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: St Joseph's Home Little Sisters of the Poor Abbey Road, Ferrybank, Waterford Type of inspection: Unannounced Date of inspection: 08 August 2018 Centre ID: OSV Fieldwork ID: MON Page 1 of 17

2 About the designated centre The following information has been submitted by the registered provider and describes the service they provide. St Josephs Home is owned and operated by the order of The Little Sisters of the poor. It is a purpose built centre registered to provide care to 51 residents. It is situated in Ferrybank in Waterford city close to all local amenities. It provides residential care to people over the age of 65. It offers care to residents with varying dependency levels ranging from low dependency to maximum dependency needs. It offers care to long-term residents with general and dementia care needs The centre comprises of three units named; Lourdes, Fatima and the convent. All resident accommodation is provided in large single en-suite bedrooms. The centre has ample communal space with numerous dining rooms, sitting rooms and lounges throughout both floors that accommodated residents. A reminiscence room, a sensory room, an aromatherapy room and physiotherapy room and hair salon are all located within the centre. Brightly-coloured shop fronts had been constructed for the medical centre, activity centre, store and tea rooms to replicate a 'village-like' environment. A large balcony was located on both floors that accommodated residents, where flowers, herbs and vegetables were being grown by residents.there is a large church where mass is celebrated daily. Outdoor space in the form of enclosed gardens and seating areas to the front of the building are available for resident and relative use. The centre provides 24-hour nursing care with a minimum of two nurses on duty during the day and one nurse at night time. The person in charge and the Assistant Director of Nursing live in the centre and are on call as required. The nurses are supported by care, catering, household and activity staff. Medical and allied healthcare professionals provide ongoing healthcare for residents. The following information outlines some additional data on this centre. Current registration end date: Number of residents on the date of inspection: 24/11/ Page 2 of 17

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 17

4 This inspection was carried out during the following times: Date Times of Inspection Inspector Role 08 August :00hrs to 17:30hrs 09 August :00hrs to 16:30hrs Caroline Connelly Caroline Connelly Lead Lead Page 4 of 17

5 Views of people who use the service The inspectors spoke with the majority of the 50 residents present on the days of the inspection and met with them either in their own rooms or in the communal areas. Feedback from residents was consistently positive about care and communication with staff at the centre. Residents were very complimentary about staff saying staff were very caring and helpful. However a number of residents felt that they often had to wait for staff when they rang the bell particularly in the evening time when staffing levels reduced. Residents said they were consulted with on a daily basis and regular residents' meetings were facilitated. Some residents likened the centre to a 'home from home' and confirmed that they felt they had good choice around how they spent their day, when they got up and what they liked for breakfast for example, or whether they would participate in the activities that were provided. Residents were particularly complimentary about the activities and the activity co-ordinator. They said there was always something to do and enjoyed the group and one to one activities. Many residents were complimentary about the frequency of the religious services in the centre and the ethos of the sisters providing the service. The majority of residents reported satisfaction with the food and said choices were offered at meal times and staff always ensured they had plenty of drinks and snacks. They equated the food service to that of a hotel and loved attending the central dining room. There was general approval expressed with laundry services however some residents reported items of personal laundry going missing. Capacity and capability The management systems in this centre were not fully effective to ensure consistent good quality care was delivered to the residents. Although there was a defined management structure in place, roles and responsibilities were not clearly outlined. It was not clear who had responsibility for the oversight of clinical care and the current governance and management of the centre required improvement. HIQA had received unsolicited information prior to and during the inspection regarding aspects of clinical care, staffing and governance of the centre. The provider was required to submit information of investigation and action in response to these concerns which was reviewed by the inspector. These areas were also looked into during the inspection and a number of the issues Page 5 of 17

