00hrs to 19:30hrs Siobhan Kennedy Gearoid Harrahill Lead Support Page 4 of 13

5 Views of people who use the service Residents who communicated with the inspectors and those who completed questionnaires were positive with regard to the control they had in their daily lives and the choices that they could make. Residents told inspectors about their daily routines, activity plans and interactions with the community. They expressed satisfaction regarding food and mealtimes and were happy with the support and assistance provided by staff. The areas which were identified by residents for further improvement related to the insufficiency of the toilet space in some of the bedroom en suites in order to have equipment, more social and recreational outings and some days lunch is served too early. Capacity and capability Overall, residents, relatives and staff considered this to be a good centre and inspectors observed that there were good interactions between residents and staff. Prior to the inspection the provider submitted the required documentation for the renewal of registration. The application was received by the Health Information Quality Authority (HIQA) on the 6 December Approval was being sought to accommodate 36 residents. An examination of the information showed that the floor plan and the statement of purpose outlining the facilities and services corresponded to the findings on inspection. Specific matters arising from the previous inspection carried out on the 18 October 2017 were addressed, however, some aspects of these regulations examined during this inspection required further improvement. The use of resources was planned and managed to provide person centred, effective and safe services to residents. The full-time person in charge had good experience of the provision of residential care to older persons and provided good leadership to the team. The staff member identified to be available in the absence of the person in charge was currently on leave. Management and staff were knowledgeable regarding their roles and the care and condition of residents. The provider representative was available during the inspection to assist in the process and for feedback. Recently two nurses had been recruited and this was carried out in compliance with employment and equality legislation, including the appropriate vetting procedures. The numbers and skill mix of staff at the time of inspection were sufficient to meet the needs of residents. There was evidence that staff had access to education and Page 5 of 13

6 training, appropriate to their role and responsibilities. They were monitored and supervised. Staff were knowledgeable and skilled for example in safe moving and handling of residents, food safety and safeguarding. The governance structure showed that there were clear lines of accountability and staff were aware of their responsibilities and to whom they were accountable. Systems in place ensured that service delivery was effective through the on-going audit and monitoring of performance. Since the last inspection all staff had participated in an appraisal. An annual review report was available and it was prepared in consultation with residents and contained a quality improvement plan. A recent development which has brought about good outcomes for residents and staff was the introduction of a new pharmacy. Prior to the inspection unsolicited information was received by HIQA in respect of ensuring that a resident's body following death is respected and aftercare is carried out in a dignified manner. The provider representative informed the inspectors that this matter had been addressed in consultation with the undertakers as far as was practicable, given the layout of the building. The complaints policy and procedure was widely advertised and residents and relatives were familiar with the process. Residents were able to identify a staff member who they would speak to if they had any concerns. The complaints record showed that complainants were satisfied with the outcome of investigations. Appropriate notifications were received by HIQA. Registration Regulation 4: Application for registration or renewal of registration An application for renewal of registration was completed and contained the necessary information. Judgment: Regulation 14: Persons in charge The centre was being managed by a suitably qualified and experienced nurse who has authority in consultation with the provider representative and is accountable and responsible for the provision of the service. Judgment: Regulation 15: Staffing From an examination of the staff duty rota, communication with residents and staff Page 6 of 13

7 it was found that the numbers and skill mix of staff at the time of inspection were sufficient to meet the needs of residents. Judgment: Regulation 16: Training and staff development Staff were up to date in their mandatory training and had received supplementary training to care for residents. Judgment: Regulation 23: Governance and management Governance arrangements were appropriate. Judgment: Regulation 24: Contract for the provision of services Each resident had a written contract of care which was agreed with the provider outlining the terms of residency and the fees. Judgment: Regulation 3: Statement of purpose The statement of purpose was in accordance with the legislation and the description of the facilities and services reflected what was found on inspection. Judgment: Regulation 31: Notification of incidents Page 7 of 13

