Report of an inspection of a Designated Centre for Older People

Report of an inspection of a Designated Centre for Older People Name of designated centre: Name of provider: Address of centre: Brabazon House Nursing Home Brabazon House Nursing Home 2 Gilford Road, Sandymount, Dublin 4 Type of inspection: Unannounced Date of inspection: 12 June 2018 Centre ID: OSV-0000017 Fieldwork ID: MON-0024095 Page 1 of 13

About the designated centre The following information has been submitted by the registered provider and describes the service they provide. Brabazon House Nursing Home is a 51 bed centre providing residential and convalescent care services to males and females over the age of 18 years. The service is nurse-led by the person in charge and delivers 24 hour care to residents with a range of low to maximum dependency needs. Admissions are primarily accepted from people living in the sheltered accommodation apartments in Brabazon Court and Strand Road, although direct admissions to the centre are accepted, in exceptional circumstances, subject to bed availability. The building is an original Edwardian House (circa 1902) that has been extended and refurbished while retaining some of it's older features. It is located in a quiet road just off the Strand Road close to the strand and Dublin Bay. Local amenities include nearby shopping centres, restaurants, libraries and parks and also the strand. Accommodation for residents is across two floors. The centre contains 40 single bedrooms of which 34 have en suite facilities. There are also three twin and two three bedded rooms.communal facilities include assisted shower bathroom and toilets, dining room, two sitting rooms, an activity room, sensory room and a library. There are small rest areas situated on the ground floor at reception and on the first floor outside the hairdressing room which residents and visitors can enjoy. The following information outlines some additional data on this centre. Current registration end date: Number of residents on the date of inspection: 08/04/2021 50 Page 2 of 13

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

This inspection was carried out during the following times: Date Times of Inspection Inspector Role 12 June 2018 11:00hrs to 18:30hrs Nuala Rafferty Lead Page 4 of 13

Views of people who use the service The inspector met and chatted with approximately 25% of residents in the centre. All of the residents were very satisfied with their life in the centre and several said they felt very lucky to live there. All of the residents spoken with had moved from the sheltered accommodation apartments in the grounds of the centre prior to moving full-time into Brabazon House. All said they maintained contact with the people who still lived in the apartments and met with most on a daily basis. All were very positive and complimentary about the care they received from staff and several spoke very highly of the person in charge. The inspector was told that they could go to any of the staff with a problem to have it resolved but usually spoke with the assistant director of nursing, person in charge, general manager or the administrator. Few had ever made a formal complaint but those that had said it was resolved quickly and to their satisfaction. Many spoke about the gentle manner in which staff provided care, and some said they had observed staff giving wonderful care to some of their friends in the centre when they were frail and ill. Others mentioned that they observed how staff treated all residents equally, and were very patient, understanding and skilled in the manner in which they cared for residents who did not have capacity to communicate their needs, or were sometimes confused or upset. The residents felt that their health and social care needs were met. They explained they could choose to attend a doctor from three local general practitioner (GP) practices, who visited regularly. A notice board outside the dining room identified the dates and times of the visiting doctor and residents could put their name down for an appointment if they wished. The inspector was also told that the nurses were very quick to refer them to a doctor or to send them to the hospital if they were unwell. The residents were all very happy with the variety and amount of activities on offer and talked about the putting green in the grounds where they regularly played challenge matches. Some talked about how several of the other residents were excellent gardeners and helped look after the plants and shrubs. Indoor activities included quiz games, music, arts and exercise classes. For residents who were too frail to enjoy group activities the inspector heard from some spouses how activity staff regularly spent time with them on a on-to-one basis. Residents spoke about the food and while the majority of comments were positive, some thought the presentation and service could be improved and others felt the evening tea was very early although all said these were small issues and overall they were quite satisfied. Page 5 of 13