6 were substantiated and are detailed in the report and the regulatory noncompliance's are outlined for required action in the compliance plan. The centre was operated by the Little Sisters of the Poor who was the registered provider. There is a regional management board who carry out a site visit at least every three months to receive updates on the operational management of the centre. There was a comprehensive governance and management framework document dated January 2018 which detailed lines of accountability and responsibility. However the inspector found that this framework had not been fully implemented in practice and the roles and responsibilities of the management team were not clear, particularly in the supervision of clinical care. One of the sisters is the registered provider representative and person in charge of the centre and has overall accountability for all aspects of governance and management for the designated centre. She is supported in the day to day management of the centre by an Assistant Director Of Nursing (ADON) and a Clinical Nurse Manager (CNM) who had responsibility for completing monthly key performance indicators and audits of the service. However, the CNM was due to leave the service following the inspection leaving this post vacant. The management team were supported by heads of departments which included an accounts manager, a building services manager and human resources personnel. Non-Nursing unit sisters oversee the non-clinical care environment for residents and oversee the housekeeping, maintenance and environmental safety at floor level. The sisters report to and are accountable to the person in charge. Both sisters were new to their roles since the previous inspection. There had been a high turnover of staff since the previous inspection and although staff that left had been replaced the inspector found that the recruitment, supervision and training for the new staff was not robust. Gaps were seen in staff files, induction and training for new staff was not satisfactory with no completed and signed records of induction. This was particularly relevant in the recruitment of new nursing staff who were in charge of units. Communication between departments was poor, an example of this was that although the building services manager provided on-site fire training and induction training for staff, he had not been made aware of new starters. Therefore a number of new staff were working without having received easily accessible mandatory fire training, which was subsequently scheduled. There was no comprehensive training matrix or up to date training records available for inspection. Although there was evidence of staff attending some training, the provision of mandatory training was not up-to-date for all staff in key areas such as fire safety, moving and handling, safeguarding and responding to responsive behaviours. Although some staff had undertaken recent appraisals many had not had an appraisal since Further supervision of staff and clarity around roles and responsibilities was required to ensure all residents needs were met. The person in charge informed the inspector that they were currently trying to put systems in place to address many of the issues outlined and particularly around the recruitment, training and supervision of staff. They had introduced a team brief initiative where the person in charge informed the team of key changes, initiatives, items of interest going on in the centre relevant to staff on a monthly basis. Clinical governance meetings were also held monthly. Improvements were seen in the recording and management of complaints since the Page 6 of 17

7 previous inspection and complaints were discussed at the governance and staff meetings. The inspector reviewed audits completed by the CNM and staff in many areas including infection control, medication management, health and safety, catering, dining experience, care plans, and falls audit. There was evidence of actions taken as the result the audits to improve the quality of care for the residents. However due to shortage of staff audits were not currently taking place on a regular basis. The person in charge received feedback from residents via the residents meetings. External consultants had completed a very comprehensive annual review of the quality and safety of care delivered to residents in the designated centre to ensure that such care is in accordance with relevant standards set by HIQA under section 8 of the Act for However the inspector noted that a number of the actions and recommendations for 2018 had not been fully implemented at the time of the inspection. The service was generally appropriately resourced, however staffing levels and skill mix particularly in the evening required review in line with the size and layout of the building and the increasing dependency needs of the residents. Residents relatives and staff all reported the requirement for more staff as some reported having to wait long periods for assistance if staff were with other residents. There is only one nurse on duty at night to administer medications to 51 residents in three units over two floors and also to supervise the care staff providing essential care to the residents this required review. Copies of the standards and regulations were readily available and accessible by staff. Maintenance records were in place for equipment such as hoists and firefighting equipment. Records and documentation as required by Schedule 3 and 4 of the regulations were securely controlled, maintained in good order and easily retrievable for monitoring purposes. Records such as a complaints log, records of notifications, fire checks and a directory of visitors were also available and effectively maintained. There were systems in place to manage critical incidents and risk in the centre and accidents and incidents in the centre were recorded, appropriate action was taken and they were followed up on and reviewed. Regulation 15: Staffing Staffing levels and skill mix in the evening required review taking into account the layout of the centre over two floors and three units. There is only one nurse on duty to administer night time medications to all 51 residents and to supervise the care provided by the care staff. Judgment: Not compliant Page 7 of 17