8 Incidents occurring in the centre were appropriately notified to HIQA. Judgment: Regulation 34: Complaints procedure An accessible and effective complaints procedure was in place. Judgment: Quality and safety Residents were consulted about the running of the centre and there were opportunities for them or their relatives to give feedback and input regarding matters in the centre such as activities and meals. Regular resident committee meetings took place in the centre. Residents had access to independent advocacy services. They were facilitated to observe their religious practices on a weekly basis and those who chose to could exercise their right to vote in local and general elections. There was a good variety of recreational activities on offer in the centre. The activities coordinator had a system of tracking attendance and engagement of residents in group and individual activities. This highlighted areas where a change in residents' interests or capacities necessitated alternative activities. The coordinator had adequate time to spend with residents who required more one-to-one engagement and there were arrangements in place for care staff to take over activities during weekends. This ensured that residents were stimulated and provided consistency. Residents had adequate space for their clothing and personal belongings including mementos such as photos and ornaments. Residents had the option of securing their personal valuables with management, and while records kept were accurate, some improvement was discussed to ensure records of money (incoming and outgoing) was clearly tracked. The provider acted as a pension agent for some residents. Arrangements for this required review to afford greater protection for residents' money and access to their finances. Property inventories, an organised inhouse laundry service and appropriate labelling system reduced the risk of residents clothing going missing and ensured that items were returned to their rightful owners. Residents had a care plan which was based on an ongoing comprehensive assessment of their needs. This was implemented, evaluated and reviewed. It reflected their changing needs and outlined the supports they required to maximise Page 8 of 13

9 their quality of life in accordance with their wishes. Staff liaised with the community services regarding appropriate admission and discharge arrangements. Residents received palliative care based on their assessed needs and this aimed at maintaining and enhancing their quality of life and respected their dignity. Residents nutritional and hydration needs were met and residents confirmed that meals and meal times were an enjoyable experience. The management of medicines was not in accordance with the centre's policy and procedures. Staff were trained in identifying and responding to actual, alleged or suspected incidents of abuse. Residents who used bed rails were continually assessed and reviewed to determine the rationale for continued use and to trial the effectiveness of alternative measures such as low-entry beds. Staff had attended fire safety training and were familiar with using evacuation sheets and horizontal evacuation. Personal emergency evacuation plans had been compiled for all residents which outlined their requirements of equipment and staff assistance for transport in the event of an emergency evacuation during either the day or at night. Fire drills were conducted which highlighted potential delays and learning for staff to achieve efficient evacuation. However, practice or simulated evacuations had not been tested for areas of higher risk, particularly the upper level which accommodated the most dependent residents. This high risk area was also the location of the smoking room. There was an access via an open stairway to the kitchen. Staff were not clear on the procedures to be followed in the event that residents had to be evacuated from the communal room if moving to the next internal compartment was not an option. Some environmental matters required attention to allow for safe containment of flame and smoke in the event of a fire. The door to the smoking room did not close correctly and the room was being used for storage of activity props and chairs. A small number of doors were observed being held open using hooks or furniture in the absence of a mechanism to allow them to be held open and released in the event of a fire alarm trigger. Overall the premises were designed and adapted to meet the needs of residents providing them opportunities to mobilise independently or with assistance. A lift was available to move between floors and handrails were available in the corridors. There were designated storage areas so that equipment was not stored inappropriately. There was adequate toilet and shower facilities for the number of residents living in the centre and these were equipped with adaptations to allow them to be used by residents with reduced mobility. Bedrooms accommodating two residents were equipped with curtain screening which afforded privacy while not obstructing the space usable or access to the en-suite toilet for the other resident. The provider had identified bedrooms which were only suitable for mobile residents as the size of the rooms would be insufficient to accommodate residents using a wheelchair or requiring a hoist. Call bells were available, in good working order and accessible to residents. Page 9 of 13

10 Regulation 11: Visits Visitors were made welcome in the centre and there was a suitable designated space for residents to receive their guests in private. Judgment: Regulation 12: Personal possessions Arrangements and procedures were in place for residents to maintain control over their property and clothing. Judgment: Regulation 13: End of life End of life care was provided in accordance with the wishes of residents and their relatives. Judgment: Regulation 17: Premises Overall, the centre was suitable in its size and layout for the number and needs of the residents. Judgment: Regulation 28: Fire precautions Adequate precautions were not taken against the risk of fire. Some fire doors were held open using means which would prevent them closing in the event of an emergency. Page 10 of 13