All of the residents said they felt very safe in the centre and would recommend it very highly to people they knew. Capacity and capability Management systems within the centre remained unchanged and continued to ensure that the service delivered to residents was safe and contributed to a good quality of life. Oversight and governance of the service is provided by the Brabazon Trust. This is comprised of a committee of management to whom the management team report on a monthly basis. Minutes of monthly reports delivered to the committee were available and reviewed. These contained information on residents care and safety, staffing, risk management and quality initiatives. The reports provided assurance that the service was delivered in line with it's stated purpose and function in an effective and efficient manner. The management team was comprised of the person in charge and general manager.other supports included an administrator, property services manager and managers of the catering and household teams. At an operational level the person in charge was also supported by an assistant director of nursing and clinical nurse manager who provided supervision and guidance to direct care staff. This inspection found that the person in charge and clinical management team were visible to staff and residents who were familiar with them. The constant presence of some or all of these managers provided ongoing support and leadership to staff that promoted a high standard of safe practice. A system was in place to assess and improve the standard of care delivered in the centre. Data was gathered under a variety of key performance indicators to inform regular audits that were carried out in a number of key areas including: use of restrictive practices, incidence of falls, level of hygiene, nutrition and medication. Although there was some evidence that the results of audits were used to improve practice in the centre, improvements were identified as required to ensure the process delivered improved outcomes for residents. It was also found that the collation of this quantitative data had not been used to inform an annual review of the quality and safety of care. In discussion with the person in charge and general manager the inspector was told that all of the information to compile such a report was available including qualitative data from resident's meetings and suggestions, further work was required to complete the review. There were systems in place to ensure the level and skill mix of staff was sufficient and effectively deployed to meet residents care needs in a responsive and timely Page 6 of 13

manner. The inspector found that these systems were implemented and that residents were assisted in a timely manner with close attention to detail. Good staff development programmes were in place. Nursing staff reported having attended recent training on supervision and delegation. This training was to support them in delegating appropriately to the health care staff and to enable them monitor care practices to ensure they were in line with centre policies. A system was in place to develop leadership skills and encourage ownership and responsibility for the delivery of care within the health care team. This was through use of a rotational supervisory role called the carer in charge, to whom nurses delegated responsibility of certain supervisory roles. All care staff were allocated to the role and this changed on a daily basis. Staff spoken with said this had improved communication and morale within the team. Robust recruitment processes were in place as part of appropriate safeguarding procedures. This included An Garda Síochána (police) vetting procedures. Insurance was in place and its certificate was displayed in the centre. A sample of contracts of care were reviewed and they had all information required as per the regulations; the residents rooms were described and any costs or fees that could be applied were clear. Complaints were managed initially by the manager or nurse on duty. If this didn't resolve the problem the person in charge sought a resolution. Although there were few complaints received the records maintained were minimal and required to be improved. Regulation 15: Staffing There were sufficient staff on on the roster and with the relevant skills and experience to meet the needs of the residents. Judgment: Regulation 16: Training and staff development Staff were supervised in their work and there was a system of staff development in place. All staff had received mandatory training and were able to carry out safe and effective care. Judgment: Page 7 of 13

Regulation 21: Records Systems were in place and implemented in practice to ensure that records, as required by the regulations, were maintained, available, safe and easily accessible. Judgment: Regulation 22: Insurance Insurance was in place and a certificate was displayed. Judgment: Regulation 23: Governance and management A governance framework, to support effective management of the service and appropriate leadership to staff, was in place. Sufficient resources to deliver the service in line with the statement of purpose were available. However, quality and safety processes to review clinical care practice and ensure improved outcomes for residents required improvement. A report on the annual review of the quality and safety of care in the centre and evidence of consultation with residents and relatives was not available. Judgment: compliant Regulation 24: Contract for the provision of services Contracts of care were in place. In a sample reviewed the type of room and the costs incurred were clear. Judgment: Page 8 of 13

Regulation 3: Statement of purpose The statement of purpose was available on inspection for review and it met the requirements. Judgment: Regulation 31: Notification of incidents All notifications had been received with the exception of one, however, this incident occurred just as the person in charge returned from a leave of absence and the notification was overlooked, the inspector was given assurance that all notifications would continue to be submitted in future. Judgment: Regulation 34: Complaints procedure The complaints process met the requirement of the regulations however,although the records included the steps taken to resolve the problem it did not refer to the satisfaction of the complainant or whether a review was conducted. Residents spoken with knew what steps to take if they wished to make a complaint. Judgment: compliant Regulation 4: Written policies and procedures Policies and procedures required by the regulations were in place and were regularly updated in line with current best practice and national guidance. However, the policy to manage use of restrictive practices was not fully implemented in practice. Judgment: compliant Quality and safety Page 9 of 13