8 Regulation 16: Training and staff development A number of staff did not have up-to-date mandatory training. There was not a comprehensive training matrix in place identifying when staff last attended mandatory training and when they are due for refresher or renewal. Training in tissue viability and wound care was a requirement for all nursing staff to ensure they provided care in accordance with contemporary evidenced based practice. The inspector was not satisfied that staff were appropriately supervised.,there was not evidence of comprehensive induction programmes for new staff including probationary meetings. Although some staff had undertaken recent appraisals many had not had an appraisal since Judgment: Not compliant Regulation 21: Records A sample of staff files viewed by the inspector did not contain all the information required by schedule 2 of the regulations. A reference was missing for one staff member another staff was missing a reference from their last employer. A record of current registration with the nursing and midwifery board of Ireland was not available for two nurses. Judgment: Not compliant Regulation 23: Governance and management A comprehensive annual review of the quality and safety of care was completed for 2017 with the assistance of an external consultancy company. However not all the actions required outlined for 2018 had been implemented to date. There were not management systems in place to ensure that the service provided is safe, appropriate, consistent and effectively monitored. There was not a clearly defined management structure in place. Judgment: Not compliant Page 8 of 17

9 Regulation 24: Contract for the provision of services Contracts for the provision of care were in place which clearly outlined the room number the resident occupied. The inspector viewed a number of contracts of care and, although they did contain details of the service to be provided and the fee to be paid, they did not detail the charges for additional services not included in the fee. Judgment: Substantially compliant Regulation 3: Statement of purpose A detailed statement of purpose was available to staff, residents and relatives. This contained a statement of the designated centre s vision, mission and values. It accurately described the facilities and services available to residents, and the size and layout of the premises. Judgment: Regulation 30: Volunteers There were a large number of volunteers working in the centre and detailed job descriptions were in place. Satisfactory vetting and references were also on file for the sample of volunteer files viewed. Judgment: Regulation 34: Complaints procedure Improvements were seen in complaints management since the previous inspection. There was evidence that complaints were recorded, investigated and actions taken. The complainant's satisfaction with the outcome of the complaint was recorded. The procedure to follow in making a complaint was updated to reflect changes to the complaints officer. Judgment: Page 9 of 17

10 Regulation 4: Written policies and procedures A new system of policies and procedures had been put in place since the last inspection and all the required policies and procedures were in place. Judgment: Quality and safety Overall, residents were supported and encouraged to have a good quality of life which was respectful of their wishes and choices. Residents' needs were being met through very good access to healthcare services, opportunities for social engagement and a high quality premises that met their needs. The quality of residents lives was enhanced by the provision of a choice of interesting things for them to do during the day. The inspector found that a ethos of respect for residents was evident and residents and relatives gave very positive feedback regarding many aspects of life and care in the centre. However issues in relation to the lack of fully effective governance systems and supervision of clinical care identified under the capacity and capability section of the report had implications for the monitoring and oversight of the quality and safety of care. Improvements were required in tissue viability, wound care and in the promotion of a restraint free environment. Residents had access to general practitioner (GP) services and there was evidence of medical reviews at least three monthly and more frequently when required. A review of residents medical notes showed that GP s visited the centre to review residents and medicines on a regular basis. Medicines were also reviewed by the pharmacist to ensure optimum therapeutic values. Improvements were seen in all aspects of medication management. The dietitian visited the centre and residents were appropriately assessed for nutritional needs on admission and were subsequently reviewed regularly. Records of weight checks were maintained on a monthly basis and more regularly where significant weight changes were indicated. Residents were seen to be provided with a regular choice of freshly prepared food. Menu options were available and residents on a modified diet had the same choice of meals as other residents with due consideration given to the presentation of these meals. The overall dining experience for residents was seen to be of a high quality. There was evidence that residents had access to other allied healthcare professionals including, physiotherapy, speech and language therapy, dental, chiropody and ophthalmology services. The centre also had access to a tissue viability specialist nurse. However the inspector saw that tissue viability and the prevention of pressure sore formation and the treatment of wounds all required significant improvement. The inspector reviewed the care of two residents who developed pressure sores in the centre and although both were seen and reviewed by the tissue viability nurse, the inspector found delays in appropriate action being taken and inconsistencies in the documentation and management of the wounds Page 10 of 17