11 Access to some fire extinguishers were obstructed by furniture. Combustible materials were stored in the smoking room and the door to this room did not close properly. Staff were not clear on the procedures to be followed when evacuating high dependent residents from the communal room on the first floor. Practice or simulated evacuations had not been tested for areas of higher risk, particularly the upper level which accommodated the most dependent residents. Judgment: Not compliant Regulation 5: Individual assessment and care plan Adequate arrangements were in place to assess residents needs and treatment plans were described in individual care plans which were formerly reviewed. Judgment: Regulation 6: Health care Appropriate medical and health care was provided. Judgment: Regulation 8: Protection The arrangements in place for when the provider acts as an agent for residents pensions required review to afford greater protection of those residents finances. Judgment: Substantially compliant Regulation 9: Residents' rights Residents were able to exercise their civil and religious rights, contribute to the running of the centre, participate in meaningful activities and have their privacy and Page 11 of 13

12 dignity respected. Judgment: Regulation 29: Medicines and pharmaceutical services The management of medicines was not satisfactory. Medicines were signed as administered prior to administration. Oral medicine was not kept safe. Individual medicines were not identified to be crushed. The refrigerator for storing medicines was not working properly. Judgment: Not compliant Page 12 of 13

13 Appendix 1 - Full list of regulations considered under each dimension Regulation Title Capacity and capability Registration Regulation 4: Application for registration or renewal of registration Regulation 14: Persons in charge Regulation 15: Staffing Regulation 16: Training and staff development Regulation 23: Governance and management Regulation 24: Contract for the provision of services Regulation 3: Statement of purpose Regulation 31: Notification of incidents Regulation 34: Complaints procedure Quality and safety Regulation 11: Visits Regulation 12: Personal possessions Regulation 13: End of life Regulation 17: Premises Regulation 28: Fire precautions Regulation 5: Individual assessment and care plan Regulation 6: Health care Regulation 8: Protection Regulation 9: Residents' rights Regulation 29: Medicines and pharmaceutical services Judgment Not compliant Substantially compliant Not compliant Page 13 of 13

14 Compliance Plan for Sheelin Nursing Home OSV Inspection ID: MON Date of inspection: 21/03/2018 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 noncompliance 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. Page 1 of 4

15 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 Regulation 28: Fire precautions Judgment Not Outline how you are going to come into compliance with Regulation 28: Fire precautions: New door closers are to be installed by MasterFire ltd, these are automatic & are connected to the fire alarm system, closing automatically when fire alarm goes off. All fire extinguishers are accessible and checked daily. Combustible material removed from smoking room and stored in appropriate location. All staff have undertaken Fire training and are aware of procedures. Fire drills now include simulated evacuations particularly for areas of higher risk. Regulation 8: Protection Substantially Outline how you are going to come into compliance with Regulation 8: Protection: A new bank account solely for Residents finances is currently in process of being set up. All pensions will be lodged to this account. Regulation 29: Medicines and pharmaceutical services Not All Nursing staff have under taken Medication Management training. Medicines are now signed after administration in accordance with Medication policy. Page 2 of 4

16 Oral medicine is now stored inside drug trolley. Individual medicines are now identified to be crushed. A new refrigerator in snow in place. 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 Regulation 28(1)(a) Regulation 28(1)(e) Regulatory requirement The registered provider shall take adequate precautions against the risk of fire, and shall provide suitable fire fighting equipment, suitable building services, and suitable bedding and furnishings. The registered provider shall ensure, by means of fire safety management and fire drills at suitable intervals, that the persons working at the designated centre and, in so far as is reasonably practicable, Judgment Substantially Risk Date to be rating complied with Yellow 31 July 2018 Not Orange 30 June 2018 Page 3 of 4

17 residents, are aware of the procedure to be followed in the case of fire. Regulation 28(2)(i) The registered provider shall make adequate arrangements for detecting, containing and extinguishing fires. 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. Regulation 8(1) The registered provider shall take all reasonable measures to protect residents from abuse. Not Orange 31 May 2018 Not Orange 01/04/2018 Substantially Yellow 31 July 2018 Page 4 of 4