This unannounced inspection found that a good standard of safe care was delivered to residents in a respectful and personalised manner. Residents had access to broad team of medical, nursing and specialist rehabilitative services, with regular and timely referral to these services found when required. Residents social needs were met through the provision of opportunities for meaningful engagement. A varied weekly activity programme was in place and there were more regular opportunities for residents to engage in community social events and outings. Progress was found on actions arising from the last inspection to devote more time to residents who, due to frailty, incapacity or choice usually did not take part in the group activities. The safety of residents was protected in the centre and advocacy services were available to residents to enable them to raise any issues of concern. Residents spoken with said they felt safe in the centre. There was access to a broad team of medical, nursing and specialist rehabilitative services, and regular and timely referral to these services was found when required for residents. Clinical inputs on a part-time or sessional basis are provided on referral including: medical cover from local general practitioners (GP) services, physiotherapy, dietitian, speech and language, podiatry and pharmacy. Access to consultant-level medical and psychiatric care was also available. Efforts to establish and maintain a restraint-free environment were ongoing and a low level of use of restrictive practices such as bed-rails, lap-belts or recliner chairs was found. Residents were assessed to determine the most appropriate measures to ensure their safety, and alternatives to restraints were available. However, evidence of a clear rationale, on which to base the decision to use a restraint,was limited in a sample of documentation viewed. Residents care needs were assessed on admission and regularly reviewed every four months or sooner if required. These assessments informed a plan of care for every need. Improvements to care planning and assessments were identified as required on the last inspection. These findings are recurrent on this inspection. Residents' rights were upheld in a variety of ways and they had access to advocacy services if required. A number of residents spoken with felt they had a meaningful routine and enough to do throughout each day. Residents had access to good information about the service and there was evidence that there were regular residents' meetings. Risk and fire safety management systems were in place and implemented. The design and layout of the centre was found to be appropriate to meet the needs of the current resident profile. Regulation 17: Premises Page 10 of 13

The centre was warm and well maintained and there was sufficient and appropriate assistive equipment available. The overall design and layout of the premises was appropriate to meet residents' needs as outlined in the statement of purpose. The determination of residents suitability to three specific bedrooms in the centre with limited access was on-going, in line with the centre's condition of registration. Actions arising from previous inspections were addressed by the provider including improvements to privacy in multi-occupancy rooms, pictorial signage and wayfinding for residents with dementia. However, highly coloured and patterned carpeting remained in place on the upper floors which could affect the orientation of residents with dementia. This was discussed with the person in charge who gave assurances that this remained as a priority on the quality improvement plan for the centre. Judgment: Regulation 5: Individual assessment and care plan Risk assessments tools to check for signs of clinical and functional deterioration were used including: risk of falls, level of cognitive ability, skin integrity, nutrition, communication, and use of restraints. However, it was noted that some of the assessment tools used were not comprehensive enough, to gather all the information required, to make a fully informed clinical decision. In particular this related to those used to assess risk of falls and use of restraints. Also,some clinical records viewed did not contain enough detail to ensure they were effectively managing the health problem. Examples included the care plans in place for use of restraints and to manage responsive behaviours. These did not fully guide staff. Some positive behavioural support plans did not include the form the behaviours might take, the triggers associated with the behaviour, and distraction or de-escalation techniques to manage the behaviours. Judgment: compliant Regulation 6: Health care Medical, nursing and specialist services were available to meet residents health care needs and regular and timely referral to these services was found when required for residents. Judgment: Page 11 of 13