11 prior to this review. As identified under capacity and capability improvements were required in the supervision of care to ensure care is provided in accordance with evidenced based practice. Since the previous inspection the centre had implemented a computerised system of assessment and care planning and the majority of residents records had been transferred to the new system by a senior nurse. The inspector viewed a number of residents records and found that care delivered was generally based on a comprehensive nursing assessment completed on admission, involving a variety of validated tools. Care plan's were developed based on resident's assessed needs and regularly reviewed and updated. Overall, care plans were found to comprehensive and person centred. However, further education and support is required for the nursing staff to be fully conversant in this new system of documentation. The inspector found the practices around restraint use were not in line with the national restraint guidance issued by the department of health. There was a high usage of restraint in the centre with nurses informing the inspectors that over half of the residents used bedrails at night. Assessments for the use of bedrails required review and alternatives to bedrail usage need to be given further consideration. Overall the centre ensured that the rights and diversity of residents were respected and promoted. Advocacy services were available to residents as required. Residents' choice, privacy and dignity and independence were safeguarded. There was evidence of consultation with residents and relatives and resident survey's had been undertaken. A varied and interesting social programme was seen and residents' photos and art work was displayed throughout the centre. The inspector saw a number of different interesting activities taking place during the inspection. An enclosed outdoor garden space with raised flower beds was available and plenty of tables and chairs had been recently acquired for the front of the centre, where some activities also took place in the good weather. The centre was purpose built and was a bright, modern and spacious building. The premises and grounds were maintained to a very high standard with suitable heating, lighting and ventilation. The centre was clean and suitably decorated, with ample furnishings, fixtures and fittings to ensure a comfortable and homely residence. There was ample space for the movement of any specialised/assistive equipment that a resident might require. The provider had put systems in place to manage risks and ensure that the health and safety of all people using the service was promoted. The health and safety statement was reviewed regularly and appropriate fire safety practices were followed. Fire safety equipment was serviced regularly and all records were well maintained. An emergency plan with appropriate response was in place for all emergency situations. The building services manager had attended specialist fire training and provided fire training in house. Staff had received up to date fire training with the exception of two new who staff were scheduled to attend the training the following week. Regular fire drills took place with comprehensive recording of actions taken and learning from same. Page 11 of 17

12 Regulation 11: Visits There was evidence that there was an open visiting policy and that residents could receive visitors in the communal area and in the designated visitors' room. The inspector saw visitors coming in and out during the inspection who confirmed that they were welcome to visit at any time and found the staff very welcoming. Judgment: Regulation 12: Personal possessions Bedrooms were furnished to a high standard and were very spacious. Each resident's bedroom had their name on the door, a private letterbox and a working doorbell. Extra signage such as residents' photos was displayed on some bedrooms to support them to locate their rooms. All bedrooms were single occupancy with a large, well equipped ensuite shower, toilet and wash hand basin. A small sink supplying drinking water was also located in each room. There was plenty of storage space to store personal possessions including locked storage space in residents bedrooms. Many bedrooms were seen to be very personalised. Judgment: Regulation 13: End of life The inspector was satisfied that caring for a resident at end-of-life was regarded as an integral part of the care service provided. The inspector saw that residents and their family members are supported and end of life care is provided in accordance with the residents and their families wishes as outlined in an end of life care plan. The resident s general practitioner and community palliative care services are available as required and provide a good support for the residential care staff team. Care plans were found to outline residents wishes at end of life including the religious needs, social and spiritual needs of each resident. Individual religious and cultural practices were facilitated and mass was held on a daily basis in the centre. Judgment: Page 12 of 17

13 Regulation 17: Premises The location, design and layout of the centre was suitable for its stated purpose and met all residents' individual needs in a comfortable and homely way. The design and layout promoted the dignity, independence and wellbeing of residents. Judgment: Regulation 18: Food and nutrition Residents' needs in relation to nutrition were met, meals and meal times were observed to be an enjoyable experience. Judgment: Regulation 26: Risk management The risk management policy was seen to be followed in practice. For each risk identified, it was clearly documented what the hazard was, the level of risk, the measures to control the risk, and the person responsible for taking action. Regular health and safety reviews were also carried out to identify and respond to any potential hazards. Judgment: Regulation 27: Infection control The centre was observed to be very clean. Appropriate infection control procedures were in place and staff were observed to abide by best practice in infection control and good hand hygiene. Staff had undertaken training in infection control. Page 13 of 17

14 Judgment: Regulation 28: Fire precautions Overall, regular fire training was delivered in the centre. Fire alarms, emergency lighting and fire fighting equipment were serviced at appropriate intervals. Staff demonstrated an awareness of what to do in the case of fire and signage on what to do in the case of fire, identifying compartments, was available throughout in the centre. Fire drills took place on a regular basis during the day and the evening and when reduced staffing levels at night time. Judgment: Regulation 29: Medicines and pharmaceutical services There were written operational policies and procedures in place on the management of medications in the centre. Medications requiring special control measures were stored appropriately and counted at the end of each shift by two registered nurses. A sample of prescription and administration records viewed by the inspector which contained appropriate identifying information. Medications requiring refrigeration were stored in a fridge and the temperature was monitored and recorded daily. Regular audits of medication management took place and the inspectors saw improvements in place since the previous inspection. Judgment: Regulation 5: Individual assessment and care plan The centre was introducing a new computerised system of assessments and care planning. Care plans viewed by the inspector were generally personalised, regularly reviewed and updated following assessments completed using validated tools. End of life care plans were in place and detailed residents wishes at end stage of life. Judgment: Page 14 of 17

15 Regulation 6: Health care Tissue viability and wound care required review to ensure staff are providing care in accordance with contemporary evidenced based practice. Judgment: Not compliant Regulation 7: Managing behaviour that is challenging From discussion with the person in charge and staff and observations of the inspector there was evidence that residents who presented with responsive behaviours were responded to in a very dignified and person-centred way by the staff using effective de-escalation methods. There was a high number of bedrails in use in the centre and restraint practices required review to be in line with the national policy on restraint use. Judgment: Not compliant Regulation 8: Protection There were a number of measures in place to safeguard residents and protect them from abuse however as identified and actioned under regulation 6 staff training, not all staff had received training in safeguarding vulnerable adults. The management of residents finances was seen to be robust with comprehensive systems in place by the finance manager and unit sisters. Judgment: Regulation 9: Residents' rights There was evidence of residents' rights and choices being upheld and respected. Residents were consulted with and formal residents' meetings were facilitated and Page 15 of 17

16 there was evidence that relevant issues were discussed and actioned. A comprehensive programme of appropriate activites were available. Advocacy services were available as required. Judgment: Page 16 of 17

17 Appendix 1 - Full list of regulations considered under each dimension Regulation Title Capacity and capability Regulation 15: Staffing Regulation 16: Training and staff development Regulation 21: Records Regulation 23: Governance and management Regulation 24: Contract for the provision of services Regulation 3: Statement of purpose Regulation 30: Volunteers Regulation 34: Complaints procedure Regulation 4: Written policies and procedures Quality and safety Regulation 11: Visits Regulation 12: Personal possessions Regulation 13: End of life Regulation 17: Premises Regulation 18: Food and nutrition Regulation 26: Risk management Regulation 27: Infection control Regulation 28: Fire precautions Regulation 29: Medicines and pharmaceutical services Regulation 5: Individual assessment and care plan Regulation 6: Health care Regulation 7: Managing behaviour that is challenging Regulation 8: Protection Regulation 9: Residents' rights Judgment Not compliant Not compliant Not compliant Not compliant Substantially compliant Not compliant Not compliant Page 17 of 17