Regulation 7: Managing behaviour that is challenging Evidence of a clear rationale, on which to base the decision to use a restraint, was not available in all cases. Restraints such as a bed rail, or an electronic device to monitor a resident's movement were in use. A risk assessment form was used to determine the suitability or requirement for use of the device. The inspector looked at several of these assessments and found that the alternatives considered, prior to using the device, were not always identified. Where alternatives were tried, the reason it was found not suitable was not always stated. Judgment: compliant Regulation 9: Residents' rights Staff in the centre supported residents to enjoy a good quality of life. Residents ability to participate in meaningful activities and past interests were assessed and documented and staff were familiar with what residents liked to do on a daily basis. A team of activity co ordinators facilitated a varied programme of activities that were available throughout the week. This included in-house activities and outings designed to meet resident s needs and interests. These reflected many of the interests and needs of most residents, including those with impaired cognitive abilities. CCTV was in place both internally and externally in the centre. A sign was placed in a prominent position to inform all visitors of its use. The centre policy was updated since the last inspection to reflect the responsibility of the provider, to be proportionate in the use of CCTV generally, and particularly in communal areas. The policy was in line with the Data Protection Acts of 1988 and 2003 in respect of the right to privacy. Judgment: Page 12 of 13

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 22: Insurance 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 Regulation 4: Written policies and procedures Quality and safety Regulation 17: Premises Regulation 5: Individual assessment and care plan Regulation 6: Health care Regulation 7: Managing behaviour that is challenging Regulation 9: Residents' rights Judgment compliant compliant compliant compliant compliant Page 13 of 13

Compliance Plan for Brabazon House Nursing Home OSV-0000017 Inspection ID: MON-0024095 Date of inspection: 12/06/2018 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: 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 6

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 23: Governance and management Judgment Outline how you are going to come into compliance with Regulation 23: Governance and management: During each year information around all aspects of quality and safety in the home is gathered monthly and discussed at staff meetings. This information will now be included in an annual review. This document will be shared with residents and families. Details of resident advisory committee meetings will be included in the review. Currently the minutes of all meetings are displayed on the notice boards. The annual review will be completed by 31-08-2018. Regulation 34: Complaints procedure Outline how you are going to come into compliance with Regulation 34: Complaints procedure: Since our inspection our complaints/issues process has been reviewed. At each staff handover during the day details of issues are discussed. If there have been no issues this too is documented. Monthly reviews of complaints and issues will be carried out and documented. The process of dealing with issues immediately will continue. Special note will be made around resident satisfaction in the future. Regulation 4: Written policies and procedures Outline how you are going to come into compliance with Regulation 4: Written policies and procedures: The centre s Policies and Procedures are under constant review. Following our recent inspection, the policy mentioned has been discussed with all staff. around Page 2 of 6

release of restraint has been highlighted. Staff were releasing restraint but on occasion omitting to document the action. Checks are carried out during the day to ensure this is being done. Regulation 5: Individual assessment and care plan Outline how you are going to come into compliance with Regulation 5: Individual assessment and care plan: Residents who exhibit Behaviours that Challenge are well known to staff and they are aware of the triggers. These triggers were not all clearly stated in Care Plans. This issue has been rectified in all cases. Regulation 7: Managing behaviour that is challenging Outline how you are going to come into compliance with Regulation 7: Managing behaviour that is challenging: The staff are aware of the rationale around the use of restraint for residents. Unfortunately, this rationale was not always clearly stated in the relevant care plan. Following a full review of practices this issue has been addressed so staff reading it are clear about the reasoning behind the decision being made. Page 3 of 6

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 23(d) Regulation 34(1)(f) Regulatory requirement The registered provider shall ensure that there is an 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 the Authority under section 8 of the Act and approved by the Minister under section 10 of the Act. The registered provider shall provide an accessible and effective complaints procedure which includes an appeals procedure, and shall ensure that the nominated Judgment Risk rating Date to be complied with Yellow 31-08-2018. Yellow 16-07-2018 Page 4 of 6

Regulation 04(1) Regulation 5(1) Regulation 5(2) person maintains a record of all complaints including details of any investigation into the complaint, the outcome of the complaint and whether or not the resident was satisfied. The registered provider shall prepare in writing, adopt and implement policies and procedures on the matters set out in Schedule 5. The registered provider shall, in so far as is reasonably practical, arrange to meet the needs of each resident when these have been assessed in accordance with paragraph (2). The person in charge shall arrange a comprehensive assessment, by an appropriate health care professional of the health, personal and social care needs of a resident or a person who intends to be a resident immediately before or on the person s admission to a designated centre. Yellow 12-07-2018 Yellow 10-07-2018 Yellow 10-07-2018 Page 5 of 6

Regulation 7(3) 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. Yellow 07-07-2018 Page 6 of 6