18 Compliance Plan for St Joseph's Home OSV Inspection ID: MON Date of inspection: 08-09/08/2018 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 7

19 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 mus/t 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 15: Staffing Judgment Not Outline how you are going to come into compliance with Regulation 15: Staffing: Following recent departure of the centre s clinical nurse manager, arrangements have been made for the commencement of employment of a new clinical nurse manager with relevant experience, commencing on 24 th September Two new registered nurses have also been recruited commencing employment in early October. Arrangements have also been put into place to have a registered nurse rostered from 19:30 hours to 23:00 hours commencing 01 st November This registered nurse will facilitate the administration of nighttime medications on one floor, leaving the registered nurse on night duty to administer medications on the other floor. The twilight nurse will also provide care and supervision to residents on one floor with the support of two healthcare assistants. Handover will be given by the twilight nurse to the night duty nurse prior to leaving the centre to ensure all necessary information is handed over. Regulation 16: Training and staff development Not Outline how you are going to come into compliance with Regulation 16: Training and staff development: A training needs analysis has been conducted based on formal and informal methods including informal observation of performance, consultation with staff, review of organisational goals / objectives, quality improvement activities including audit and so on. Following on from this, a comprehensive training matrix has been created that details all training staff have attended and the expiry dates of such training. Training on various topics such as safeguarding, patient moving and handling, tissue viability, behaviours that challenge, autonomy and positive risk-taking, has been scheduled for the remainder of the year to ensure any gaps in the training needs of staff are addressed. Training in tissue viability has been arranged for clinical staff on 23 rd October Page 2 of 7

20 An annual training plan will be prepared in January 2019 for the coming year and this will be disseminated to all staff. This training plan will be reviewed every three months and will show actions for compliance according to training expiry dates. A comprehensive induction programme has been developed with a corresponding booklet that will be completed by all new employees as induction tasks are accomplished. All new employees will undergo this induction programme with the support of the Human Resource Manager, Building Services Manager, the clinical nurse manager, the new employees designated mentor and Unit Sisters. Performance appraisals for new employees will be conducted after the first three months, at which time a subsequent date will be set for the next appraisal. This date will be agreed based upon the goals and outcomes of the first appraisal. When an employee successfully completes his/her probationary period, annual performance appraisals will be carried out thereafter. The centre has been conducting performance appraisals for staff however not all staff had attended an appraisal within the previous 12 months. Because of this, all staff will have an annual performance review undertaken by the Person in Charge and/or their line manager in accordance with their reporting structures, completed by 31 st December Regulation 21: Records Not Outline how you are going to come into compliance with Regulation 21: Records: A staff file audit tool was developed, and a comprehensive audit was conducted of all staff files to identify those files that did not contain all necessary information as required by schedule 2 of the regulations. Efforts are currently being made to ensure all information is obtained and available for inspection. This will be completed by 31 st October Regulation 23: Governance and Not management Outline how you are going to come into compliance with Regulation 23: Governance and management: The Centres governance and management framework has been updated to include the roles and responsibilities of the nursing management team with regard to the supervision of clinical care. These roles and responsibilities have been implemented and include the person in charge and assistant director of nursing now conducting two rounds each day, mid-morning and afternoon. On each of these rounds, the person in charge and assistant director of nursing will speak with the registered nurse on duty on each floor and receive verbal feedback on any priority residents e.g. deterioration in condition, the development of any pressure ulcers, skin tears, any residents experiencing an infection, any incidents such as a fall, and so on. Additional to this, the clinical nurse manager will complete a newly developed handover form for the person in charge each evening detailing important information about residents and their care. The person in charge is supported in their role by a clinical nurse manager (newly appointed) and two senior staff nurses (also newly appointed). These three nurses are primarily supernumery in their role and new job descriptions have been developed to provide clear guidance as to their roles and responsibilities including the supervision of nurses and healthcare assistants at floor Page 3 of 7

21 level. As outlined above in Regulation 15: Staffing, arrangements have been put into place to have a registered nurse rostered from 19:30hours to 23:00hours commencing 01st November 2018 to support the night duty nurse with the administration of medications and supervision of residents and healthcare assistants. The three items that had yet to be actioned as identified from the annual review of quality are as follows: Consent and positive risk-taking training this has been scheduled for 12th October A Policy on open disclosure is currently in draft format and will be finalised by 31 st October Stimulating environmental cues such as rummage boxes have been made available for residents with dementia. Regulation 24: Contract for the provision of services Substantially Outline how you are going to come into compliance with Regulation 24: Contract for the provision of services: An addendum has been inserted to the Terms and Conditions of the Centre s Contract of Care outlining what is included and what is not included in the Fee. Regulation 6: Health care Not Outline how you are going to come into compliance with Regulation 6: Health care: Tissue viability training has been scheduled for 23 rd October 2018 to ensure staff are providing care in accordance with contemporary evidenced based practice. Earlier this year, the centre implemented a computerised system of assessment and care planning. A senior staff nurse is the identified link nurse for the computerised system and as she is primarily supernumery in her role, she is available to all staff to provide support and education on the system, as required. Over the coming months, the senior staff nurse will liaise with all staff to identify any knowledge gaps and provide one to one mentoring, as required. Regulation 7: Managing behaviour that is challenging Not Outline how you are going to come into compliance with Regulation 7: Managing behaviour that is challenging: On the day of the inspection, there were 26 residents using bedrails. An audit of the use of these bedrails has been carried out and after consultation and discussion with the residents where possible and / or their families where circumstances dictated, the use of bedrails has now decreased to 19. Of the 19 residents with bedrails in place, 10 expressed a preference to have them even after being made aware of the risks associated with their use. Nine residents were deemed to be at risk from a health and Page 4 of 7

22 safety point of view and require bedrails. Alternatives such as low beds, bed alarms and bed wedges were discussed/offered but bedrails were the preferred option with these 10 residents. These discussions have been documented in the resident s care plans. The use of these bedrails will continue to be reviewed on a 4 monthly basis or where there is a significant change to a resident s condition and the wishes and preferences of each resident will be ascertained and respected. 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 15(1) Regulation 16(1)(a) Regulation 16(1)(b) Regulation 21(1) Regulatory requirement 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. The person in charge shall ensure that staff have access to appropriate training. The person in charge shall ensure that staff are appropriately supervised. The registered provider shall ensure that the records set out in Schedules 2, 3 Judgme nt Not Not Not Orange Not Risk Date to be complied rating with Orange 1 st November 2018 Orange 24 September November 2018 Orange 31 October 2018 Page 5 of 7

23 Regulation 23(b) Regulation 23(c) Regulation 24(2)(d) Regulation 6(1) and 4 are kept in a designated centre and are available for inspection by the Chief Inspector. The registered provider shall ensure that there is a clearly defined management structure that identifies the lines of authority and accountability, specifies roles, and details responsibilities for all areas of care provision. The registered provider shall ensure that management systems are in place to ensure that the service provided is safe, appropriate, consistent and effectively monitored. The agreement referred to in paragraph (1) shall relate to the care and welfare of the resident in the designated centre concerned and include details of any other service of which the resident may choose to avail but which is not included in the Nursing Homes Support Scheme or to which the resident is not entitled under any other health entitlement. The registered provider shall, having regard to the care plan prepared under Regulation 5, provide appropriate medical Not Not Orange Substanti ally Not Orange Orange 24 September November 2018 Yellow 24 September rd October Page 6 of 7

24 Regulation 7(3) and health care, including a high standard of evidence based nursing care in accordance with professional guidelines issued by An Bord Altranais agus Cnáimhseachais from time to time, for a resident. The registered provider shall ensure that, where restraint is used in a designated centre, it is only used in accordance with national policy as published on the website of the Department of Health from time to time. Not Orange 24 September Page 7 of 7